Diabetes,plasma insulin,and cardiovascular disease: subgroup analysis from the Department of Veterans Affairs high-density lipoprotein intervention trial (VA-HIT)

BACKGROUND: Diabetes mellitus, impaired fasting glucose level, or insulin resistance are associated with increased risk of cardiovascular disease. OBJECTIVES: To determine the efficacy of gemfibrozil in subjects with varying levels of glucose tolerance or hyperinsulinemia and to examine the association between diabetes status and glucose and insulin levels and risk of cardiovascular outcomes. METHODS: Subgroup analyses from the Department of Veterans Affairs High-Density Lipoprotein Intervention Trial, a randomized controlled trial that enrolled 2531 men with coronary heart disease (CHD), a high-density lipoprotein cholesterol level of 40 mg/dL or less (/=271 pmol/L) was associated with a 31% increased risk of events (P =.03). Gemfibrozil was effective in persons with diabetes (risk reduction for composite end point, 32%; P =.004). The reduction in CHD death was 41% (HR, 0.59; 95% CI, 0.39-0.91; P =.02). Among individuals without diabetes, gemfibrozil was most efficacious for those in the highest fasting plasma insulin level quartile (risk reduction, 35%; P =.04). CONCLUSION: In men with CHD and a low high-density lipoprotein cholesterol level, gemfibrozil use was associated with a reduction in major cardiovascular events in persons with diabetes and in nondiabetic subjects with a high fasting plasma insulin level.     

Fasting and 2-hour postchallenge serum glucose measures and risk of incident cardiovascular events in the elderly: the Cardiovascular Health Study.

BACKGROUND: The contributions of fasting and 2-hour postchallenge glucose level to cardiovascular events remain ill-defined, especially for nondiabetic adults. This study examined the relative predictive power of fasting and 2-hour glucose level on cardiovascular event risk. METHODS: A total of 4014 community-dwelling adults 65 years or older who participated in the baseline visit of the Cardiovascular Health Study and who were without treated diabetes or previous myocardial infarction or stroke were eligible for analyses. Participants with treated diabetes at baseline were excluded. Incident myocardial infarction or stroke, or coronary death, was the outcome of interest. Age-, sex-, and race-adjusted proportional hazards regression models described individual and joint associations between baseline measures of fasting and 2-hour postchallenge glucose level and event risk. RESULTS: There were 764 incident cardiovascular events during 8.5 years of follow-up. Fasting glucose level of 115 mg/dL (6.4 mmol/L) or more was associated with an increased cardiovascular risk (hazard ratio [HR], 1.66 [95% confidence interval (CI), 1.39-1.98]) in adjusted analyses compared with fasting glucose level less than 115 mg/dL. Two-hour glucose level was associated with a linear risk (HR, 1.02 [95% CI, 1.00-1.04] per 10 mg/dL [0.6 mmol/L]) that included an additional increase in risk for 2-hour glucose level of 154 mg/dL (8.5 mmol/L) or more (HR, 1.29 [95% CI, 1.04-1.59]) in adjusted analyses. In joint fasting and 2-hour glucose models, only 2-hour glucose level remained predictive of event risk. CONCLUSIONS: Two-hour glucose level was better than fasting glucose level alone at identifying older adults at increased risk of major incident cardiovascular events.     

Clustering of components of the metabolic syndrome and risk for development of type 2 diabetes in Japanese male office workers

To investigate the effects of the clustering of components of the metabolic syndrome (MS) on development of diabetes, we examined 3298 Japanese male office workers aged 35-59 years who did not have type 2 diabetes (a fasting plasma glucose level of > or =7.0 mmol/l or receipt of hypoglycemic medication) or a history of cardiovascular disease. Fasting plasma glucose levels were measured at periodic annual health examinations from May 1994 through May 2001. After adjustment for potential risk factors for diabetes, the multivariate-adjusted relative risk of type 2 diabetes compared with the subjects without components of the MS was 1.58 (95% CI: 1.08-2.32), 2.48 (95% CI: 1.69-3.63), 3.10 (95% CI: 2.05-4.68), and 5.22 (95% CI: 3.49-7.83) (P-value for trend <0.001) for those with 1, 2, 3, and > or =4 components, respectively. Even after the subjects were stratified according to fasting plasma glucose level, the clustering of components of the MS was associated with an increased risk of type 2 diabetes for subjects in all three categories of low-normal fasting glucose (a fasting plasma glucose level of <5.1 mmol/l), high-normal fasting glucose (a fasting plasma glucose level of 5.0-6.0 mmol/l), and impaired fasting glucose (a fasting plasma glucose level of 6.1-6.9 mmol/l). These results indicate that clustering of components of the MS associated with diabetes precedes an increase in the risk of type 2 diabetes in Japanese men.     

