Evaluation of Myocardial Damage in Relation to HbA1c in Patients with Previously Unrecognized Diabetes Presenting with STEMI

Abstract

Objective: The mechanisms underlying worse clinical outcomes in previously unrecognized diabetic (DM) patients in ST-elevation myocardial infarction (STEMI) are unclear. It was hypothesized that poor chronic glucose control might be related to greater myocardial damage. Material and Method: 51 newly diagnosed DM patients with glycated hemoglobin A1c (HbA1c) > 6.5 comprised the DM group, 54 sex- and age-matched individuals with normal glucose metabolism served as the non-DM group. Each patient underwent primary angioplasty for STEMI. The levels of cardiac specific markers before angioplasty, during angioplasty, at 6, 12, and 18 h after angioplasty were recorded. SPSS 10 package program was used to analyse data. Results: In both DM and non-DM groups troponin peaked at 6 h. Peak troponin levels were similar in both groups (diabetics, 22.89 ± 18.19 vs. non-diabetics, 32.67 ± 17.68 ng/ml, p=0.168). Conclusions: HbA1c > 6.5 is not related to extent of infarction in previously unrecognized DM patients presenting with STEMI. Future studies assessing the effects of other factors unrelated to chronic glucose control on myocardial damage and cardiovascular event rates in these patients would be of great interest.

Keywords

• Acute coronary syndrome
• Cardiac markers
• diabetes mellitus
• Acute ST-segment elevation myocardial infarction
• Coronary angioplasty

STEMI ile Başvuran Önceden Tanı Almamış Diyabetli Hastalarda HbA1c ile İlişkili Miyokard Hasarının Değerlendirilmesi

Abstract

Amaç: Daha önce tanısı konulmamış diyabetik hastalarda ST elevasyonlu miyokard enfarktüsünde (STEMI) kötü klinik sonuçların altında yatan mekanizmalar belirsizdir. Kötü glisemik kontrolün daha büyük miyokard hasarı ile ilişkili olabileceği hipotezi oluşturulmuştur. Gereç ve Yöntem: Glikolize hemoglobin A1c (HbA1c)> 6.5 olan yeni tanı konmuş 51 DM hastası DM grubunu, normal glikoz metabolizması olan 54 cinsiyet ve yaş eşleşmeli birey DM olmayan grup olarak çalışmaya dahil edildi. Her hastaya STEMI için primer anjiyoplasti yapıldı. Anjiyoplasti öncesi, anjiyoplasti sırasında, anjiyoplastiden 6, 12 ve 18 saat sonra kardiyak spesifik belirteç seviyeleri kaydedildi. Veriler SPSS 10 paket program eşliğinde analiz edildi. Bulgular: Hem DM hem de DM olmayan gruplarda troponin 6. saatte zirve yaptı. Pik troponin düzeyleri her iki grupta da benzerdi (diyabetliler, 22.89 ± 18.19 ve nondiyabetikler, 32.67 ± 17.68 ng / ml, p = 0.168). Sonuç: HbA1c’nin 6,5’tan büyük olması, STEMI ile başvuran ve daha önce DM tanısı olmayan hastalarda infarkt alanının genişliği bakımından fark bulunmamıştır. Bu hastalarda miyokard hasarı ve kardiyovasküler olay oranlarını etkileyecek kronik glikoz kontrolü dışında faktörleri değerlendirmek için gelecek çalışmalara ihtiyaç vardır.

Keywords

• Akut koroner sendrom
• kardiyak belirteçler
• diabetes mellitus
• Akut ST segment elevasyonlu miyokard infarktüsü
• Koroner anjiyoplasti

