Glucose dysregulation in nondiabetic patients with ST-elevation myocardial infarction: acute and chronic glucose dysregulation in STEMI

BACKGROUND: Admission hyperglycaemia is associated with an increased risk of mortality after myocardial infarction.Whether long-term glucose dysregulation (assessed by HbA1c) is more important than acute hyperglycaemia is unknown. We evaluated the prognostic value of admission glucose and HbA1c levels in nondiabetic patients with ST-segment elevation acute myocardial infarction (STEMI). METHODS: In 504 unselected, consecutive patients with STEMI, glucose and HbA1c levels were measured on admission. Glucose was categorised as <11.1 mmol/l (n=422) and >or= 11.1 mmol/l (n=82). HbA1c levels were categorised as <6.0% (n=416) and >or=6.0% (n=88). Mean follow-up was 1.6+/-0.6 years. RESULTS: Patients with hyperglycaemia on admission were comparable with those with normoglycaemia. However,patients with HbA1c >or=6.0%, as compared with those with HbA1c <6%, were older, were more often on beta-blockers and more frequently had multivessel disease. Thirty-day mortality in the subsequent glucose categories (<11.1 mmol/l and >or=11.1 mmol/l) was 4% and 19% (p<0.001) and in the subsequent HbA1c categories (<6% and >or=6%) was 5% and 12% (p=0.03).After multivariable analyses, admission glucose (OR 4.91,95% CI 2.03 to 11.9, p< 0.001) but not HbA1c (OR 1.33, 95%CI 0.48 to 3.71, p=0.58) was significantly associated with 30-day mortality. Among 30-day survivors, neither admission glucose nor HbA1c were predictors of long-term mortality. CONCLUSION: Elevated admission glucose is an important predictor of 30-day outcome after STEMI, while prior long-term glucose dysregulation is a covariate of other high-risk clinical characteristics. Among 30-day survivors, neither admission blood glucose nor HbA1c were predictors of long-term outcome.     

Long-term, cause-specific mortality after myocardial infarction in diabetes.

AIMS: To compare long-term, cause-specific mortality after reperfusion therapy for ST segment elevation myocardial infarction (STEMI) in patients with and without diabetes. METHODS AND RESULTS: Patients with STEMI (n = 395) were randomised to intravenous streptokinase (SK) or primary percutaneous coronary intervention (PCI). Median follow-up was 7.5 years (interquartile range 5.6-8.5). A total of 74 patients (19%) had diabetes. Reduced left ventricular ejection fraction (<40%) after STEMI was more often observed in patients with diabetes (27% vs. 15%, P = 0.02). Patients with diabetes had a higher total mortality compared to patients without diabetes (HR 2.4; P < 0.001). Multivariate analysis confirmed that diabetes was an independent risk factor for long-term mortality (HR 2.3; P < 0.001). The incidence of sudden death was comparable in both patient groups (HR 1.6; P = 0.23). The increased mortality in patients with diabetes was mainly caused by heart failure (HR 3.1; P = 0.004). In patients with diabetes, primary PCI was associated with an improved prognosis. CONCLUSIONS: Despite reperfusion therapy, STEMI patients with diabetes have an increased long-term mortality. This is due to death by heart failure and not by an increase in sudden death. Primary PCI is associated with an improved prognosis, particularly in patients with diabetes.     

Relationship between blood glucose on admission and prognosis in patients with acute myocardial infarction treated with percutaneous coronary intervention

