Elevated Admission Glucose Is Associated With Increased Long-term Mortality in MI Patients
Elevated Admission Glucose Is Associated With Increased Long-term Mortality in MI Patients
Background It is uncertain if elevated admission plasma glucose (APG) remains an independent determinant of longer-term mortality in myocardial infarction (MI) patients with early restoration of coronary reperfusion by primary percutaneous coronary intervention. The objective of the study was to describe the relation between elevated APG and long-term mortality in MI patients undergoing invasive management.
Methods We studied 1,185 consecutive MI patients treated in the Medical Center Alkmaar in the separate years 1996 and 1999 (preinvasive era) and 2003 and 2006 (invasive era). In both eras, APG was derived according to a standard protocol. A multivariate Cox regression model was created to study the relation between APG, reperfusion era, and 5-year mortality.
Results During a median follow-up of 63 months, 261 patients had died. Mortality was lower in the invasive (19%) than in the preinvasive era (28%). Increased APG was associated with increased mortality, irrespective of the initial reperfusion strategy, although the relation was more pronounced in the preinvasive era (P value for heterogeneity of effects < .001). Each millimole-per-liter APG increase corresponded to a 7% increased mortality (adjusted hazard ratio 1.07, 95% CI 1.04–1.10). Patients with an APG >11 mmol/L had nearly 2-fold higher mortality (hazard ratio 1.9, 95% CI 1.3–2.7) than those with lower values.
Conclusion Elevated APG remains a determinant of long-term mortality in MI patients, irrespective of the advances that have been made in reperfusion therapy.
Elevated glucose levels are associated with adverse prognosis in patients with myocardial infarction (MI). Several investigators have demonstrated that elevated admission plasma glucose (APG) is associated with increased mortality in patients who are admitted for MI, even if these glucose levels remain less than the diagnostic threshold for diabetes mellitus (DM), that is, 11 mmol/L. We realize that most of these studies were undertaken in patients receiving fibrinolytic (FL) therapy as initial reperfusion strategy. Nowadays, a more invasive approach has become the standard of care for MI treatment, based on early coronary angiography (CAG) and followed by percutaneous coronary intervention (PCI) if indicated. Regional networks are constructed, which allow rapid prehospital triage, with subsequent transportation to dedicated hospitals with adequate PCI facilities and experienced operators. In view of these developments, it is uncertain if elevated admission glucose remains an independent determinant of longer-term mortality, particularly in patients without previously diagnosed DM.
We aimed to describe the relation between APG and long-term (5-year) mortality in MI patients undergoing early CAG and subsequent PCI. We were also interested to learn if the APG-outcome relation has changed along with the change in the initial treatment strategy.
Our analyses are based on a single-center registry of consecutive MI patients. This design implies an important advantage over earlier reports, which were based on more stringent patient selection, such as patients undergoing particular treatment (eg, fibrinolysis or primary PCI), elderly patients, or patients with previously diagnosed DM.
Abstract and Introduction
Abstract
Background It is uncertain if elevated admission plasma glucose (APG) remains an independent determinant of longer-term mortality in myocardial infarction (MI) patients with early restoration of coronary reperfusion by primary percutaneous coronary intervention. The objective of the study was to describe the relation between elevated APG and long-term mortality in MI patients undergoing invasive management.
Methods We studied 1,185 consecutive MI patients treated in the Medical Center Alkmaar in the separate years 1996 and 1999 (preinvasive era) and 2003 and 2006 (invasive era). In both eras, APG was derived according to a standard protocol. A multivariate Cox regression model was created to study the relation between APG, reperfusion era, and 5-year mortality.
Results During a median follow-up of 63 months, 261 patients had died. Mortality was lower in the invasive (19%) than in the preinvasive era (28%). Increased APG was associated with increased mortality, irrespective of the initial reperfusion strategy, although the relation was more pronounced in the preinvasive era (P value for heterogeneity of effects < .001). Each millimole-per-liter APG increase corresponded to a 7% increased mortality (adjusted hazard ratio 1.07, 95% CI 1.04–1.10). Patients with an APG >11 mmol/L had nearly 2-fold higher mortality (hazard ratio 1.9, 95% CI 1.3–2.7) than those with lower values.
Conclusion Elevated APG remains a determinant of long-term mortality in MI patients, irrespective of the advances that have been made in reperfusion therapy.
Introduction
Elevated glucose levels are associated with adverse prognosis in patients with myocardial infarction (MI). Several investigators have demonstrated that elevated admission plasma glucose (APG) is associated with increased mortality in patients who are admitted for MI, even if these glucose levels remain less than the diagnostic threshold for diabetes mellitus (DM), that is, 11 mmol/L. We realize that most of these studies were undertaken in patients receiving fibrinolytic (FL) therapy as initial reperfusion strategy. Nowadays, a more invasive approach has become the standard of care for MI treatment, based on early coronary angiography (CAG) and followed by percutaneous coronary intervention (PCI) if indicated. Regional networks are constructed, which allow rapid prehospital triage, with subsequent transportation to dedicated hospitals with adequate PCI facilities and experienced operators. In view of these developments, it is uncertain if elevated admission glucose remains an independent determinant of longer-term mortality, particularly in patients without previously diagnosed DM.
We aimed to describe the relation between APG and long-term (5-year) mortality in MI patients undergoing early CAG and subsequent PCI. We were also interested to learn if the APG-outcome relation has changed along with the change in the initial treatment strategy.
Our analyses are based on a single-center registry of consecutive MI patients. This design implies an important advantage over earlier reports, which were based on more stringent patient selection, such as patients undergoing particular treatment (eg, fibrinolysis or primary PCI), elderly patients, or patients with previously diagnosed DM.