References

1. McGuire DK. Diabetes and the cardiovascular system. in: Bonow RO, Mann DL, Zipes DP, Libby P. Braunwald’s heart disease. 9th ed. Elsevier Saunders, Philadelphia 2012:1392-1409.
2. King H, Aubert RE, Herman WH. Global burden of diabetes, 1995-2025:prevalence, numerical estimates, and projections. Diabetes Care 1998;21:1414-1431.
3. Gholap N, Davies MJ, Mostafa SA, Squire I, Khunti K. A simple strategy for screening for glucose intolerance, using glycated haemoglobin, in individuals admitted with acute coronary syndrome. Diabet Med 2012;29:838-843.
4. Arruda-Olson AM, Roger VL, Jaffe AS, Hodge DO, Gibbons RJ, Miller TD. Troponin T levels and infarct size by SPECT myocardial perfusion imaging. JACC: Cardiovasc Imaging 2011;4:523-533.
5. Gustafsson I, Kistorp CN, James MK, Faber JO, Dickstein K, Hildebrandt PR. Unrecognized glycometabolic disturbance as measured by hemoglobin A1c is associated with a poor outcome after acute myocardial infarction. Am Heart J 2007;154:470-476.
6. Hermanides RS, Kennedy MW, Kedhi E, van Dijk PR, Timmer JR, Ottervanger JP, at al. Impact of elevated HbA1c on long-term mortality in patients presenting with acute myocardial infarction in daily clinical practice: insights from a ‘real world’prospective registry of the Zwolle Myocardial Infarction Study Group. Eur Heart J Acute Cardiovasc Care. 2020 Sep;9(6):616-625.
7. Cherneva ZV, Denchev SV, Gospodinova MV, Milcheva NP, Petrova MG, Cherneva RV. Clinical significance of hyperglycaemia in acute coronary syndrome patients. Acute Card Care 2011;13:211-218.
8. Chan CY, Li R, Chan JY, Zhang Q, Chan CP, Dong M, et al. The value of admission HbA(1c) level in diabetic patients with acute coronary syndrome. Clin Cardiol 2011;34:507-512.