BACKGROUND: Diabetes mellitus in patients with myocardial infarction affects in-hospital and late mortality. It has been shown that the glucose level on admission can also affect prognosis. This conclusion was based on an analysis performed on a heterogeneous group of patients, treated not only with percutaneous coronary intervention (PCI) but also with fibrinolysis. Moreover, the threshold values hyperglycaemia for the diagnosis of were also variable. AIM: To assess whether glucose level on admission affects in-hospital and one-year prognosis in patients with ST-segment elevation myocardial infarction (STEMI) treated with PCI. METHODS: Consecutive patients with STEMI treated with PCI were included in the analysis. Patients with STEMI complicated by cardiogenic shock were also included. Three groups according to the glucose level on admission were analysed: group I - <7.8 mmol/l (140 mg/dl), group II - 7.8-11.1 mmol/l (140-200 mg/dl), and group III - > or = 11.1 mmol/l (200 mg/dl). RESULTS: The incidence of diabetes mellitus in the total group (1027 patients) was 26.1%, and of cardiogenic shock - 9.2%. Group I consisted of 472 patients, group II - 307 patients, and group III - 248 patients. Compared with normoglycaemic patients, those with elevated glucose level were older, more often female, had more often hypertension, diabetes mellitus, cardiogenic shock, were more often treated with fibrinolysis before PCI but were less often smokers. Multivessel disease and initial patency of the infarct-related artery (TIMI 0-1) were more often observed in patients with higher glucose level. A trend towards a higher incidence of reocclusion was also more often present in patients with increased glucose level. Moreover, mean creatine kinase concentration was the highest and the left ventricular ejection fraction was the lowest in group III. During the in-hospital stay, the complication rate was as follows: stroke (1.1% vs. 1.3% vs. 4.4%), and mortality (2.8 vs. 4.9 vs. 13.3%) in groups I, II, and III, respectively. The same tendency was observed during the one-year follow-up period: stroke (1.3 vs. 2.9 vs. 6.9%), mortality (6.4 vs. 9.1 vs. 22.6%). The 1 mmol/l (18 mg/dl) increase of the baseline glucose level among various risk factors was an independent prognostic factor of higher -year mortality (HR=1.06; 95% CI 1.02-1.09). Diabetes mellitus did not affect prognosis among patients included in the analysis. CONCLUSION: Elevated glucose level on admission is associated with adverse prognosis in patients with STEMI treated with PCI.     

入院血糖水平对ST抬高急性心肌梗死预后的影响

目的 探讨入院时血糖水平对ST段抬高急性心肌梗死(STEMI)患者30 d死亡和主要心血管不良事件(MACE)发生率的预测价值.方法 对7446例12 h内STEMI患者以入院时不旧的血糖水平和有否糖尿病史分成4组(高血糖定为入院血糖>10 mmol/L),Ⅰ组:无糖尿病史且血糖正常组(对照组);Ⅱ组:有糖尿病史但血糖正常组;Ⅲ组:无糖尿病史但高血糖组;Ⅳ组:有糖尿病史且高血糖组.结果 入院高血糖两组患者30 d病死率和MACE的发生率明显高于对照组(病死率Ⅰ组8.6%比Ⅲ组17.1%、组Ⅳ18.6%;MACE Ⅰ组21.6%比Ⅲ组36.3%、Ⅳ组38.8%;P值均<0.001).Ⅱ组与对照组相比,30 d病死率没有明显增加(11.6%比8.6%,P=0.096).多因素回归分析显示Ⅲ、Ⅳ组的死亡危险分别为Ⅰ组患者的1.51倍(P<0.001)和1.83倍(P<0.1301);入院血糖水平是30 d死亡的独立危险因素,血糖水平每升高1 mmol/L,病死率增加5%(OR 1.05,95%CI1.04～1.07,P<0.001),而糖尿病史对30 d病死率不具有独立预测价值(OR 1.11,95%CI 0.87～1.42,P=0.412).结论 入院高血糖STEMI患者30 d病死率和MACE的发生率显著高于入院血糖正常者,入院高血糖为近期预后不良的独立危险因素,糖尿病史与近期病死率并无明显相关性.     

应激性高血糖对急性ST段抬高型心肌梗死患者远期预后的影响

目的探讨急性sT段抬高型心肌梗死（STEMI）患者发生应激性高血糖的相关危险因素,并评估应激性高血糖对STEMI患者远期预后的影响。方法白求恩国际和平医院2009年8月至2010年4月92例初次发生STEMI的非糖尿病住院患者,根据入院后测定的空腹血糖或随机血糖分A组（应激性高血糖组）41例和B组（血糖正常组）51例。平均随访1．5年。结果应激性高血糖的发生率是44．6％（41／92）。A和B组间经logistic回归分析提示女性（OR=8．952,P=0．013）、心功Killip分级越高（OR=3．530,P=0．048）、肌酸激酶同工酶（CK．MB）峰值越高（OR=9．408,P〈0．001）均是应激性高血糖发生的相关危险因素。Cox回归对A和B组患者1～2年内发生的死亡风险进行分析,提示应激性高血糖是远期死亡（RR1．532,95％CI1．004--2．337,P=0．048）的独立预测因子。高甘油三酯血症患者远期死亡风险是正常者1．557倍（P=0．041）。结论女性、Killip分级、CK．MB增高是应激性高血糖发生的相关危险因素。应激性高血糖可能是STEMI患者远期预后不良的独立预测因子和危险因素。高甘油三酯血症可能加重患者的死亡风险。     

