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Higher Random Plasma Glucose Level Is Associated With Increased Plasma Cardiac Troponin in Emergency Department Patients With Suspected Acute Coronary Syndrome

      There is clear evidence indicating that impaired glucose regulation is a risk factor for incident cardiovascular events and death.
      • DeFronzo R.A.
      • Abdul-Ghani M.
      Assessment and treatment of cardiovascular risk in prediabetes: impaired glucose tolerance and impaired fasting glucose.
      Increasing emphasis is also being placed on the predictive value of plasma glucose level on admission and clinical outcomes in hospitalized patients with acute myocardial infarction acute coronary syndromes (ACS),
      • Pinto D.S.
      • Kirtane A.J.
      • Pride Y.B.
      • Murphy S.A.
      • Sabatine M.S.
      • Cannon C.P.
      • Gibson C.M.
      CLARITY-TIMI 28 Investigators
      Association of blood glucose with angiographic and clinical outcomes among patients with ST-segment elevation myocardial infarction (from the CLARITY-TIMI-28 study).
      especially in those who undergo primary percutaneous coronary intervention.

      Hoebers LP, Damman P, Claessen BE, Vis MM, Baan J Jr, van Straalen JP, Fischer J, Koch KT, Tijssen JG, de Winter RJ, Piek JJ, Henriques JP. Predictive value of plasma glucose level on admission for short and long term mortality in patients with ST-elevation myocardial infarction treated with primary percutaneous coronary intervention. Am J Cardiol. In press.

      The purpose of this study was to examine the relation between cardiac plasma troponin and random plasma glucose levels in a large sample of patients admitted to the emergency department (ED) with suspected ACS.
      The study sample consisted of 2,304 men and 2,041 women (median age 60 years) who were consecutively admitted to the ED of the Verona University Hospital with nontraumatic chest pain and suspected ACS over a 2-year period (from January 2009 to January 2011). Nonfasting blood samples were obtained at ED admission. Plasma glucose and troponin T (TnT) levels were measured using a Modular System (Roche Diagnostics GmbH, Mannheim, Germany). The detection limit for the TnT immunoassay was 0.01 ng/ml, whereas the recommended diagnostic thresholds for myocardial injury and myocardial infarction were 0.03 to 0.30 and >0.30 ng/ml, respectively.
      • Dolci A.
      • Dominici R.
      • Luraschi P.
      • Panteghini M.
      10% CV concentration for the fourth generation Roche cardiac troponin T assay derived from internal quality control data.
      Patients were stratified according to the diagnostic thresholds of plasma TnT. Results are expressed as median and interquartile range (IQR) and were analyzed using Kruskal-Wallis tests.
      The main results of our study are summarized in Figure 1. Overall, 81 patients had plasma TnT >0.30 ng/ml, 389 had TnT of 0.03 to 0.30 ng/ml, and 3,875 had TnT <0.03 ng/ml. As shown in Figure 1, random plasma glucose level increased remarkably across TnT categories from 6.2 mmol/L (IQR 5.5 to 7.6) in patients with TnT <0.03 ng/ml, to 7.6 mmol/L (IQR 6.2 to 10.1) in those with TnT of 0.03 to 0.30 ng/ml, and up to 8.8 mmol/L (IQR 6.9 to 12.7) in those with TnT >0.30 ng/ml. The same significant trends were observed for men and women (data not shown). The prevalence of patients with random plasma glucose levels ≥11.1 mmol/L (i.e., an established glucose criterion for the diagnosis of diabetes)
      American Diabetes Association
      Clinical practice recommendations Standards of medical care in diabetes—2011.
      was 7% (n = 265), 20% (n = 77), and 32% (n = 26) in the 3 TnT categories, respectively (p <0.001 for trend). Notably, even after excluding those patients, random plasma glucose level on admission significantly increased across TnT categories, ranging from 6.1 mmol/L (IQR 5.4 to 7.2) in those with TnT <0.03 ng/ml, to 7.0 mmol/L (IQR 5.9 to 8.2) in those with TnT of 0.03 to 0.30 ng/ml, and up to 7.4 mmol/L (IQR 6.3 to 9.0) in those with TnT >0.30 ng/ml.
      Figure thumbnail gr1
      Figure 1Relation between plasma cardiac TnT and random plasma glucose on admission in patients with suspected ACS seen in the ED. The horizontal line and box represent the median and IQR, respectively.
      In conclusion, the results of our study demonstrate that there is a positive, graded relation between random plasma glucose levels and plasma TnT levels in patients admitted to the ED with suspected ACS. These results provide further strong evidence that screening for glucose dysregulation in these patients should be part of standard testing.

      References

        • DeFronzo R.A.
        • Abdul-Ghani M.
        Assessment and treatment of cardiovascular risk in prediabetes: impaired glucose tolerance and impaired fasting glucose.
        Am J Cardiol. 2011; 108: 3B-24B
        • Pinto D.S.
        • Kirtane A.J.
        • Pride Y.B.
        • Murphy S.A.
        • Sabatine M.S.
        • Cannon C.P.
        • Gibson C.M.
        • CLARITY-TIMI 28 Investigators
        Association of blood glucose with angiographic and clinical outcomes among patients with ST-segment elevation myocardial infarction (from the CLARITY-TIMI-28 study).
        Am J Cardiol. 2008; 101: 303-307
      1. Hoebers LP, Damman P, Claessen BE, Vis MM, Baan J Jr, van Straalen JP, Fischer J, Koch KT, Tijssen JG, de Winter RJ, Piek JJ, Henriques JP. Predictive value of plasma glucose level on admission for short and long term mortality in patients with ST-elevation myocardial infarction treated with primary percutaneous coronary intervention. Am J Cardiol. In press.

        • Dolci A.
        • Dominici R.
        • Luraschi P.
        • Panteghini M.
        10% CV concentration for the fourth generation Roche cardiac troponin T assay derived from internal quality control data.
        Clin Chem Lab Med. 2006; 44: 1495-1496
        • American Diabetes Association
        Clinical practice recommendations.
        Diabetes Care. 2011; 34: S11-S61

      Linked Article

      • Assessment and Treatment of Cardiovascular Risk in Prediabetes: Impaired Glucose Tolerance and Impaired Fasting Glucose
        American Journal of CardiologyVol. 108Issue 3
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          Individuals with impaired glucose tolerance (IGT) and/or impaired fasting glucose (IFG) are at high risk, not only to develop diabetes mellitus, but also to experience an adverse cardiovascular (CV) event (myocardial infarction, stroke, CV death) later in life. The underlying pathophysiologic disturbances (insulin resistance and impaired β-cell function) responsible for the development of type 2 diabetes are maximally/near maximally expressed in subjects with IGT/IFG. These individuals with so-called prediabetes manifest all of the same CV risk factors (dysglycemia, dyslipidemia, hypertension, obesity, physical inactivity, insulin resistance, procoagulant state, endothelial dysfunction, inflammation) that place patients with type 2 diabetes at high risk for macrovascular complications.
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