Criteria for previously undiagnosed diabetes and risk of mortality: 15-year follow-up of the Edinburgh Artery Study cohort.

AIMS: To compare risk of all-cause and cardiovascular mortality associated with different criteria for undiagnosed diabetes and glucose tolerance. METHODS: A population-based cohort of 758 men and 738 women of 55-74 years of age who had an oral glucose tolerance test or known diabetes at baseline were followed up until death or for 15 years. Mortality outcomes were compared by baseline diabetes status using people with normal glucose tolerance (i.e. those without diabetes, impaired fasting glucose or impaired glucose tolerance) as the reference group. RESULTS: Prevalence of undiagnosed diabetes using World Health Organization (WHO) criteria (fasting glucose of > or = 7.0 mmol/l and/or a 2-h post-challenge glucose of > or = 11.1 mmol/l) was 6.6%, of which 81% was associated with fasting glucose > or = 7.0 mmol/l and 19% was associated with isolated post-challenge hyperglycaemia. Hazard ratios (95% CI) for all-cause mortality adjusted for age and sex were 1.51 (1.09-2.08) for new diabetes by the American Diabetes Association (ADA) criterion (fasting glucose of > or = 7.0 mmol/l regardless of post-challenge glucose), 1.60 (1.20-2.13) for new diabetes by WHO criteria and 1.98 (1.14-3.44) for isolated post-challenge hyperglycaemia. Hazard ratios (95% CI) for cardiovascular mortality adjusted for age and sex were 1.89 (1.17-3.00), 1.73 (1.12-2.66) and 1.08 (0.34-3.40) for new diabetes by ADA and WHO criteria and for isolated post-challenge hyperglycaemia, respectively. CONCLUSIONS: Undiagnosed diabetes was associated with increased risk of all-cause mortality by any criteria but significantly increased cardiovascular disease mortality was only associated with diabetes diagnosed using the fasting glucose criterion. Mortality risks were similar in this population using either ADA or WHO criteria for diagnosis of diabetes.     

Prevalence of gestational diabetes mellitus – do the new WHO criteria make a difference?

AIMS: To describe the prevalence of gestational diabetes mellitus (GDM) according to the 1998 WHO provisional recommendations and compare it to that found with previous 1985 WHO criteria. METHODS: A total of 5564 consecutive women aged 20 years or more without diagnosis of diabetes mellitus outside of pregnancy in general prenatal care clinics of the National Health Service in 6 state capitals of Brazil, between their 20th and 28th gestational weeks were enrolled. RESULTS: Of the 5004 women who completed a 75-g oral glucose tolerance test, 379 (7.6%, 95% confidence interval (CI) 6.9% to 8.4%) had GDM by the 1998 criteria (fasting glucose > or = 7.0 mmol/l or 2 h glucose > or = 7.8 mmol/l). Of these 379 cases, only 21 (5.5%) had hyperglycaemia in the range considered diabetes mellitus outside pregnancy (fasting glucose > or = 7.0 mmol/l or 2 h glucose > or = 11.1 mmol/l); the remaining 358 (94.5%) had hyperglycaemia in the impaired glucose tolerance range (fasting glucose < 7.0 and 2 h glucose > or = 7.8 mmol/l and < 11.1 mmol/l). Using the 1985 criteria (fasting or 2 h glucose > or = 7.8 mmol/l), 378 cases of GDM were found, 15 in the diabetes range and 363 in the impaired glucose tolerance range. CONCLUSIONS: Prevalence of GDM is minimally altered by the new WHO definition. Although GDM is a common condition, the vast majority of the cases have hyperglycaemia in the range considered impaired glucose tolerance outside pregnancy.     