急性心肌梗死合并心原性休克死亡危险因素分析

目的 探讨ST段抬高的急性心肌梗死合并心原性休克(cardiogenic shock,CS)患者的近期预后和影响病死率的独立危险因素,为CS患者的死亡风险评估提供参考.方法 采用国际多中心CREATE研究的中国ST段抬高急性心肌梗死患者517例资料,平均年龄(68.5±10.3)岁,男性患者占57.6%.用单变量和多变量logistic回归分析合并CS患者的基线特征因素和治疗因素与30 d病死率的相关性.结果 517例CS患者30 d的病死率为62.3%(322例).将全部变量进行多因素logistic回归分析显示年龄(OR=1.46,95%GI:1.18～1.81)、前壁梗死(OR=2.01,95%CI:1.29～3.11)、入院基线血糖＞7.8 mmol/L(OR=2.17,95%CI:1.26～3.73)、血钠＜130 mmoL/L(OR=2.21,95%CI:1.21～4.04)、左心室射血分数(LVEF)＜40%或重度左心功能障碍(LVD)(OR=3.78,95%CI:2.28～6.27)、未紧急血运重建(OR=3.53,95%CI:1.20～10.41)和使用利尿剂(OR=1.90,95%CI:1.21～2.97)是30 d病死率增加的独立危险因素.仅包含基线特征变量的logistic回归分析显示,上述前5项基线变量是死亡的独立基线危险因素.受试者工作特征曲线(ROC)分析两个回归模型均有较高的判别死亡高危患者的能力,ROC下面积分别为0.81(95%CI:0.77～0.86)和0.80(95%CI:0.75～0.84).结论 STEMI并发CS的患者30 d病死率超过60%,年龄等基线因素和未紧急血运重建等治疗因素是影响30 d病死率的独立危险因素.     

Relationship of admission hematological indexes with myocardial reperfusion abnormalities in acute ST segment elevation myocardial infarction patients treated with primary percutaneous coronary interventions

BACKGROUND:

Elevated values of mean platelet volume (MPV) and elevated white blood cell (WBC) count are predictors of an unfavourable outcome among survivors of ST segment elevation myocardial infarction (STEMI). However, their relationship with reperfusion abnormalities is less clear.

OBJECTIVE:

To evaluate the value of admission MPV and WBC count in predicting impaired reperfusion in patients with acute STEMI who are treated with primary percutaneous coronary intervention (PCI).

METHODS:

Blood samples were obtained on admission from 368 STEMI patients who underwent successful PCI. According to the 60th minute ST segment resolution ratio, patients were divided into impaired reperfusion and reperfusion groups.

RESULTS:

Impaired reperfusion was detected in 40% of study patients. Patients in the impaired reperfusion group had a higher admission MPV (9.8±1.3 fL versus 8.6±1.0 fL; P<0.001) and a higher WBC count (14.4±5.5×10⁹/L versus 12.1±3.8×10⁹/L; P<0.001) compared with the patients in the reperfusion group. In regression analysis, MPV (OR 2.21, 95% CI 1.69 to 2.91; P<0.001) and WBC count (OR 1.08, 95% CI 1.02 to 1.15; P=0.01) were found to be independently associated with impaired reperfusion. The best cut-off value of MPV for predicting impaired reperfusion was determined to be 9.05 fL, with a sensitivity of 74% and a specificity of 73%.

CONCLUSIONS:

The results indicate that leukocytes and platelets have a role in the mediation of reperfusion injury. In patients with STEMI who are undergoing PCI, admission MPV may be valuable in discriminating a higher-risk patient subgroup and thus, may help in deciding the need for adjunctive therapy to improve the outcome.     

Hyperglycaemia and mortality of diabetic patients with candidaemia.

AIMS: To determine whether the degree of hyperglycaemia has an impact on in-hospital mortality in diabetic patients with candidaemia. METHODS: A retrospective cohort study of 87 diabetic patients with candidaemia admitted between June 1995 and June 2003 was carried out at two medical centres. Patients were stratified into two groups: those with moderate hyperglycaemia (7 days post-candidaemia mean blood glucose < 13.9 mmol/l) and those with severe hyperglycaemia (7 days post-candidaemia mean blood glucose > or = 13.9 mmol/l). A stepwise logistic regression analysis was performed to determine whether the degree of hyperglycaemia was a significant predictor of mortality. RESULTS: During the follow-up period from admission till discharge, 34 (39.1%) patients had died. Nine (69.2%) of 13 patients with severe hyperglycaemia have died while 25 (33.8%) of 74 patients with moderate hyperglycaemia have died. Multivariate analysis identified three independent determinants of death; Apache II score > or = 23 [OR 8.1, 95% CI (2.6, 25.3), P = 0.0003], mean blood glucose levels 7 days post-candidaemia > or = 13.9 mmol/l [OR 6.8, 95% CI (1.2, 38.2), P = 0.03], and mechanical ventilation [OR 6.5, 95% CI (2.21), P = 0.03]. CONCLUSION: Severe hyperglycaemia is an important marker of increased mortality among hospitalized diabetic patients with candidaemia.     

