Stress Hyperglycemia Ratio may Portend Poor Outcomes in COVID-19.

Magoon R, Jose J. Stress Hyperglycemia Ratio may Portend Poor Outcomes in COVID-19. Indian J Crit Care Med 2021;25(11):1329.

Augmented glycaemic gap is a marker for an increased risk of post-infarct left ventricular systolic dysfunction.

BACKGROUND: Left ventricular systolic dysfunction (LVSD) occurs frequently after acute ST-segment elevation myocardial infarction (STEMI). The predisposing factors and underlying mechanism of post-infarct LVSD are not fully understood. The present study mainly investigated the correlation between glycaemic gap, a novel index of stress-induced hyperglycaemia (SIH), and post-infarct LVSD. METHODS: A total of 274 first STEMI patients were enrolled in this cross-sectional study. Transthoracic echocardiography was performed within 48 h after admission and at 6 months after discharge to obtain left ventricular ejection fraction (LVEF). The change in LVEF was calculated as LVEF at 6 months after discharge minus baseline LVEF. Additionally, post-infarct LVSD was defined as LVEF ≤ 50%. Most importantly, glycaemic gap was calculated as admission blood glucose (ABG) minus the estimated average glucose over the previous 3 months. RESULTS: In patients without diabetes mellitus (DM), multivariate linear regression analysis revealed that both glycaemic gap (Beta = - 1.214, 95% CI - 1.886 to - 0.541, p < 0.001) and ABG (Beta = - 1.124, 95% CI - 1.795 to - 0.453, p = 0.001) were associated with change in LVEF. In DM patients, only glycaemic gap was still associated with change in LVEF, although this association was not observed in univariate linear regression analysis. Regarding the association between SIH and post-infarct LVSD, multivariate logistic regression analysis revealed that both glycaemic gap (OR = 1.490, 95% CI 1.043 to 2.129, p = 0.028) and ABG (OR = 1.600, 95% CI 1.148 to 2.229, p = 0.005) were associated with an increased risk of having post-infarct LVSD in non-DM patients. However, after multivariate adjustment in DM patients, only glycaemic gap (OR = 1.399, 95% CI 1.021 to 1.919, p = 0.037) remained associated with an increased risk of having post-infarct LVSD. Furthermore, the predictive value of glycaemic gap for post-infarct LVSD was not inferior to ABG in non-DM patients (p = 0.499), and only glycaemic gap, instead of ABG, could significantly predict post-infarct LVSD in DM patients (AUC = 0.688, 95% CI 0.591 to 0.774, p = 0.002). CONCLUSIONS: Glycaemic gap was strongly associated with a change in LVEF and an increased risk of having post-infarct LVSD in patients following STEMI. In STEMI patients with DM, glycaemic gap could provide more valuable information than ABG in identifying patients at high risk of developing post-infarct LVSD.

Admission blood glucose and 10-year mortality among patients with or without pre-existing diabetes mellitus hospitalized with heart failure.

BACKGROUND: High admission blood glucose (ABG) level has been associated with a poor short-term outcome among non-diabetic patients with heart failure (HF). We aimed to investigate the association between ABG levels and long-term (10 years) mortality in patients with or without pre-existing diabetes mellitus (DM) admitted with HF. METHODS: We analyzed data on 1811 patients with DM and 2182 patients without pre-existing DM who were hospitalized with HF during a prospective national survey. The relationship between ABG and 10-year mortality was assessed using the Cox proportional hazard model adjusting for multiple variables. ABG was analyzed both as a categorical (<110, 110-140, 140-200, and >200 mg/dL) and as a continuous variable. RESULTS: At 10 years of follow-up the cumulative probability of mortality was 85 and 78% among patients with DM and patients with no pre-existing DM (p < 0.001), respectively. Among patients with no pre-existing DM, glucose levels of 110-140, 140-200 and ≥200 mg/dL were associated with 9% (p = 0.140), 16% (p = 0.031) and 53% (p < 0.001) increased mortality risk compared to ABG < 110 mg/dL. Each 18-mg/dL (1-mmol/L) increase in glucose level was associated with a 5% increased risk of mortality (p < 0.001) among patients with no-pre-existing DM. In contrast, among patients with DM, only those with glucose levels >200 mg/dL had an increased mortality risk (>200 mg/dL versus <110 mg/dL; HR = 1.20, p = 0.032). CONCLUSION: Among hospitalized HF patients with no pre-existing DM there is a linear relationship between ABG level and long-term mortality, whereas among patients with DM only ABG level >200 mg/dL is associated with increased mortality risk.