Increased preoperative glucose levels are associated with perioperative mortality in patients undergoing noncardiac, nonvascular surgery

OBJECTIVE: To determine the relationship between preoperative glucose levels and perioperative mortality in noncardiac, nonvascular surgery. RESEARCH DESIGN AND METHODS: We performed a case-control study in a cohort of 108 593 patients who underwent noncardiac surgery at the Erasmus MC during 1991-2001. Cases were 989 patients who underwent elective noncardiac, nonvascular surgery and died within 30 days during hospital stay. From the remaining patients, 1879 matched controls (age, sex, calendar year, and type of surgery) were selected. Information was obtained regarding the presence of cardiac risk factors, medication, and preoperative laboratory results. Preoperative random glucose levels <5.6 mmol/l (110 mg/dl) were normal. Impaired glucose levels in the range of 5.6-11.1 mmol/l were prediabetes. Glucose levels >or=11.1 mmol/l (200 mg/dl) were diabetes. RESULTS: Preoperative glucose levels were available in 904 cases and 1247 controls. A cardiovascular complication was the primary cause of death in 207 (23%) cases. Prediabetes glucose levels were associated with a 1.7-fold increased mortality risk compared with normoglycemic levels (adjusted odds ratio (OR) 1.7 and 95% confidence interval (CI) 1.4-2.1; P<0.001). Diabetes glucose levels were associated with a 2.1-fold increased risk (adjusted OR 2.1 and 95% CI 1.3-3.5; P<0.001). In cases with cardiovascular death, prediabetes glucose levels had a threefold increased cardiovascular mortality risk (adjusted OR 3.0 and 95% CI 1.7-5.1) and diabetes glucose levels had a fourfold increased cardiovascular mortality risk (OR 4.0 and 95% CI 1.3-12). CONCLUSIONS: Preoperative hyperglycemia is associated with increased (cardiovascular) mortality in patients undergoing noncardiac, nonvascular surgery.     

Antihypertensive drugs as predictors of type 2 diabetes among subjects with impaired glucose tolerance

Aims: to examine the incidence rate of progression to Type 2 diabetes and baseline prognostic risk factors, focusing on hypertension and antihypertensive medication, in a cohort (n=207) with impaired glucose tolerance (IGT). Methods: after 2 and 4.6 (1.9–6.4) years new cases of diabetes were diagnosed by the oral glucose tolerance test (OGTT). Hypertension (BP 160/95 or antihypertensive medication) was included in multiple regression analyses to assess the effect of risk factors on the development of diabetes. Results: diabetes developed in 32 subjects (19%), an incidence of 41/1000 (95% CI 28–57/1000) person-years. In univariate analyses, progression to diabetes was associated with a high (>9.0 mmol/l) 2-h OGTT value (P=0.008), a high fasting insulin (>12.0 mU/l) level (P=0.000), a high triglyceride (≥1.3 mmol/l) level (P=0.028), a high BMI (≥28.0 kg/m²) (P=0.013) and hypertension (P=0.003). The risk for the development of diabetes was not increased in hypertensive subjects without antihypertensive medication compared with normotensive subjects (OR 0.8, 95% CI 0.3–2.6). However, it was increased in subjects with on medication, especially diuretics alone or in combination with other drugs. Hypertensive subjects on diuretics had higher levels of fasting insulin and triglycerides and higher BMIs at baseline than normotensive subjects. After adjustment for 2-h OGTT, fasting insulin, triglycerides and BMI, the OR for diabetes was 7.7 (95% CI 2.1–28.2) in hypertensive subjects using diuretics alone or in combination with other drugs and 2.6 (95% CI 1.0–6.7) in those using other drugs compared with normotensive subjects. The OR of diabetes corresponding to a one-unit increase in the 2-h OGTT concentration was 2.5 (95% CI 1.6–4.0) in the whole cohort. Conclusions: the rate of progression from IGT to Type 2 diabetes in this population was similar to that seen in other studies among Caucasian populations. The use of antihypertensive medication, especially diuretics, and a high 2-h OGTT level were significant predictors of subsequent deterioration to diabetes.     

The association between blood glucose value and long-term mortality

This study aims at estimating the association between different fasting blood glucose levels (FBG) and total mortality during a long-term follow-up. In all 2,300 subjects were health examined, out of a stratified sample of 32,185 individuals aged 18—64 years drawn from the population in Stockholm County from the years 1969—70. FBG values were divided into following groups: < 3.0, 3.0-4.4, 4.5-5.5, 5.66.0, 6.1-6.6, and > 6.6 mmol/l (corresponding to fasting plasma glucose, FPG, < 3.5, 3.5-4.9, 5.0-6.0, 6.1-6.9, 7.0-7.7 and > 7.7 mmol/l), and known diabetes mellitus. All participants were followed up in the National Cause of Death Register up to the end of 1996. Multivariate analysis was performed by Cox regression, with three models, the first age- and sex-adjusted, the second also adjusted for care need category and hypertension, and the third with added BMI-category, with hazard ratios (HR) and 95% confidence interval (CI). Smoking habits were available for around half of the sample. Compared to the FBG showing the lowest mortality, i.e. FBG 5.6-6.0 mmol/l, we found an age- and sex-adjusted excess risk for subjects with known diabetes (HR 7.39, 95% CI 3.78-14.45), with FBG > 6.6 mmol/l (HR 2.30, 95% CI 1.20-4.39), and with FBG < 3.0 mmol/l (HR 3.44, 95% CI 1.47-8.06). The excess risk persisted when adjusting for care need, hypertension, BMI, and also for smoking. The cause of the increased mortality risk with low FBG values is unclear, but low FBG value seems to be a risk marker of poor health.     