Glucose as a risk predictor in acute medical emergency admissions

Aims

The aims of this study were to examine the relationship between admission blood glucose and mortality in a large, unselected cohort of acutely ill medical patients and to assess the impact of diabetes on this relationship.

Methods

We studied the broad pattern of acute medical admissions over an eight year period and the impact of admission serum glucose on in-hospital mortality. Significant predictors of outcome, including acute illness severity and co-morbidity, were entered into a multivariate regression model, adjusting the univariate estimates of the glycaemic status on mortality.

Results

There were 45,068 consecutive acute medical emergency admissions between 2005 and 2012. The normoglycaemic (>4.0 ≤7.0 mmol/l) cohort (86%) had a 3.9% in-hospital mortality. Both hypoglycaemia (OR: 3.23: 95% CI: 2.59–4.04; p < 0.001) and hyperglycaemia (OR: 2.1; 95% CI: 1.9–2.4; p < 0.001) predicted an increased risk of an in-hospital death. Neither of these increased risks were fully adjusted nor explained by a highly predictive outcome model, using multiple acute illness parameters. Hyperglycaemia did not carry similar adverse prognostic implications for patients with diabetes.

Conclusion

In patients without diabetes, an abnormal serum glucose is independently predictive of an increased mortality among the broad cohort of acute emergency medical patients. Similar disturbances of glucose homeostasis for patients with diabetes do not confer equivalent adverse prognostic implications.     

Association of C-reactive protein and myocardial perfusion in patients with ST-elevation acute myocardial infarction

This study sought to evaluate the relation between C-reactive protein (CRP) on admission of patients with acute myocardial infarction (AMI) and myocardial perfusion as defined by postintervention angiographic myocardial blush grade (MBG) and their impact on subsequent mortality. The patient population comprised 191 consecutive patients with AMI undergoing PTCA within 12h of symptom onset on a native vessel. Patients were divided based on the CRP level on admission (Rolf Greiner BioChemica, Germany, cutpoint for the assay CRP: 5mg/l) into a group with elevated CRP (>or=5mg/l) and a group with normal CRP. Angiographic myocardial blush grade (MBG) after revascularization of the infarct-related artery was determined to evaluate myocardial reperfusion. Revascularization of the infarct-related artery was successful in 176 (92.6%) patients. The frequency of impaired perfusion (MBG 0-2) was higher in the elevated CRP group than in the normal CRP group (74.5% versus 59.7%, respectively, p=0.046). Elevated CRP on admission was an independent predictor of impaired myocardial perfusion (MBG 0-2, OR 1.92, 95% CI 1.02-4.01, p=0.042) in addition to age >70 years. Elevated CRP (OR 2.64, 95% CI 1.26-5.53, p=0.009) and MBG 0-2 (OR 4.58; 95% 1.73-12.20, p=0.002) were independent predictors of mortality during a 22.4+/-15.3 months follow-up in addition to heart rate on admission >100 beats/min (OR 3.07; 95% CI 1.30-7.25, p=0.009). In sequential Cox models, the predictive power of clinical data and MBG for mortality (model chi-squared 18.3) was strengthened by the inclusion of CRP levels (model chi-squared 24.3). In conclusion, there is a relation between elevated admission CRP and impaired reperfusion in the myocardium subtended to the infarct-related artery. The combination of clinical data, myocardial reperfusion levels after primary angioplasty for AMI and admission CRP increases the predictive value for subsequent survival.     