Do admission glucose levels independently predict coagulopathy in multiple trauma patients? A retrospective cohort analysis.

BACKGROUND: Coagulopathy is prevalent in multiple trauma patients and worsens bleeding complications, leading to higher morbidity and mortality rates. Hyperglycemia upon admission predicts hemorrhagic shock and mortality in severely injured patients. This study aimed to assess admission glucose levels as an independent prognostic factor for coagulopathy in multiply injured patients. METHODS: This retrospective cohort study observed multiple trauma patients treated at a level I trauma center between January 1, 2005, and December 31, 2020. Coagulopathy was defined as an international normalized ratio (INR) > 1.4 and/or activated thromboplastin time (APTT) > 40 s. Analysis of variance compared clinical and laboratory parameters of patients with and without coagulopathy. Receiver-operating-characteristic (ROC) and multivariate logistic regression analyses identified risk factors associated with coagulopathy. RESULTS: The study included 913 patients, of whom 188 (20%) had coagulopathy at admission. Coagulopathy patients had higher mortality than those without (26% vs. 5.0%, p < 0.001). Mean glucose level in coagulopathy patients was 10.09 mmol/L, significantly higher than 7.97 mmol/L in non-coagulopathy patients (p < 0.001). Admission glucose showed an area under the curve (AUC) of 0.64 (95% CI [0.59-0.69], p < 0.001) with an optimal cut-off point of 12.35 mmol/L. After adjusting for other factors, patients with high admission glucose had a 1.99-fold risk of developing coagulopathy (95% CI 1.07-3.60). Other laboratory parameters associated with coagulopathy included haemoglobin, bicarbonate (HCO3), and lactate levels. CONCLUSION: This study emphasizes the significance of admission blood glucose as an independent predictor of coagulopathy. Monitoring hyperglycemia can aid in identifying high-risk patients.

Admission blood glucose and 30-day mortality in patients with acute decompensated heart failure: prognostic significance in individuals with and without diabetes.

Objective: Diabetes is a significant risk factor for acute heart failure, associated with an increased risk of mortality. This study aims to analyze the prognostic significance of admission blood glucose (ABG) on 30-day mortality in Chinese patients with acute decompensated heart failure (ADHF), with or without diabetes. Methods: This retrospective study included 1,462 participants from the JX-ADHF1 cohort established between January 2019 to December 2022. We conducted multivariate cox regression, restricted cubic spline, receiver operating characteristic curve analysis, and mediation analysis to explore the association and potential mechanistic pathways (inflammation, oxidative stress, and nutrition) between ABG and 30-day mortality in ADHF patients, with and without diabetes. Results: During the 30-day follow-up, we recorded 20 (5.36%) deaths in diabetic subjects and 33 (3.03%) in non-diabetics. Multivariate Cox regression revealed that ABG was independently associated with 30-day mortality in ADHF patients, with a stronger association in diabetics than non-diabetics (hazard ratio: Model 1: 1.71 vs 1.16; Model 2: 1.26 vs 1.19; Model 3: 1.65 vs 1.37; Model 4: 1.76 vs 1.33). Further restricted cubic spline analysis indicated a U-shaped relationship between ABG and 30-day mortality in non-diabetic ADHF patients (P for non-linearity < 0.001), with the lowest risk at ABG levels approximately between 5-7 mmol/L. Additionally, receiver operating characteristic analysis demonstrated that ABG had a higher predictive accuracy for 30-day mortality in diabetics (area under curve = 0.8751), with an optimal threshold of 13.95mmol/L. Finally, mediation analysis indicated a significant role of inflammation in ABG-related 30-day mortality in ADHF, accounting for 11.15% and 8.77% of the effect in diabetics and non-diabetics, respectively (P-value of proportion mediate < 0.05). Conclusion: Our study confirms that ABG is a vital indicator for assessing and predicting 30-day mortality risk in ADHF patients with diabetes. For ADHF patients, both with and without diabetes, our evidence suggests that physicians should be alert and closely monitor any changes in patient conditions when ABG exceeds 13.95 mmol/L for those with diabetes and 7.05 mmol/L for those without. Timely adjustments in therapeutic strategies, including endocrine and anti-inflammatory treatments, are advisable.