Short-term reproducibility of impaired fasting glycaemia, impaired glucose tolerance and diabetes The ADDITION study, DK

We evaluated variations in glucose measurements and the reproducibility of glucose tolerance classification in a high-risk screening setting in general practice. Screening for diabetes was performed in persons aged 40-69 years. Based on capillary fasting (FBG) and 2-h blood glucose (2 hBG) individuals with impaired fasting glycaemia (IFG), impaired glucose tolerance (IGT) and diabetes had a second test done after 14 days. Intra-individual coefficients of variation (CV) were estimated in each glucose tolerance class using the approximation CV(2)(x)=var(ln(x)). Bland-Altman plots with limits of agreement were made. In the total population, the CV(intra) was 7.9% and 13.8% for FBG and 2 hBG, respectively. Limits of agreement ranged from -1.15 to 1.67 mmol/l for FBG and from - 2.62 to 3.27 mmol/l for 2 hBG. One individual with IFG and 22.5% with IGT had diabetes at the second test, 76.1% with diabetes had this diagnosis confirmed, and about 30% with IFG and IGT had normal glucose tolerance at the second test. The expected values of repeated capillary blood glucose measurements were about+/-1 and+/-3 mmol/l for FBG and 2 hBG, respectively. Yet, 70% of high-risk prediabetic individuals were persistently classified with abnormal glucose regulation; diabetes was confirmed in 76% of the cases.     

Incidence of Type 2 diabetes in England and its association with baseline impaired fasting glucose: the Ely study 1990-2000.

AIM: To determine the incidence of Type 2 diabetes and to examine the effect of different cut-points for impaired fasting glucose (IFG) on diabetes incidence. METHODS: Population-based longitudinal study (1990-2000) with clinical, anthropometric and biochemical measurements, including an oral glucose tolerance test (OGTT), in 1040 non-diabetic adults aged 40-69 years at baseline. Baseline glucose status was defined as normoglycaemia < 5.6, IFG-lower 5.6-6.0 and IFG-original 6.1-6.9 mmol/l. The all-IFG group included fasting glucose values of 5.6-6.9 mmol/l. RESULTS: The 10-year cumulative incidence of diabetes was 7.3 per 1000 person-years. Diabetes incidence was 2.4 [95% confidence interval (CI) 1.2, 4.8], 6.2 (4.0, 9.8) and 17.5 (12.5, 24.5) per 1000 person-years in those with normoglycaemia, IFG-lower and IFG-original, respectively. Compared with normoglycaemia, the age/sex-adjusted risk [hazard ratio (HR) and 95% CI] for incident diabetes was greatest in the IFG-original category (HR 6.9; 3.1, 15.2) and increased to a lesser degree in the IFG-lower (HR 2.5; 1.1, 5.7) and all-IFG categories (HR 4.1; 1.9, 8.7). When adjusted for confounding factors, the magnitude and direction of associations persisted, with HR 1.9, 4.4 and 2.9, for the categories IFG-lower, IFG-original and all-IFG, respectively. CONCLUSIONS: Diabetes incidence is more strongly related to IFG defined as fasting glucose between 6.1 and 6.9 mmol/l than to the lower category of 5.6-6.0 mmol/l, or entire range of 5.6-6.9 mmol/l. Future studies should examine the association of IFG with cardiovascular outcomes, but for diabetes risk our study supports the use of the IFG cut-point at 6.1 mmol/l.     