Association of Epicardial and Tissue-Level Reperfusion with Left Ventricular End-Diastolic Pressures in ST-Elevation Myocardial Infarction

Unfavorable hemodynamics among patients with ST-elevation myocardial infarction (STEMI) have been associated with adverse clinical outcomes and may be linked to a failure to achieve complete reperfusion. We hypothesized that impaired epicardial and tissue-level perfusion after fibrinolytic therapy would be associated with adverse hemodynamics. The relationship between left ventricular end-diastolic pressure (LVEDP), baseline clinical characteristics, and angiographic findings were examined in 666 patients with STEMI treated with fibrinolytic therapy from the TIMI 14, INTEGRITI (TIMI 20), ENTIRE (TIMI 23), and FASTER (TIMI 24) trials. LVEDP was analyzed as a dichotomous variable with an elevated LVEDP defined as LVEDP >18 mmHg (median value). Higher post-fibrinolytic LVEDP was associated with age > or = 65, female gender, Killip Class II-IV on presentation, and LAD culprit location. Elevated LVEDP was associated with both a closed infarct-related artery (58.8% of TIMI Flow Grade (TFG) 0/1 with elevated LVEDP vs. 46.6% of TFG 2/3, p = 0.03) and impaired myocardial perfusion (55.7% of TIMI Myocardial Perfusion Grade (TMPG) 0/1 with elevated LVEDP vs. 43.8% of TMPG 2/3, p = 0.02). In a multivariate analysis, impaired myocardial perfusion (OR 1.7, p = 0.02), abnormal Killip Class (OR 4.8, p = 0.001), age > or = 65 (OR 1.6, p = 0.04), and female gender (OR 1.9, p = 0.01) were independently associated with elevated LVEDP. Elevated LVEDP was independently associated with a greater incidence of in-hospital (OR 11.8, p = 0.02) and 30-day congestive heart failure (OR 4.4, p = 0.02). In STEMI, angiographic indices of incomplete reperfusion are associated with an elevated LVEDP, and elevated LVEDP is associated with adverse clinical outcomes.     

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.     

Admission glycemia: a predictor of death after acute coronary syndrome in non-diabetic patients?

BACKGROUND: Previous studies have demonstrated that acute phase hyperglycemia is associated with increased in-hospital mortality in diabetic patients admitted with acute coronary syndrome (ACS), but this has not been clearly demonstrated in non-diabetic patients. The present study was designed to determine whether admission hyperglycemia (AG) is an independent predictor of in-hospital and six-month mortality after ACS in non-diabetic patients. METHODS: This was a retrospective cohort study of 426 non-diabetic patients consecutively admitted with ACS. The patients were stratified into quartile groups according to AG, which was also analyzed as a continuous variable. Vital status was obtained at six-month follow-up in 96.8% of the patients surviving hospitalization. Logistic regression analysis was used to identify independent predictors of in-hospital and six-month death. RESULTS: Of the 426 patients included in the study (age 62.6 years+/-13.1, 77% male), 22 (5.4%) patients died during hospitalization and 20 (5.2% of the patients surviving hospitalization) within six months of ACS. Mean AG was 134.89 mg/dl+/-51.95. The higher the AG, the more probable was presentation with ST-segment elevation ACS (STEMI), anterior STEMI, higher heart rate, Killip class higher than one (KK >1), higher serum creatinine and greater risk of in-hospital and six-month death. In multivariate analysis, only age (OR=1.10; 95% CI 1.04-1.17), STEMI (OR=3.02; 95% CI 1.07-8.50), AG (OR=1.073; 95% CI 1.004-1.146), serum creatinine (OR=1.10; 95% CI 1.009-1.204) and KK >1 on admission (OR=4.65; 95% CI 1.59-13.52) were independently associated with in-hospital death. Age (OR=1.07; 95% CI 1.03-1.12), serum creatinine (OR=1.09; 95% CI 1.01-1.18) and in-hospital development of heart failure (OR=2.34; 95% CI 1.07-5.10) were independently associated with higher risk of death within six months of ACS. CONCLUSIONS: AG is an independent predictive factor of in-hospital death after ACS in non-diabetic patients. Although it did not show an independent association with higher risk of six-month death, AG appears to contribute to it, since the risk is greater the higher the AG. Its predictive value may have been blunted by the insufficient power of the sample and/or by the time interval between acquisition of AG and the evaluated endpoint.     

Elevated random glucose levels at admission are associated with all-cause mortality and cardiogenic shock during hospitalisation in patients with acute myocardial infarction and without diabetes: A retrospective cohort study

Background

Elevated glucose levels at admission are associated with a worse prognosis in patients with acute myocardial infarction (AMI); additionally, such elevation has a higher prognostic value for patients without diabetes.