Prognostic significance of the stress hyperglycemia ratio and admission blood glucose in diabetic and nondiabetic patients with spontaneous intracerebral hemorrhage.

BACKGROUND: The role of stress hyperglycemia ratio (SHR) on the prognosis of spontaneous intracerebral hemorrhage (ICH) in patients with different diabetic status has not been elucidated. This study aimed to evaluate the prognostic value of SHR and admission blood glucose (ABG) for the short- and long-term mortality in diabetic and nondiabetic populations with ICH. METHOD: Participants with ICH were retrospectively retrieved from the Medical Information Mart for Intensive Care (MIMIC-IV). The primary outcome was all-cause 30-day and 1-year mortality. The association of SHR and ABG with the primary outcomes in diabetic and nondiabetic cohorts were assessed by Cox proportional hazard regression. RESULTS: Overall, 1029 patients with a median age of 71.09 (IQR: 60.05-81.97) were included. Among them, 548 (53%) individuals were male, and 95 (19%) as well as 323 (31%) ones experienced the 30-day and 1-year mortality, respectively. After adjusting for confounding variables, individuals in quintile 5 of SHR had significantly higher risk of the 30-day and 1-year mortality than those in quintile 1 in the whole cohort (30-day mortality: HR 3.33, 95%CI 2.01-5.51; 1-year mortality: HR 2.09, 95% CI 1.46-3.00) and in nondiabetic patients (30-day mortality: HR 4.55, 95%CI 2.33-8.88; 1-year mortality: HR 3.06, 95%CI 1.93-4.86), but no significant difference was observed in diabetic patients. Similar results were observed for ABG as a categorical variable. As continuous variable, SHR was independently correlated with the 30-day and 1-year mortality in both of the diabetic and nondiabetic cohorts (30-day mortality: HR 2.63, 95%CI 1.50-4.60. 1-year mortality: HR 2.12, 95%CI 1.33-3.39), but this correlation was only observed in nondiabetic cohort for ABG (HR 1.00, 95%CI 0.99-1.01 for both of the 30-day and 1-year mortality). Moreover, compared with ABG, SHR can better improve the C-statistics of the original models regarding the 30-day and 1-year outcomes, especially in patients with diabetes (p < 0.001 in all models). CONCLUSION: SHR might be a more useful and reliable marker than ABG for prognostic prediction and risk stratification in critically ill patients with ICH, especially in those with diabetes.

The stress hyperglycemia ratio improves the predictive ability of the GRACE score for in-hospital mortality in patients with acute myocardial infarction.

BACKGROUND: The Global Registry of Acute Coronary Events (GRACE) score is a powerful tool used to predict in-hospital mortality after acute myocardial infarction (AMI) and does not include a glycometabolism-related index. We investigated whether the addition of the stress hyperglycemia ratio (SHR) provides incremental prognostic value in addition to the GRACE score. METHODS: A retrospective cohort of 613 AMI patients was enrolled in the present analyses. The patients were stratified according to the primary endpoint (in-hospital mortality) and the tertiles of the SHR. RESULTS: During hospitalization, 40 patients reached the primary endpoint, which was more frequently observed in patients with a higher SHR. The SHR, but not admission blood glucose (ABG), adjusted for the GRACE score independently predicted in-hospital mortality [odds ratio 2.5861; 95% confidence interval (CI), 1.3910-4.8080; P = 0.0027]. The adjustment of the GRACE score by the SHR improved the predictive ability for in-hospital death (an increase in the C-statistic value from 0.787 to 0.814; net reclassification improvement, 0.6717, 95% CI 0.3665-0.977, P < 0.01; integrated discrimination improvement, 0.028, 95% CI 0.0066-0.0493, P = 0.01028). The likelihood ratio test showed that the SHR significantly improved the prognostic models, including the GRACE score. Adding the SHR to the GRACE score presented a larger net benefit across the range of in-hospital mortality risk than the GRACE score alone. CONCLUSION: The SHR, but not the ABG, is an independent predictor of in-hospital mortality after AMI even after adjusting for the GRACE score. The SHR improves the predictability and clinical usefulness of prognostic models containing the GRACE score.