Plasma glucose levels as predictors of diabetes: the Mexico City diabetes study

Aims/hypothesis  The value of diagnostic categories of glucose intolerance for predicting type 2 diabetes is much debated. We therefore sought to estimate relative and population-attributable risk of different definitions based on fasting (impaired fasting glucose [IFG]) or 2 h plasma glucose concentrations (impaired glucose tolerance [IGT]) and to describe the associated clinical phenotypes. Methods  We prospectively observed a population-based cohort of 1,963 non-diabetic participants (mean age 47 years), in whom an OGTT was performed at baseline and 7 years later. Results  IGT was fivefold more prevalent (13.5%) than IFG. In both categories, participants were older, heavier, hyperinsulinaemic, hyperproinsulinaemic and dyslipidaemic compared with participants with normal glucose tolerance. Relative risk of incident diabetes was similar for IFG and IGT categories (3.73 [95% CI: 2.18–6.39] and 4.01 [95% CI: 3.12–5.14], respectively), but the population-attributable risk was fivefold higher for IGT (29% [95% CI: 26–32]) than for IFG (6% [95% CI: 5–7]). Isolated IFG carried no increase in risk. Lowering the threshold to 5.6 mmol/l raised the population-attributable risk of IFG to 23% (95% CI: 20–25); its contribution to diabetes progression, however, was largely due to co-existent IGT. In multivariate analysis adjusting for sex, age, familial diabetes and BMI, fasting and 2 h glucose were independent predictors. Conclusions/interpretation  Fasting and 2 h glucose values are independent predictors of incident diabetes. Isolated IFG is not a high-risk condition; lowering the diagnostic threshold increases the population-attributable risk of IFG fourfold, but performing an OGTT captures additional diabetes progressors compared with the number identified by IFG.     

Diabetes screening after gestational diabetes mellitus: poor performance of fasting plasma glucose

Abstract. Gestational diabetes mellitus (GDM) is an established risk factor for the development of overt diabetes. Since the change in diagnostic criteria for diabetes in 1997, it is unclear whether there should be any preference for fasting or post-glucose challenge blood glucose in diagnosing diabetes after GDM. The study aimed at assessing the usefulness of both diagnostic methods in women after GDM. The study enrolled 193 women with previous GDM. Women who did not have a current diagnosis of diabetes were screened for impaired fasting glucose (IFG) and for glucose intolerance with an oral 75-g glucose tolerance test. A total of 45 (23.3%) subjects declared to be already diabetic. Of the 148 non-diabetic subjects, 141 (95.3%) had normal fasting plasma glucose, whereas four (2.8%) had IFG (i.e. FPG6.1 and <7.0 mmol/l) and 3 (2.5%) had FPG7.0 mmol/l. Upon OGTT, among the 141 subjects with normal FPG, 6 (4.3%) were diagnosed with diabetes and 23 (16.3%) with impaired glucose tolerance (IGT); the remaining 112 (79.5%) had normal glucose tolerance. Three out of four subjects with IFG had IGT. The sensitivities of fasting criteria for diagnosis of diabetes and IFG/IGT were 14.3% (95% CI, 8.0%–37.2%) and 17.1% (95% CI, 8.6%–19.8%), respectively. The specificities were 98.6% (95% CI, 97.9%–99.7%) and 99.1% (95% CI, 96.5%–100%), respectively. The kappa for diabetes diagnosis was 0.177 (95% CI, 0.018–0.507). For women with previous GDM, the sensitivity of the new criteria based upon fasting plasma glucose is unacceptably low. In addition, the two sets of criteria are not interchangeable. Therefore, we suggest full glucose tolerance diagnostic procedures in women after GDM, including assessment of post-glucose challenge values.     

Increasing prevalence of diabetes mellitus in Oman.

AIMS: To determine the prevalence of diabetes mellitus and impaired fasting glucose by age, gender, and by region and compare results with the 1991 survey; and estimate previously undiagnosed diabetes mellitus in the Omani population. METHODS: Cross-sectional survey containing a probability random sample of 5838 Omani adults aged >or= 20 years. Diabetes and impaired fasting glucose (IFG) were assessed by fasting venous plasma glucose using 1999 World Health Organization's diagnostic criteria (normoglycaemia < 6.1 mmol/l, IFG >or= 6.1 but < 7 mmol/l,and diabetes >or= 7 mmol/l). The 1991 survey was reanalysed using the same diagnostic criteria, and results were compared. RESULTS: In 2000, the age-adjusted prevalence of diabetes among Omanis aged 30-64 years reached 16.1% (95% confidence interval (CI) 14.7-17.4) compared with 12.2% (95% CI11.0-13.4) in 1991. IFG was found among 7.1% (95% CI6.2-8.1) of males and 5.1% (95% CI 4.4-6.0) of females. Generally, diabetes was more common in urban then rural regions. Only one-third of diabetic subjects knew that they had diabetes. Nearly half of the study population had a body mass index > 25 kg/m2. CONCLUSIONS: The prevalence of diabetes is high in Oman and has increased over the past decade. The high rate of abnormal fasting glucose together with high rates of overweight and obesity in the population make it likely that diabetes will continue to be a major health problem in Oman. Primary prevention programmes are urgently needed to counteract major risk factors that promote the development of diabetes.     

