Newly diagnosed hyperglycemia and stress hyperglycemia in a coronary intensive care unit,☆☆

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Abstract

Aims

To determine prevalence of newly diagnosed hyperglycemia (NDH) among patients with acute coronary disease, inquire relationship of stress hyperglycemia (SH) with functional outcomes.

Methods

Admission (APG) and first morning fasting plasma glucose (FPG) measurements were obtained, capillary glucose measurements (CGM) every 6-h within first day were performed—Group 1: Normoglycemics. Group 2: NDH cases: No known diabetes, APG > 200 mg/dl and/or FPG > 126 and/or any of CGM > 200. Group 2a: unrecognized glycemic disorder, HbA1c > 6.0%. Group 2b: stress hyperglycemia, HbA1c < 6.0%. Group 3: Recognized diabetes. Duration of ICU stays, APACHE-II scores were recorded. Logistic regression analysis was performed using ICU stay as dependent variable and age, groups, co-morbidities, problems in hospital, APACHE-II scores, CGMs were used as independent risk factors.

Results

There were 255 (51.6%) in Group 1, 82 (16.6%) in Group 2; 37 (7.5%) cases in Group 2a, 45 (9.1%) in Group 2b and 157 (31.8%) in Group 3. Group 2b spent longer time in ICU, had higher APACHE-II scores (p = 0.0001, p = 0.0001). Regression analysis demonstrated SH as an independent risk factor for duration of ICU stay (OR: 2.8, 95% CI: 1.3–6.2).

Conclusions

Hyperglycemia was present in 48.4%; 16.6% had NDH, 9.1% had SH. Poor functional conditions of SH cases pointed that they need to be considered carefully.

Introduction

In-hospital hyperglycemia is a common co-morbidity and is closely associated with poor outcomes regardless of diabetes [1], [2]. The probability of stress hyperglycemia makes the diagnosis of diabetes a challenge in hospitals, and the prevalence of diabetes among hospitalized adult patients is supposed to be about 12–25% [3], [4]. In a recent retrospective study, hyperglycemia was detected in 38% of the cases admitting to the hospital, even though one-third had no history of diabetes prior to admission. The latter cases were grouped as those with newly diagnosed hyperglycemia (NDH) [1]. Owing to the retrospective design of that study, it was not possible to discuss whether those NDH cases were the patients with unrecognized diabetes or those with stress hyperglycemia (SH). However, they were observed to be more severely ill than the ones with known diabetes and than the normoglycemics.

Stress hyperglycemia represents a transient increase in blood glucose in reaction to acute illness and is reported to be a non-physiological condition. It is the result of a cascade of hormonal events; increased substrate supply in the form of lactate, increased gluconeogenesis and decreased glycogenolysis [5]. Insulin resistance is also seen in an acutely ill patient and is attributed to cytokine excess in addition to the release and actions of counter-regulatory hormones [6]. Cases with stress hyperglycemia have higher mortality rates and worse functional outcomes than the ones with known diabetes or normoglycemia. It is not clear whether a high blood glucose concentration is independently associated with poor prognosis or it indicates more severe underlying illness with an augmented response to stress [5], [7], [8].

Considering the limitations of currently available large-scale studies, it seems not possible to detect the prevalence of glycemic disorders among hospitalized cases. They are usually meta-analysis or retrospectively designed studies, they include both intensive care unit (ICU) and ward patients, follow-up records are usually not available, inadequate information is presented about the drugs and fluids given during hospitalization, objective scoring systems are not used for determining disease severity, no information is given regarding the therapeutic strategies to treat hyperglycemia and finally HbA1c is usually not measured routinely [1], [2], [9], [10]. Controlled studies with sufficient number of in-hospital cases in convenient clinics should be performed to high-lighten this dilemma. Coronary ICU seems to be the best place to perform such a study. Accordingly, there are trials in the literature demonstrating the negative impact of hyperglycemia on mortality, heart failure and cardiogenic shock among patients with acute myocardial infarction (AMI) regardless of diabetes [2], [10], [11]. Coronary ICU is almost always free of infection, the admitted patients are acutely ill and usually with any disease requiring medications such as glucocorticoids and mannitol solution that may interfere with blood glucose negatively.

The aim of the present study is twofold: (1) to determine the prevalence of newly diagnosed hyperglycemia among cases admitted to coronary ICU with acute coronary artery disease, (2) to search for the cases with stress hyperglycemia and inquire the relationship of SH with disease severity and functional outcomes, such as length of stay in ICU.

Section snippets

Subjects, materials and methods

Patients with acute coronary artery disease; acute coronary syndrome with non-ST segment elevation (ACS) and acute myocardial infarction (AMI), admitted to the coronary ICU of Adana Research Center, Baskent University Faculty of Medicine, through emergency room were recruited consecutively between May 2007 and November 2008. Patients who had non-coronary artery heart diseases and who were admitted through wards, other ICU's or out-patient clinics were excluded. Those who required medications

Results

Total number of admissions to coronary ICU during study period was 2419. Seven hundred and eleven (29.39%) patients had non-coronary cardiac diseases, 377 (15.58%) were admitted through wards or outpatient clinics and/or had accompanying non-cardiac diseases, 639 (26.41%) cases had chronic coronary diseases and were hospitalized for elective coronary artery interventions. Among 692 (28.60%) admissions with the diagnosis of acute coronary artery disease, following applying the exclusion

Discussion

We found that hyperglycemia was present in 48.4% of our patients with acute coronary heart disease; 31.8% had known history of diabetes and 16.6% had newly diagnosed hyperglycemia. These percentages were higher when compared with the study that our power analysis was built on; 26% and 12% respectively [1].

In the literature, among cases with AMI and admission blood glucose below 200 mg/dl, the prevalence of impaired glucose tolerance and diabetes was found to be 40% and 25%, respectively when

Financial disclosure

Nothing to declare.

Conflict of interest statement

There are no conflicts of interest.

Acknowledgements

We cordially thank to Dr. Gulsah Seydaoglu for her contribution about statistical analyses, to diabetes specialist nurse; Selda Celik, and the staff of coronary ICU for their great efforts and collaboration.

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    This study is registered at www.clinicaltrials.gov with the registration # NCT00984737.

    ☆☆

    It was presented as poster at the 45th Annual Meeting of European Association for the Study of Diabetes in Vienna on Oct. 2nd, 2009: M.E. Ertorer, F.E. Haydardedeoglu, T. Erol, I. Anaforoglu, S. Binici, N. B. Tutuncu, A. Sezgin, N.G. Demirag. “Stress hyperglycemia in a Coronary Intensive Care Unit”, Diabetologia 52: 398, Suppl. 1, 2009.

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