Association between admission-blood-glucose-to-albumin ratio and clinical outcomes in patients with ST-elevation myocardial infarction undergoing percutaneous coronary intervention.

Introduction: It is unclear whether admission-blood-glucose-to-albumin ratio (AAR) predicts adverse clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) who are treated with percutaneous coronary intervention (PCI). Here, we performed a observational study to explore the predictive value of AAR on clinical outcomes. Methods: Patients diagnosed with STEMI who underwent PCI between January 2010 and February 2020 were enrolled in the study. The patients were classified into three groups according to AAR tertile. The primary outcome was in-hospital all-cause mortality, and the secondary outcomes were in-hospital major adverse cardiac events (MACEs), as well as all-cause mortality and MACEs during follow-up. Logistic regression, Kaplan-Meier analysis, and Cox proportional hazard regression were the primary analyses used to estimate outcomes. Results: Among the 3,224 enrolled patients, there were 130 cases of in-hospital all-cause mortality (3.9%) and 181 patients (5.4%) experienced MACEs. After adjustment for covariates, multivariate analysis demonstrated that an increase in AAR was associated with an increased risk of in-hospital all-cause mortality [adjusted odds ratio (OR): 2.72, 95% CI: 1.47-5.03, P = 0.001] and MACEs (adjusted OR: 1.91, 95% CI: 1.18-3.10, P = 0.009), as well as long-term all-cause mortality [adjusted hazard ratio (HR): 1.64, 95% CI: 1.19-2.28, P = 0.003] and MACEs (adjusted HR: 1.58, 95% CI: 1.16-2.14, P = 0.003). Receiver operating characteristic (ROC) curve analysis indicated that AAR was an accurate predictor of in-hospital all-cause mortality (AUC = 0.718, 95% CI: 0.675-0.761) and MACEs (AUC = 0.672, 95% CI: 0.631-0.712). Discussion: AAR is a novel and convenient independent predictor of all-cause mortality and MACEs, both in-hospital and long-term, for STEMI patients receiving PCI.

A review of stress-induced hyperglycaemia in the context of acute ischaemic stroke: Definition, underlying mechanisms, and the status of insulin therapy.

The transient elevation of blood glucose produced following acute ischaemic stroke (AIS) has been described as stress-induced hyperglycaemia (SIH). SIH is common even in patients with AIS who have no previous diagnosis of diabetes mellitus. Elevated blood glucose levels during admission and hospitalization are strongly associated with enlarged infarct size and adverse prognosis in AIS patients. However, insulin-intensive glucose control therapy defined by admission blood glucose for SIH has not achieved the desired results, and new treatment ideas are urgently required. First, we explore the various definitions of SIH in the context of AIS and their predictive value in adverse outcomes. Then, we briefly discuss the mechanisms by which SIH arises, describing the dual effects of elevated glucose levels on the central nervous system. Finally, although preclinical studies support lowering blood glucose levels using insulin, the clinical outcomes of intensive glucose control are not promising. We discuss the reasons for this phenomenon.

Effects of perioperative glycemic indicators on outcomes of endovascular treatment for vertebrobasilar artery occlusion.