Undiagnosed diabetes mellitus among patients with prior myocardial infarction

OBJECTIVE: To determine the prevalence of undiagnosed diabetic subjects in a group of long-term myocardial infarction (MI) survivors and to investigate their cardiovascular risk factors and medical care. METHODS: Glucose tolerance (OGTT WHO 1985), cardiovascular risk factors (blood pressure, lipids, urinary albumin), and primary medical care during the previous year were assessed among 244 patients without previously known diabetes (mean age +/- SD: 70.5 +/- 6.9 yrs; 75% males; time since incident infarction: 6.5 years (median), inter-quartile range: 4-9 years) from the population-based MONICA myocardial infarction registry in Augsburg (Germany). RESULTS: Proportion of undiagnosed diabetes among MI registry patients was 29/244, 12% (95%CI: 8-17%); impaired glucose tolerance was found in 27% (22-34%). Using fasting glucose according to ADA 1997 criteria, 11% (7-16%) had diabetes and 17% (12-22%) impaired fasting glucose. MI registry patients with newly detected diabetes (WHO or ADA) showed a more adverse risk factor profile (higher triglycerides, lower HDL-cholesterol, increased urinary albumin) than subjects with normal glucose tolerance after controlling for possible confounders (age, sex, time since MI, antihypertensive and lipid-lowering medication). No significant differences were observed for self-reported medical care during the previous year among diabetic compared to non-diabetic subjects (number of physician visits and basic investigations). CONCLUSIONS: There was a high prevalence of undiagnosed diabetes mellitus among the selected elderly long-term MI survivors. Because mortality rate after MI has been previously shown to be increased in diabetic patients, screening for glucose intolerance appears to be as essential as for standard cardiovascular risk factors.     

Prognostic value of admission glucose in non-diabetic patients with myocardial infarction

Background

Patients with acute myocardial infarction (AMI) who have diabetes have an increased risk of death. In nondiabetic patients, admission glucose levels may be a predictor of survival. However, data regarding admission glucose and long-term outcome in nondiabetic patients treated with reperfusion therapy for AMI are limited.

Methods

We investigated long-term clinical outcome in 356 consecutive nondiabetic patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention or thrombolysis as reperfusion therapy. Mean follow-up time was 8 ± 2 years. The patients were divided on the basis of admission glucose level: group 1, <7.8 mmol/L; group 2, 7.8 to 11.0 mmol/L; and group 3, ≥11.1 mmol/L.

Results

Mortality rate in group 1 (n = 163) was 19.0%; in group 2 (n = 151), 26.5%; and in group 3 (n = 42), 35.7% (P < .05). Higher glucose levels were associated with larger enzymatic infarct sizes (P < .01) and more reduced residual left ventricular function (P < .05). Multivariate analysis showed that Killip class >1 at admission (OR, 2.9; 95% CI, 1.7 to 5.0; P < .001), age ≥60 years (OR, 2.4; 95% CI, 1.5 to 4.0, P = .001), thrombolysis as compared with percutaneous coronary intervention (OR, 1.7; 95% CI, 1.1 to 2.7, P = .02), admission glucose category (OR, 1.4; 95% CI, 1.0 to 1.9, P = .04), and anterior location (OR, 1.6; 95% CI, 1.0 to 2.6, 0.03) were independent predictors of long-term clinical outcome.

Conclusions

Elevated admission glucose levels in nondiabetic patients treated with reperfusion therapy for ST-segment elevation myocardial infarction are independently associated with larger infarct size and higher long-term mortality rates.     

Glucose tolerance of offspring of mother with gestational diabetes mellitus in a low-risk population.