Methods

We retrospectively recruited 2412 AMI patients without diabetes from 1 August 2011 to 10 January 2022. The primary outcome was all-cause mortality during hospitalisation, and the secondary outcomes were cardiogenic shock, ventricular tachycardia, ventricular fibrillation, atrioventricular block and new stroke.

Results

The mean age of participants was 65 years and 78.6% were male. Of the 2412 patients, all-cause mortality occurred in 236 patients (9.8%) during hospitalisation. In multivariate-adjusted models that corrected for variable weights, the risk of all-cause mortality increased with an increase in random glucose levels at admission; specifically, the risk of all-cause mortality increased per 1 mg/dL (odds ratio [OR] 1.006, 95% confidence interval [CI]: 1.004–1.008), per 9 mg/dL (OR: 1.06, 95% CI: 1.04–1.08), and per 18 mg/dL (OR: 1.12, 95% CI: 1.07–1.16) increases in admission glucose levels. When admission glucose levels were expressed as a categorical variable, increased levels of glucose (relative to the reference glucose value <140 mg/dL) led to an increased risk of all-cause mortality; specifically, the OR of all-cause mortality for 140–200 mg/dL glucose was 1.55 (95% CI: 1.09–2.17) and the OR for glucose >200 mg/dL was 3.08 (95% CI: 2.00–4.62) (P for trend <0.001). The risk of cardiogenic shock also increased with glucose levels with an OR of 1.68 (95% CI: 1.21–2.31) for 140–200 mg/dL glucose and an OR of 3.72 (95% CI: 2.50–5.46) for >200 mg/dL, compared with that of glucose <140 mg/dL. In multivariate-adjusted spline regression models, an increased risk of all-cause mortality was observed in patients with glucose ≥122 mg/dL (OR: 1.81, 95% CI: 1.38–2.38, p < 0.001) compared with the reference cohort. Furthermore, patients with glucose ≥111 mg/dL (OR: 2.36, 95% CI: 1.80–3.12) had a higher risk of cardiogenic shock than patients with glucose <111 mg/dL.

Conclusions

Patients with AMI and without diabetes who had elevated random glucose levels at admission had a higher risk of all-cause mortality and cardiogenic shock during hospitalisation. In particular, patients with glucose ≥122 mg/dL had an increased risk of all-cause mortality, and those with glucose ≥111 mg/dL had an increased risk of cardiogenic shock.     

Admission glycemia and markers of inflammation are independent outcome predictors in primary PCI in non-diabetic patients

AIM: To assess the prognostic value of admission plasma glucose (APG) respect to clinical variables and inflammatory markers in a selected population of non-diabetic patients with ST elevation myocardial infarction (STEMI) treated with primary angioplasty (primary coronary intervention, PCI). METHODS: A total of 188 consecutive non-diabetic STEMI patients undergoing primary PCI were divided into four quartiles based on APG (<117, 117-140, 141-170, >170 mg/dL). Combined end-point of major adverse cardiac events (MACE) was defined as death, acute heart failure, re-infarction, unstable angina or inducible ischemia. RESULTS: Event-free survival from MACE was significantly (P<0.001) correlated with APG quartiles and decrease from the lowest to the highest: 6 months event-free survival was 89.3%, 77.4%, 59.1%, 42.5%. Patients with higher APG were characterized by a significantly higher Killip class (P<0.001), higher serum creatinine (P<0.05) on admission, and a lower rate of thrombolysis in myocardial infarction (TIMI) 3 flow after PCI (P<0.05). Multivariate analysis showed APG>170 mg/dL (hazard ratio [HR] 2.39, 95% confidence interval [CI] 1.24 to 4.65, P<0.01), admission high-sensitivity C-reactive protein level (HR 1.19, 95% CI 1.07 to 1.31, P<0.001), white blood cells count (HR 1.07, 95% CI 1.00 to 1.14, P<0.04) and heart rate (HR 1.02, 95% CI 1.00 to 1.04, P<0.02) to be independent predictors of MACE. CONCLUSION: Admission glycemia and inflammatory markers are independent predictors of MACE in the mid-term follow-up in non-diabetic STEMI treated with primary PCI. Further investigations are needed to study the pathogenesis of stress hyperglycaemia, interactions with mechanisms of inflammation and whether early and aggressive treatment with insulin may influence outcome of primary PCI.     