Objective: Endovascular treatment (EVT) is, to date, the most promising treatment of vertebrobasilar artery occlusion (VBAO). The study aimed to determine the influence of perioperative glucose levels on clinical outcomes in patients with acute VBAO treated with EVT. Methods: We retrospectively collected consecutive VBAO patients received EVT in 21 stroke centers in China. The associations between perioperative glycemic indicators (including fasting blood glucose[FBG], admission hyperglycemia, stress hyperglycemia ratio [SHR] and short-term glycemic variability [GV]) and various clinical outcomes were analyzed in all patients and subgroups stratified by diabetes mellitus (DM). Results: A total of 569 patients were enrolled. Admission hyperglycemia significantly correlated with increased risk of symptomatic intracranial hemorrhage (sICH) (odds ratio [OR] 3.24, 95% confidence interval [CI]: 1.40-7.46), poor functional outcomes at 90 days (OR 1.91, 95%CI: 1.15-3.18) and 1 year (OR 1.96, 95%CI: 1.20-3.22). Similar significant correlations exist between FBG, SHR, GV and all the adverse outcomes except higher levels GV was not associated with increased risk of sICH (OR 1.04, 95% CI: 0.97-1.12). Subgroup analyses showed that admission hyperglycemia, FBG and SHR were significantly associated with adverse outcomes in non-diabetic patients, but not in DM patients. While, GV was associated with poor functional outcomes regardless of diabetes history. Conclusions: Admission hyperglycemia, FBG, SHR and short-term GV in VBAO patients treated with EVT were associated with adverse outcomes. The results suggested that comprehensive evaluation and appropriate management of perioperative glucose might be important for patients with VBAO and treatment with EVT.

Relationship between the mean of 24-h venous blood glucose and in-hospital mortality among patients with subarachnoid hemorrhage: A matched cohort study.

Objective: The aim of this study was to explore the correlation between the mean of 24-h venous blood glucose (BG) and in-hospital mortality and all-cause mortality (ACM) in patients with subarachnoid hemorrhage (SAH). Methods: Detailed clinical information was acquired from the Medical Information Mart for Intensive IV (MIMIC-IV) database. The best cutoff value of mean BG was calculated using the X-tile program. Univariate and multivariate logistic regressive analyses were utilized to analyze the prognosis significance of mean BG, and survival curves were drawn using the Kaplan-Meier (K-M) approach. To improve the reliability of results and balance the impact of underlying confounders, the 1:1 propensity score matching (PSM) approach was utilized. Results: An overall of 1,230 subjects were selected herein. The optimal cutoff value of the mean BG for in-hospital mortality was 152.25. In addition, 367 pairs of score-matched subjects were acquired after PSM analysis, and nearly all variables' differences were balanced. K-M analysis showed that patients with mean BG ≥ 152.25 mg/dl had significantly higher in-hospital, 3-month, and 6-month mortalities compared with patients with mean BG < 152.25 mg/dl (p < 0.001). The multivariable logistic regressive analyses revealed that patients with mean BG ≥ 152.25 mg/dl had significantly increased in-hospital mortality compared with patients with mean BG < 152.25 mg/dl after the adjustment for possible confounders (OR = 1.994, 95% CI: 1.321-3.012, p = 0.001). Similar outcomes were discovered in the PSM cohort. Conclusion: Our data suggested that mean BG was related to ACM of patients with SAH. More studies are needed to further analyze the role of the mean of 24-h venous BG in patients with SAH.

Association of admission blood glucose level and clinical outcomes in elderly community-acquired pneumonia patients with or without diabetes.