AIMS: To describe the prevalence of impaired glucose tolerance and obesity in offspring of mothers whose pregnancies were complicated by gestational diabetes mellitus (GDM) in a low-risk population and to investigate the effect on these outcomes of minimal intervention compared with tight control for management of GDM. METHODS: Eighty-nine children (mean age 9.1 years, 93% Caucasian) were recruited through a follow-up study of women previously involved in a randomized controlled trial of minimal intervention (control group) vs. tight glycaemic control (treatment group) for GDM. Fasting blood glucose (FBG) and 2-h glucose tolerance tests (2hGTT) were performed on offspring and body mass index (BMI) calculated. Glucose tolerance and BMI of treatment groups were compared using non-inferiority tests (non-inferiority margin -15%). RESULTS: Of those offspring, 6.9% (5/72) had abnormal glucose metabolism [four children had impaired glucose tolerance (IGT) and one had Type 2 diabetes mellitus (DM) (all Caucasian)]. Of the four children with IGT, three were male, three had normal BMI, and three had a family history of Type 2 diabetes. Of the 71 offspring who underwent 2hGTT, 25/25 (100%) of the control offspring and 46/46 (100%) of the treatment offspring had normal FBG (FBG < 5.7 mmol/l). Twenty-five of 25 (100%) of control and 42/46 (91.3%) of the treatment offspring had normal glucose tolerance (2hGTT < 7.8 mmol/l) (% difference 8.7, 95% CI -5.6, 20.3). BMI < 85th percentile was found in 25/33 (75.8%) of the treatment group and 44/52 (84.6%) of the control group (difference in percentage -8.9, 95% CI -27.2, 7.8). CONCLUSIONS: School-age children of mothers with GDM are at risk of IGT and overweight, even if from a low-risk ethnic population. FBG was not adequate for screening this population. Minimal intervention for glycaemic control in GDM pregnancies appears to be as effective as tight control for preventing IGT in childhood but not for preventing obesity.     

Impact of impaired fasting glucose on cardiovascular disease: the Framingham Heart Study.

OBJECTIVES: We sought to determine whether impaired fasting glucose (IFG) predicts cardiovascular disease (CVD) events. BACKGROUND: It is unclear which glucose threshold should define prediabetes. We compared the 1997 and 2003 American Diabetes Association (ADA) definitions of IFG to predict CVD. METHODS: Framingham offspring participants free of CVD, categorized by the 1997 ADA IFG definition (fasting plasma glucose 110 to 125 mg/dl; 6.1 to 6.9 mmol/l) or the 2003 definition (100 to 125 mg/dl; 5.6 to 6.9 mmol/l), were followed from 1983 to 2004. Pooled logistic regression was used to calculate multivariable-adjusted odds ratios (ORs) for incident coronary heart disease (CHD; 291 events) or CVD (423 events). RESULTS: Four-year CHD event rates among women were 1.3% (100 to 109 mg/dl), 2.3% (110 to 125 mg/dl), and 2.9% (diabetes); whereas corresponding rates in men were 2.9%, 3.0%, and 8.7%. For the 2003 IFG definition, the OR for CHD among women was 1.7 (95% confidence interval [CI] 1.0 to 3.0, p = 0.048), whereas for the 1997 IFG definition, the OR for CHD in women was 2.2 (95% CI 1.1 to 4.4, p = 0.02), which was almost as high as for women with diabetes (OR 2.5, 95% CI 1.2 to 5.2, p = 0.01). For CVD, only the 1997 IFG definition yielded significantly greater odds of CVD in women (OR 2.1, 95% CI 1.2 to 3.6, p = 0.01). Men were not at increased odds of developing CVD or CHD by either definition. CONCLUSIONS: In women, both IFG definitions were associated with increased CHD risk, whereas neither IFG definition identified men at increased short-term risk for CHD or CVD. The finding that women with FPG 110 to 125 mg/dl had similar CHD risk compared with women with diabetes suggests that CHD risk in women may be elevated at a lower glucose level than for men.     

Temporal change in glucose tolerance in non-ST-elevation myocardial infarction

We assessed the prevalence and 3-month change in glucose tolerance status in consecutive non-ST-elevation myocardial infarction (NSTEMI; European Society of Cardiology 2007 definition) patients (N=49; mean (S.D.) age 65 (11) years) admitted to a coronary care unit, without known diabetes. These patients underwent an oral glucose tolerance test (OGTT) 36-hour (median, IQR: 18-72) after admission and at 3 months. Undiagnosed abnormal glucose tolerance (AGT: impaired fasting glucose (IFG), impaired glucose tolerance (IGT) or new diabetes) was common (61% at admission and 41% at 3 months, p<0.05) and the majority (approximately 3/4) had IGT. Glucose tolerance status improved in a higher proportion of patients than it worsened (31% vs. 8%, p=0.04). At 3 months, fasting glucose was unchanged but 2-hour OGTT glucose was lower (mean (S.D.): 8.5 (2.7) mmol/L vs. 7.7 (2.7) mmol/L, p=0.004). 'Stress hyperglycaemia' could explain higher admission glucose levels and this raises the question about the optimal timing of OGTT in relation to myocardial infarction. Newly diagnosed diabetes was present in approximately 10% of patients and this was not reliably detected by fasting plasma glucose. In NSTEMI patients OGTT is the only reliable strategy to identify subjects with IGT and diabetes.     