9. Tian L, Zhu J, Liu L, Liang Y, Li J, Yang Y. Hemoglobin A1c and short-term outcomes in patients with acute myocardial infarction undergoing primary angioplasty: an observational multicenter study. Coron Artery Dis 2013;24:16-22.
10. Hage C, Lundman P, Rydén L, Mellbin L. Fasting glucose, HbA1c, or oral glucose tolerance testing for the detection of glucose abnormalities in patients with acute coronary syndromes. Eur J Prev Cardiol 2013;20:549-554.
11. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2014;37 Suppl 1:S62-69.
12. Killip T 3rd, Kimball JT. Treatment of myocardial infarction in a coronary care unit. A two year experience with 250 patients. Am J Cardiol 1967;20:457-464.
13. Rentrop KP, Cohen M, Blanke H, Phillips RA. Changes in collateral channel filling immediately after controlled coronary artery occlusion by an angioplasty balloon in human subjects. J Am Coll Cardiol 1985;5:587-592.
14. TIMI Study Group. The thrombolysis in myocardial infarction (TIMI) trial. Phase I findings. N Engl J Med 1985;312(14):932-936.
15. Hadjadj S, Coisne D, Mauco G, Ragot S, Duengler F, Sosner P, et al. Prognostic value of admission plasma glucose and HbA in acute myocardial infarction. Diabet Med 2004;21(4):305-310.
16. Timmer JR, Ottervanger JP, Bilo HJ, Dambrink JH, Miedema K, Hoorntje JC, et al. Prognostic value of admission glucose and glycosylated hemoglobin levels in acute coronary syndromes. QJM 2006;99(4):237-243.
17. Pan W, Lu H, Lian B, Liao P, Guo L, Zhang M. Prognostic value of HbA1c for in-hospital and short-term mortality in patients with acute coronary syndrome: a systematic review and meta-analysis. Cardiovasc Diabetol 2019;18:169.
18. Shin D, Ahn J, Cha K, Park JS, Oh JH, Lee HW, et al. Impact of initial glycosylated hemoglobin level on cardiovascular outcomes in prediabetic patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. Coron Artery Dis 2016;27:40-46.
19. Li G, Hou X, Li Y, Zhang P, Zhao Q, Li J, Shi J. Prognostic value of glycated hemoglobin among patients with ST-segment elevation myocardial infarction:a systematic review and meta-analysis. Clin Chem Lab Med (CCLM) 2017:55;1090-1099.
20. Olshansky SJ, Passaro DJ, Hershow RC, Layden J, Carnes BA, Brody J, et al. A potential decline in life expectancy in the United States in the 21st century. N Engl J Med 2005;352:1138-1145.
21. Kosiborod M, Rathore SS, Inzucchi SE, Masoudi FA, Wang Y, Havranek EP, et al. Admission glucose and mortality in elderly patients hospitalized with acute myocardial infarction: implications for patients with and without recognized diabetes. Circulation 2005;111:3078-3086.
22. Giraldez RR, Clare RM, Lopes RD, Dalby AJ, Prabhakaran D, Brogan GX Jr, et al. Prevalence and clinical outcomes of undiagnosed diabetes mellitus and prediabetes among patients with high-risk non-ST-segment elevation acute coronary syndrome. Am Heart J 2013;165:918-925.
23. Oswald G, Yudkin JS. Prognostic value of admission plasma glucose and HbA in acute myocardial infarction. Diabet Med 2005;22:509-510.
24. Selvin E, Steffes MW, Zhu H, Matsushita K, Wagenknecht L, Pankow J, et al. Glycated hemoglobin, diabetes, and cardiovascular risk in nondiabetic adults. N Engl J Med 2010;362:800-811.
25. Kmet M, Rajer B, Pernat A. Hemoglobin A1c is a better predictor of prognosis following the non-ST elevation acute coronary syndrome than fasting and admission glucose. Wien Klin Wochenschr 2014;126:156-162.
26. Stratton IM, Adler AI, Neil HA, Matthews DR, Manley SE, Cull CA, et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): Prospective observational study. BMJ 2000;321:405-412.
27. Lee MG, Jeong MH, Kim DH, Lee KH, Park KH, Sim DS, et al. Predictive value of glycosylated hemoglobin for mortality of patients with acute myocardial infarction undergoing percutaneous coronary intervention. Int J Cardiol 2012;156:110-112.
28. Britton KA, Aggarwal V, Chen AY, Alexander KP, Amsterdam E, Fraulo E, et al. No association between hemoglobin A1c and in-hospital mortality in patients with diabetes and acute myocardial infarction. Am Heart J 2011;161:657-663.
29. Riddle MC, Ambrosius WT, Brillon DJ, Buse JB, Byington RP, Cohen RM, et al. Action to control cardiovascular risk in diabetes investigators. Epidemiologic relationships between A1c and all-cause mortality during a median 3.4-year follow-up of glycemic treatment in the ACCORD trial. Diabetes Care 2010;33:983-990.
30. Berry C, Noble S, Gregoire JC, Ibrahim R, Levesquie S, Lavoie MA, et al. Glycaemic status influences the nature and severity of coronary artery disease. Diabetologia. 2010 Apr;53(4):652-658.
31. Cao JJ, Hudson M, Jankowski M, Whitehouse F, Weaver WD. Relation of chronic and acute glycemic control on mortality in acute myocardial infarction with diabetes mellitus. Am J Cardiol 2005;96:183-186.
32. Lazzeri C, Valente S, Chiostri M, Picariello C, Attana P, Gensini GF. The prognostic impact of glycated hemoglobin in diabetic ST-elevation myocardial infarction. Int J Cardiol 2011;151:250-252.
33. Ravipati G, Aronow WS, Ahn C, Sujata K, Saulle LN, Weiss MB. Association of hemoglobin A(1c) level with the severity of coronary artery disease in patients with diabetes mellitus. Am J Cardiol 2006;97:968-969.
34. Mi SH, Gong SU, Zhao LI, Yang HX, Zheng H, Tao H, et al. Comparison of glycemic variability and glycated hemoglobin as risk factors of coronary artery disease in patients with undiagnosed diabetes. Chin Med J 2012;125:38-43.
35. Ertem AG, Bağbancı H, Kılıç H, Yeter E, Akdemir R. Relationship between HbA1c levels and coronary artery severity in nondiabetic acute coronary syndrome patients. Turk Kardiyol Dern Ars 2013;41:389-395.
36. Habib S, Ullah SZ, Tahir Saghir ASM, Deen ZU, Naseeb K, Sherwani R. The association between hemoglobin A1c and the severity of coronary artery disease in non-diabetic patients with acute coronary syndrome. Cureus. 2020 Jan 12;12(1):e6631.