INTRODUCTION: Community-acquired pneumonia (CAP) is the major cause of infection-related mortality worldwide. Patients with CAP frequently present with admission hyperglycemia. OBJECTIVES: The aim of this study was to evaluate the association between admission blood glucose (ABG) level and clinical outcomes in elderly CAP patients (≥80 years of age) with or without diabetes. METHODS: In this single center retrospective study, 290 elderly patients diagnosed with CAP were included. Demographic and clinical information were collected and compared. The associations between admission blood glucose level and the 30-day mortality as well as intensive care unit (ICU) admission and invasive mechanical ventilation (IMV) in elderly CAP patients with or without diabetes were assessed. RESULTS: Of the 290 eligible patients with CAP, 159 (66.5%) patients were male, and 64 (22.1%) had a known history of diabetes at hospital admission. After adjusting for age and sex, the logistic regression analysis had identified several risk factors that might be associated with clinical outcomes in elderly patients with CAP. Multivariable logistic regression analysis revealed that admission glucose level > 11.1 mmol/L was significant associated with ICU admission, IMV, and 30-day mortality both in non-diabetic and diabetic patients. Furthermore, Kaplan-Meier analysis indicated that patients with higher admission glucose level were correlated statistically significantly with 30-day mortality in patients with CAP (P < 0.001). CONCLUSION: Admission blood glucose is correlated with 30-day hospital mortality, ICU admission, and IMV of CAP in elderly patients with and without diabetes. Specially, admission glucose > 11.1 mmol/L was a significant risk factor for 30-day hospital mortality.

Admission Blood Glucose and 2-Year Mortality After Acute Myocardial Infarction in Patients With Different Glucose Metabolism Status: A Prospective, Nationwide, and Multicenter Registry.

Background: The prognostic effect of admission blood glucose (ABG) for patients with acute myocardial infarction (AMI) has not been well validated, especially in patients with diabetes. We performed this study to assess the predictive value of ABG for all-cause mortality in AMI patients with different glucose metabolism status. Methods: We evaluated a total of 6,892 AMI patients from the prospective, nationwide, multicenter CAMI registry, of which 2,820 had diabetes, 2,011 had pre-diabetes, and 2,061 had normal glucose regulation (NGR). Patients were divided into high ABG and low ABG groups according to the optimal cutoff values of ABG to predict 2-year mortality for patients with diabetes, pre-diabetes and NGR, respectively. The primary endpoint was all-cause mortality. Results: The optimal cutoff values of ABG for predicting 2-year mortality was 9.0mmol/l, 7.2mmol/l and 6.2mmol/l for patients with diabetes, pre-diabetes and NGR, respectively. Overall, the risk of all-cause mortality in high ABG group was significantly increased compared with that in low ABG group among patients with diabetes (15.2% vs. 8.9%; hazard ratio [HR] 1.787, 95% confidence interval [CI] 1.413-2.260; P<0.0001), pre-diabetes (12.1% vs. 6.1%; HR 2.069, 95%CI 1.518-2.821; P<0.0001) and NGR (11.8% vs. 6.1%; HR 2.009, 95%CI 1.473-2.740; P<0.0001). After the potential confounders were adjusted, high ABG was significantly associated with higher risk of 2-year mortality in patients with diabetes (adjusted HR 1.710, 95%CI 1.327-2.203; P<0.0001), pre-diabetes (adjusted HR 1.731, 95%CI 1.249-2.399; P=0.001) and NGR (adjusted HR 1.529, 95%CI 1.110-2.106; P=0.009). Moreover, adding ABG to the original model led to a slight albeit significant improvement in C-statistic and net reclassification in patients with diabetes and NGR (all P<0.05). Conclusions: This study is the first to demonstrate a strong positive association between ABG and 2-year mortality in AMI patients with diabetes, pre-diabetes and NGR. ABG should be considered as a useful marker for risk stratification in patients with diabetes and NGR. Further randomized trials are warranted to investigate the effects of blood glucose control on the reduction of long-term mortality according to the corresponding ABG thresholds for different glucose metabolism status. Clinical Trial Registration: ClinicalTrials.gov, identifier NCT01874691.

Impact of admission hyperglycaemia on clinical outcomes in non-diabetic heart failure with preserved ejection fraction.