Is fasting glucose sufficient to define diabetes? Epidemiological data from 20 European studies

Aims/hypothesis. The World Health Organisation Consultation recommended new diagnostic criteria for diabetes mellitus including: lowering of the diagnostic fasting plasma glucose to 7.0 mmol/l and introduction of a new category: impaired fasting glycaemia. The diagnostic 2-h glucose concentrations for diabetes and for impaired glucose tolerance were unchanged. This study identifies fasting plasma glucose concentrations predicting a diabetic 2-h plasma glucose of 11.1 mmol/l or more, analyses the sensitivity and specificity of different screening strategies for diabetes and describes the cardiovascular risk profile in people with impaired fasting glycaemia. Methods. European population based studies (n = 17) or large, representative samples of employees (n = 3) with both fasting and 2-h post load glucose concentrations following 75-g oral glucose tolerance tests were included (18 918 men and 10 190 women). The Iceland study (8881 men and 9407 women) is presented separately as a 50-g glucose load was used. Results. The fasting plasma glucose predicting a 2-h plasma glucose of 11.1 mmol/l or more with optimal sensitivity and specificity was a) 5.8 mmol/l in women and 6.4 mmol/l in men; b) independent of age; c) increased with obesity. Fasting plasma glucose of 7.0/7.8 mmol/l or more predicted a diabetic 2-h plasma glucose with sensitivities of 49.0/29.8 % and specificities of 98.2/99.7 %, respectively. Conclusion/interpretation. If fasting glucose is used alone, the 31 % of diabetic subjects with a non-diabetic fasting glucose but a diabetic 2-h glucose, will not be diagnosed; impaired fasting glycaemia and impaired glucose tolerance do not identify the same people; the risk profile of people with impaired fasting glycaemia depends on 2-h glucose concentrations. Obesity is the main confounder in the association between fasting and 2-h glucose. [Diabetologia (1999) 42: 647–654] Received: 18 December 1998 and in revised form: 12 February 1999     

Impaired fasting glucose is not a risk factor for atherosclerosis.

AIM: To determine a new category of dysfunctional glucose homeostasis - impaired fasting glucose (IFG) - introduced by the American Diabetes Association (ADA) and the World Health Organization (WHO) defining those with abnormal but nondiabetic fasting glucose values and with a possible risk for developing diabetes. It is not known whether IFG is a risk factor for atherosclerosis, as is impaired glucose tolerance (IGT). METHODS: In this case-control cross-sectional study in which the oral glucose tolerance (75-g OGTT) and the carotid intima-media thickness (IMT) with B mode ultrasound, as a marker of atherosclerosis, were measured, together with HbA1c, lipids, plasminogen activator (PAI), insulin and proinsulin concentrations in blood plasma. Out of 788 subjects of the risk factors in IGT for Atherosclerosis and Diabetes (RIAD) study we found 104 IFG cases that were compared to 104 controls with fasting plasma glucose (FPG)<6.1 mmol/l, matched for age, sex and body mass index. Subjects with 2h postprandial (pp) plasma glucose > or = 11.1 mmol/l were excluded. The rest were subdivided into those with 2h plasma glucose < 7.8 mmol/l (63 pairs, NGT) and those with plasma glucose > 7.8 mmol/l and < 11.1 mmol/l (41 pairs, IGT). RESULTS: The case and control groups showed no significant differences in the major risk factors except for waist-to-hip ratio (WHR) which was higher in the IFG with NGT. IFG with NGT exhibited significantly higher levels of HbA1c, true insulin and proinsulin. In IFG with IGT, only HbA1c and proinsulin were significantly increased vs. controls. IMT was in the same range for cases and controls in both subgroups. However, IMT mean and IMTmax were significantly increased in IFG with IGT vs. IFG with NGT (0.95 mm vs. 0.80 mm and 1.10 mm vs. 0.90 mm). Cumulative distribution analysis of IMT illustrates that IMT in IFG with IGT is more shifted to higher artery wall thickness than in IFG with NGT. CONCLUSIONS: In our case-control study IFG alone was not related to increased IMT. Only IFG in a combination with IGT exhibited atherosclerotic changes of the carotid arteries. IFG is not analogous to IGT as a risk factor for atherosclerosis.