影响ST段抬高心肌梗死患者再灌注决定延迟的因素

目的 调相急性ST段抬高心肌梗死(STEMI)患者的再灌注决定延迟程度并分析其影响因素.方法 本研究为多中心现况调查.入选2006年1月1日至12月31日期间就诊于北京市19所医院并接受心肌再灌注治疗的635例急性STEMI患者.入院1周内,通过与患者进行结构式访谈及查阅病例记录收集资料.再灌注决定延迟定义为院内完成首份心电图至患者或家属签署治疗同意书的时间间隔.根据再灌注决定延迟时间分为早决定组(≤30 min)和晚决定组(＞30 min),采用单凶素和多因素分析识别影响再灌注决定延迟的相关凶素.结果 接受溶栓者129例(20.3%),接受直接PCI者506例(79.7%).中位再灌注决定延迟时间为47 min,中位进门-溶栓时间为82 min,中位进门-球囊扩张时间为135 min.多元logistic回归分析显示,了解再灌注治疗(OR=1.723,95%CI:1.156～3.212,P=0.040)、有院前心电图(OR=1.566,95% CI:1.018～2.409,P=0.036)、入院时心功能Killip分级≥2(OR=1.579,95% CI:1.004～2.483,P=0.021)以及就诊于心血管专科医院(OR=5.075,95%CI:1.380～18.655,P=0.014)是再灌注决定延迟≤30 min的独立预测因素.早决定组的中位进门-溶栓时间(47 min比103 min,P＜0.001)和中位进门-球囊扩张时间(100 min比154min,P＜0.001)明显短于晚决定组.结论 STEMI的再灌注决定延迟时间偏长,是院内延迟的主要部分.普及再灌注治疗知识以及通过救护车转运增加院前心电图完成率可能缩短院内延迟.     

Mean platelet volume on admission predicts impaired reperfusion and long-term mortality in acute myocardial infarction treated with primary percutaneous coronary intervention

OBJECTIVES: We sought to determine the prognostic value of mean platelet volume (MPV) for angiographic reperfusion and six-month mortality in patients with acute ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). BACKGROUND: Mean platelet volume is predictive of unfavorable outcome among survivors of STEMI when measured after the index event. No data are available for the value of admission MPV in patients with STEMI treated with primary PCI. METHODS: Blood samples for MPV estimation, obtained on admission in 398 consecutive patients presenting with STEMI, were measured before primary PCI. Follow-up up to six months was performed. RESULTS: No-reflow was significantly more frequent in patients with high MPV (> or =10.3 fl) compared with those with low MPV (<10.3 fl) (21.2% vs. 5.5%, p < 0.0001). The MPV was correlated strongly with corrected Thrombolysis In Myocardial Infarction frame count (CTFC) (r = 0.698, p < 0.0001). Kaplan-Meier survival analysis showed six-month mortality rate of 12.1% in patients with high MPV versus 5.1% in low MPV group (log rank = 6.235, p = 0.0125). After adjusting for baseline characteristics, high MPV remained a strong independent predictor of no-reflow (odds ratio [OR] 4.7, 95% confidence interval [CI] 2.3 to 9.9, p < 0.0001), CTFC > or =40 (OR 10.1, 95% CI 5.7 to 18.1, p < 0.0001), and mortality (OR 3.2, 95% CI 1.1 to 9.3, p = 0.0084). Abciximab administration resulted in significant mortality reduction only in patients with high MPV values (OR 0.02, 95% CI 0.01 to 0.48, p = 0.0165). CONCLUSIONS: Mean platelet volume is a strong, independent predictor of impaired angiographic reperfusion and six-month mortality in STEMI treated with primary PCI. Apart from prognostic value, admission MPV may also carry further practical, therapeutic implications.     

Determinants of in-hospital death in left main coronary artery myocardial infarction complicated by cardiogenic shock

BACKGROUND: Acute myocardial infarction (AMI) due to left main coronary artery disease is associated with significantly elevated morbidity and mortality. The aim of this study was to identify the predictors of in-hospital death from left main AMI complicated by cardiogenic shock. METHODS: Clinical record review identified a total of 25 cases of left main AMI with cardiogenic shock. Patients' background characteristics, laboratory data, and angiographic findings were analyzed according to the in-hospital mortality. RESULTS: In this patient subset, in-hospital mortality (60%) was associated with a history of hypertension (p=0.02) and a higher heart rate (p=0.02). Furthermore, in-hospital mortality was also associated with a complete right bundle branch block (CRBBB) pattern in the admission ECG (p=0.01) and low HCO(3)(-) (p=0.0004). In stepwise logistic regression analysis, a CRBBB pattern (OR 48.59, 95% CI 1.34-1768.10, p=0.03) and low HCO(3)(-) (OR 0.62, 95% CI 0.40-0.94, p=0.02) were found to be independent predictors of mortality. CONCLUSIONS: Left main AMI with cardiogenic shock was associated with high in-hospital mortality. A CRBBB pattern in the ECG on admission and a low HCO(3)(-) concentration were significant independent predictors of in-hospital death.     