AIMS: At present, the clinical significance of admission hyperglycaemia in heart failure with preserved ejection fraction (HFpEF) patients remains unknown. This study was designed to evaluate the relationship between admission hyperglycaemia and clinical outcome in HFpEF patients, especially in non-diabetic patients. METHODS AND RESULTS: We enrolled 486 non-diabetic HFpEF (left ventricular ejection fraction ≥50%) patients hospitalized due to acute decompensated heart failure from the PURSUIT-HFpEF registry, a prospective, multicentre observational study. We divided non-diabetic patients into two groups, an admission hyperglycaemia group whose blood glucose on admission was ≥7.0 mmol/L (148 patients) and a normoglycaemic group whose blood glucose on admission was <7.0 mmol/L (338 patients). The primary endpoint was all-cause mortality, and the secondary endpoints were heart failure death and other causes of cardiac death. During a mean follow-up period of 400 ± 335 days, all-cause mortality was 69 patients. Twenty-five patients suffered cardiac death. All-cause mortality (P = 0.002), cardiac death (P = 0.009), and heart failure death (P = 0.001) were significantly more frequent in the admission hyperglycaemia group than in the normoglycaemic group. Admission hyperglycaemia was independently and significantly associated with all-cause mortality and cardiac death (HR 2.01, 95% CI 1.20-3.34, P = 0.008 and HR 3.03, 95% CI 1.35-6.96, P = 0.007, respectively). CONCLUSIONS: Non-diabetic HFpEF patients with admission hyperglycaemia when hospitalized for heart failure had poorer clinical outcomes than normoglycaemic patients.

Stress Induced Hyperglycemia in the Context of Acute Coronary Syndrome: Definitions, Interventions, and Underlying Mechanisms.

Elevation of glucose level in response to acute coronary syndrome (ACS) has been recognized as stress induced hyperglycemia (SIH). Plenty of clinical studies have documented that SIH occurs very common in patients hospitalized with ACS, even in those without previously known diabetes mellitus. The association between elevated blood glucose levels with adverse outcome in the ACS setting is well-established. Yet, the precise definition of SIH in the context of ACS remains controversial, bringing confusions about clinical management strategy. Several randomized trials aimed to evaluate the effect of insulin-based therapy on outcomes of ACS patients failed to demonstrate a consistent benefit of intensive glucose control. Mechanisms underlying detrimental effects of SIH on patients with ACS are undetermined, oxidative stress might play an important role in the upstream pathways leading to subsequent harmful effects on cardiovascular system. This review aims to discuss various definitions of SIH and their values in predicting adverse outcome in the context of ACS, as well as the effect of intensive glucose control on clinical outcome. Finally, a glimpse of the underlying mechanisms is briefly discussed.

Influence of Admission Blood Glucose in Predicting Outcome in Patients With Spontaneous Intracerebral Hematoma.

Background and Aims: Hyperglycemia or elevated blood glucose levels have been associated with poor outcomes in patients with ischemic stroke yet control of hyperglycemia has not resulted in good outcomes. High admission blood glucose (ABG) values have been mitigated by other poor prognosticators like large hematoma volume, intraventricular extension (IVE) of hematoma and poor GCS. The aim of this study was to evaluate the effects of blood glucose levels at admission, on mortality and functional outcomes at discharge and 3 months follow up. Methods: This was a retrospective observational study conducted at a tertiary care. Patients with spontaneous SICH were enrolled from a prospective SICH register maintained at our hospital. Blood glucose values were recorded on admission. Patients with traumatic hematomas, vascular malformations, aneurysms, and coagulation abnormalities were excluded from our study. Results: A total of 510 patients were included in the study. We dichotomised our cohort into two groups, group A with ABG>160 mg/dl and group B with ABG<160 mg/dl. Mean blood glucose levels in these two groups were 220.73 mg/dl and 124.37 mg/dl respectively, with group A having twice the mortality. mRS at discharge and 3 months was better in Group B (p ≤ 0.001) as compared to Group A. Age, GCS, volume of hematoma, ABG, IVE and Hydrocephalus were significant predictors of mortality and poor outcome on univariate analysis with a p < 0.05. The relationship between ABG and mortality (P = 0.249, 95% CI 0.948-1.006) and outcome (P = 0.538, 95% CI 0.997-1.005) failed to reach statistical significance on multivariate logistic regression. Age, Volume of hematoma and GCS were stronger predictors of mortality and morbidity. Conclusion: Admission blood glucose levels was not an independent predictor of mortality in our study when adjusted with age, GCS, and hematoma volume. The effect of high ABG on SICH outcome is probably multifactorial and warrants further research.

