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ESC Congress 2004: Glucose Abnormalities in patients with Myocardial Infarction
August 31, 2004This trial reveals important new information on the relation between reduced ability to handle glucose (sugar) and acute heart attacks.
1. About two thirds of people with heart attacks but without any known diabetes or other disturbance in there ability to handle glucose had such pertubations when tested.
2. It is possible to identify patients with disturbed glucose tolerance already few days after heart attacks.
3. Newly detected disturbed glucose tolerance was linked to a high risk for death or new heart attacks during the nearest 2-3 years.
The study may open new possibilities to treat patients with heart attacks in order to prevent such dismal outcome, some of which are already available, however, not used to their full extent.
It is recommended that glucose tolerance is tested in all patients with heart attacks before hopsital discharge. This should be done by means of an oral glucose load (see below), an inexpensive and easily performed investigation.
Trial design an outcome
The GAMI study investigated 1) whether abnormal glucose metabolism defined as newly detected diabetes mellitus or impaired glucose tolerance, is more frequent in patients with heart attacks (acute myocardial infarction) without previous diabetes than in healthy controls from the same population; 2) whether abnormal glucose metabolism can be identified early after a MI; 3) differences in metabolic characteristics between patients and controls; 4) whether newly detected abnormal glucose metabolism assessed early after a myocardial infarction relates to long term prognosis.
Glucose parameters were followed during hospital stay and an oral glucose tolerance test (OGTT; 75 gram glucose dissolved in 200 ml water ingested by the patient; blood glucose measured immediately before and two hours thereafter) was performed just before hospital discharge 5-6 days after the heart attack and 3 and 12 months later in patients (n = 181) admitted with acute MI and free from known diabetes. Sex- and age- matched controls (n = 185) without diabetes or cardiovascular (CV) disease were recruited from the general population.
An abnormal glucose tolerance was more common (number/all classified) in patients at discharge 113/168 (67%) and after 3 months 95/145 (66%) than in controls 65/185 (35%; p<0.001). Abnormal glucose tolerance diagnosed at hospital discharge remained after 3 and 12 months. Increased blood lipids (70% vs. 29%; p<0.001) and high blood pressure (32 vs. 18%; p<0.01) were more frequent among patients while obesity (18% vs. 24%) did not differ. Blood glucose, HbA1c (a measure of blood glucose over time), proinsulin, proinsulin/insulin ratio, triglycerides, insulin resistance (by HOMA) and fibrinogen were consistently higher in patients than controls (p<0.01). The only independent predictors of impaired glucose tolerance or newly detected diabetes at 3 months were HbA1c (p= 0.024) and fasting blood glucose on day 4 (p=0.044).
During follow-up (average: 2.8±0.8 years) 8 pat, all with abnormal glucose tolerance, died by CV reasons, 15 had non-fatal heart attacks, 6 stroke and 10 severe hearrt failure. The composite cardiovascular event (= at least one of these conditions) occurred in 31 (18%) pat. The probability of remaining free from cardiovascular events was significantly higher with normal than abnormal glucose metabolism (p=0.002). Together with previous myocardial infarction abnormal glucose metabolism was the strongest predictor of a future cardiovascular event (hazard ratio 4.18; CI 1.26-13.84; p=0.019).
Conclusion
Previously undiagnosed abnormal glucose metabolism is very common in patients with heart attacks, almost twice as common as in matched controls. Abnormal glucose metabolism, easily disclosed by an OGTT during the early phase of the heart attack, is a strong risk factor for future cardiovascular events. Thus the early detection of abnormal glucose metabolism after an heart attack is a useful marker of high risk individuals and may be a fruitful target for novel secondary preventive efforts. Moreover such patients should be adviced to eat appropriately and exercise to keep their blood glucose regulation in a better balance.
What is new?
Data derived from the control population and comparisons between them and patients have not previously been reported on. The prognostic follow up brings new information.
A Norhammer (Stockholm, SE) & L Ryden (Stockholm, SE)
European Society of Cardiology (ESC)
3. Newly detected disturbed glucose tolerance was linked to a high risk for death or new heart attacks during the nearest 2-3 years.
The study may open new possibilities to treat patients with heart attacks in order to prevent such dismal outcome, some of which are already available, however, not used to their full extent.
It is recommended that glucose tolerance is tested in all patients with heart attacks before hopsital discharge. This should be done by means of an oral glucose load (see below), an inexpensive and easily performed investigation.
Trial design an outcome
The GAMI study investigated 1) whether abnormal glucose metabolism defined as newly detected diabetes mellitus or impaired glucose tolerance, is more frequent in patients with heart attacks (acute myocardial infarction) without previous diabetes than in healthy controls from the same population; 2) whether abnormal glucose metabolism can be identified early after a MI; 3) differences in metabolic characteristics between patients and controls; 4) whether newly detected abnormal glucose metabolism assessed early after a myocardial infarction relates to long term prognosis.
Glucose parameters were followed during hospital stay and an oral glucose tolerance test (OGTT; 75 gram glucose dissolved in 200 ml water ingested by the patient; blood glucose measured immediately before and two hours thereafter) was performed just before hospital discharge 5-6 days after the heart attack and 3 and 12 months later in patients (n = 181) admitted with acute MI and free from known diabetes. Sex- and age- matched controls (n = 185) without diabetes or cardiovascular (CV) disease were recruited from the general population.
An abnormal glucose tolerance was more common (number/all classified) in patients at discharge 113/168 (67%) and after 3 months 95/145 (66%) than in controls 65/185 (35%; p<0.001). Abnormal glucose tolerance diagnosed at hospital discharge remained after 3 and 12 months. Increased blood lipids (70% vs. 29%; p<0.001) and high blood pressure (32 vs. 18%; p<0.01) were more frequent among patients while obesity (18% vs. 24%) did not differ. Blood glucose, HbA1c (a measure of blood glucose over time), proinsulin, proinsulin/insulin ratio, triglycerides, insulin resistance (by HOMA) and fibrinogen were consistently higher in patients than controls (p<0.01). The only independent predictors of impaired glucose tolerance or newly detected diabetes at 3 months were HbA1c (p= 0.024) and fasting blood glucose on day 4 (p=0.044).
During follow-up (average: 2.8±0.8 years) 8 pat, all with abnormal glucose tolerance, died by CV reasons, 15 had non-fatal heart attacks, 6 stroke and 10 severe hearrt failure. The composite cardiovascular event (= at least one of these conditions) occurred in 31 (18%) pat. The probability of remaining free from cardiovascular events was significantly higher with normal than abnormal glucose metabolism (p=0.002). Together with previous myocardial infarction abnormal glucose metabolism was the strongest predictor of a future cardiovascular event (hazard ratio 4.18; CI 1.26-13.84; p=0.019).
Conclusion
Previously undiagnosed abnormal glucose metabolism is very common in patients with heart attacks, almost twice as common as in matched controls. Abnormal glucose metabolism, easily disclosed by an OGTT during the early phase of the heart attack, is a strong risk factor for future cardiovascular events. Thus the early detection of abnormal glucose metabolism after an heart attack is a useful marker of high risk individuals and may be a fruitful target for novel secondary preventive efforts. Moreover such patients should be adviced to eat appropriately and exercise to keep their blood glucose regulation in a better balance.
What is new?
Data derived from the control population and comparisons between them and patients have not previously been reported on. The prognostic follow up brings new information.
A Norhammer (Stockholm, SE) & L Ryden (Stockholm, SE)
European Society of Cardiology (ESC)
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