入院24 h平均血糖对急性ST段抬高型心肌梗死患者近期预后的影响

目的 探讨人院24 h平均血糖(mean blood glucose,MBG)与急性ST段抬高型心肌梗死(STEMI)患者近期病死率及不良心血管事件的相关性.比较MBG与入院血糖(admission glucose,AG)对顶后影响的顶测价值.方法 人选病例来自2001至2004年间我国274家中心参加CREATE(Clinical trial of reviparin and metabolic modulation in acute myocardial infarction treatment evaluation)研究数据库、症状出现12 h内STEMI的中国患者7446例,将入院即刻、6 h、24 h血糖值计箅均值,以入院第1个24 h的MBG水平分成6组,即MBG＜4.5 mmol/L组、4.5～5.5 mmol/L组、5.6～7.0 mmol/L组、7.1～8.5 mmol/L组、8.6～11.0 mmol/L组和MBG＞11.0 mmol/L组.以MBG 4.5～5.5 mmol/L组作为对照组,其他血糖水平组与之进行比较.分析7 d和30 d病死率及联合终点事件发生情况.比较MBG与AG对上述事件预测价值的影响.结果 单因素分析显示,7 d、30 d病死率、联合终点事件发生率随着MBG水平升高而逐渐升高.MBG 7.1～8.5 mmol/L及以上组与MBG 4.5～5.5 mmol/L组的患者比较,差异均有统计学意义.多因素logistic回归分析显示MBG 7.1～8.5 mmol/L及以上各组是STEMI患者7 d、30 d病死率、联合终点事件的独立危险因素.MBG 7.1～8.5 mmol/L、8.6～11.0 mmol/L和＞11.0 mmol/L的患者7 d死亡危险分别比对照组患者增加56%(P=0.022)、61%(P=0.018)和230%(P＜0.001),30 d死亡危险分别比对照组患者增加41%(P=0.048)、40%(P=0.032)和185%(P＜0.001).MBG＜4.5 mmol/L组30 d联合终点事件发生危险无明显增加(P=0.085).应用Nested模型对AG及24 h MBG对病死率以及联合终点事件预测模型比较显示,24 hMBG较AG预测价值更大(均P＜0.001).结论 24 h MBG≥7.1 mmol/L与STEMI患者7 d、30 d病死率增高相关.24 h MBG较AG对预后具有更好的预测价值.     

平均空腹血糖对ST段抬高型心肌梗死患者住院预后的影响

目的 评价平均空腹血糖对ST段抬高型心肌梗死(STEMI)患者住院顶后的影响.方法 对357例发病3 d内入院的无糖尿病史的STEMI患者进行回顾性分析,依据入院后72 h内平均空腹血糖水平分为＜5.6、5.6～7.0和＞7.0 mmol/L 三组.比较其临床特征、住院治疗经过和主要心脏事件及死亡的发生率,通过受试者工作特征(ROC)曲线评估平均空腹血糖对住院死亡的预测价值.结果 平均空腹血糖＜5.6、5.6～7.0和＞7.0 mmol/L的三组患者分别为165、122和70例,其广泛前壁心肌梗死的比例分别占18.2%、29.5%和45.7%(P＜0.05.各组患者在年龄、既往梗死史及溶栓或经皮冠状动脉介入治疗等差异无统计学意义(P＞0.05).入院时心率、白细胞计数、CK-MB峰值随着平均空腹血糖升高而增加(P＜0.05).随着血糖升高,左心室射血分数降低,心力衰竭、恶性心律失常发生率及住院病死率明显增加(P＜0.05).多因素分析显示入院72 h内平均空腹血糖是住院病死率的独立危险因素(OR=1.31,95%CI:1.10～1.57;P=0.003),其顶测住院死亡ROC曲线下面积为0.758(P＜0.001),而单次入院随机血糖、空腹血糖预测住院死亡的ROC曲线下面积分别为0.674和0.717.结论 入院72 h内平均空腹血糖是STEMI住院患者死亡的独立危险因素,其预测价值高于单次的入院随机血糖或空腹血糖.