Comparison of in-hospital glycemic variability and admission blood glucose in predicting short-term outcomes in non-diabetes patients with ST elevation myocardial infarction underwent percutaneous coronary intervention.

AIMS: Admission hyperglycemia is associated with increased mortality and major adverse cardiac events (MACE) in patients with or without diabetes mellitus after acute myocardial infarction (AMI). However, effects of glycemic variability (GV) on outcomes of non-diabetes patients with AMI still remains unclear. The aim of this study is to compare the prognostic value of in-hospital GV with admission blood glucose (ABG) for 3-month MACE in non-diabetes patients with ST elevation myocardial infarction (STEMI) who underwent percutaneous coronary intervention (PCI). METHODS: We analyzed 256 non-diabetes patients with STEMI in study. The GV accessed by mean amplitude of glycemic excursions (MAGE) was calculated from blood glucose profiles of continuous glucose monitoring system (CGMS) during hospitalization. ABG was measured on admission. Main endpoints were 3-month MACE; secondary endpoints were GRACE scores and enzymatic infarct size. Predictive effects of MAGE and ABG on the MACE in patients were analyzed. RESULTS: In all participants, MAGE level was associated with ABG level (r = 0.242, p < 0.001). Both elevated MAGE levels (p = 0.001) and elevated ABG (p = 0.046) were associated with incidences of short-term MACE. Patients with a higher MAGE level had a significantly higher cardiac mortality (5.8 vs. 0.6%, p = 0.017) and incidence of acute heart failure (12.8 vs. 2.4%, p = 0.001) during 3 months follow-up. In multivariable analysis, high MAGE level (HR 2.165, p = 0.023) was significantly associated with incidence of short-term MACE, but ABG (HR 1.632, p = 0.184) was not. The area under the receiver-operating characteristic curve for MAGE (0.690, p < 0.001) was superior to that for ABG (0.581, p = 0.076). CONCLUSIONS: To compare with ABG, in-hospital GV may be a more important predictor of short-term MACE and mortality in non-diabetes patients with STEMI treated with PCI.

Admission blood glucose predicted haemorrhagic shock in multiple trauma patients.

INTRODUCTION: Admission blood glucose is known to be a predictor for outcome in several disease patterns, especially in critically ill trauma patients. The underlying mechanisms for the association of hyperglycaemia and poor outcome are still not proven. It was hypothesised that hyperglycaemia upon hospital admission is associated with haemorrhagic shock and in-hospital mortality. METHODS: Data was extracted from an observational trauma database of the level 1 trauma centre at Innsbruck Medical University hospital. Trauma patients (≥18 years) with multiple injuries and an Injury Severity Score ≥17 were included and analysed. RESULTS: In total, 279 patients were analysed, of which 42 patients (15.1%) died. With increasing blood glucose upon hospital admission, the rate of patients with haemorrhagic shock rose significantly [from 4.4% (glucose 4.1-5.5mmol/L) to 87.5% (glucose >15mmol/L), p<0.0001]. Mortality was also associated with initial blood glucose [≤5.50mmol/L 8.3%; 5.51-7.50mmol/L 10.9%, 7.51-10mmol/L 12.4%; 10.01-15mmol/L 32.0%; ≥15.01mmol/L 12.5%, p=0.008]. Admission blood glucose was a better indicator for haemorrhagic shock (cut-off 9.4mmol/L, sensitivity 67.1%, specificity 83.9%) than haemoglobin, base excess, bicarbonate, pH, lactate, or vital parameters. Regarding haemorrhagic shock, admission blood glucose is more valuable during initial patient assessment than the second best predictive parameter, which was admission haemoglobin (cut-off value 6.5mmol/L (10.4g/dL): sensitivity 61.3%, specificity 83.9%). CONCLUSIONS: In multiple trauma, non-diabetic patients, admission blood glucose predicted the incidence of haemorrhagic shock. Admission blood glucose is an inexpensive, rapidly and easily available laboratory value that might help to identify patients at risk for haemorrhagic shock during initial evaluation upon hospital admission.