Åke Tenerz

Glucose metabolism in patients with acute myocardial infarction and no previous diagnosis of diabetes mellitus: a prospective study.

BACKGROUND Glycometabolic state at hospital admission is an important risk marker for long-term mortality in patients with acute myocardial infarction, whether or not they have known diabetes mellitus. Our aim was to ascertain the prevalence of impaired glucose metabolism in patients without diagnosed diabetes but with myocardial infarction, and to assess whether such abnormalities can be identified in the early course of a myocardial infarction. METHODS We did a prospective study, in which we enrolled 181 consecutive patients admitted to the coronary care units of two hospitals in Sweden with acute myocardial infarction, no diagnosis of diabetes, and a blood glucose concentration of less than 11.1 mmol/L. We recorded glucose concentrations during the hospital stay, and did standardised oral glucose tolerance tests with 75 g of glucose at discharge and again 3 months later. FINDINGS The mean age of our cohort was 63.5 years (SD 9) and the mean blood glucose concentration at admission was 6.5 mmol/L (1.4). The mean 2-h postload blood glucose concentration was 9.2 mmol/L (2.9) at hospital discharge, and 9.0 mmol/L (3.0) 3 months later. 58 of 164 (35%, 95% CI 28-43) and 58 of 144 (40%, 32-48) individuals had impaired glucose tolerance at discharge and after 3 months, respectively, and 51 of 164 (31%, 24-38) and 36 of 144 (25%, 18-32) had previously undiagnosed diabetes mellitus. Independent predictors of abnormal glucose tolerance at 3 months were concentrations of HbA(1c) at admission (p=0.024) and fasting blood glucose concentrations on day 4 (p=0.044). INTERPRETATION Previously undiagnosed diabetes and impaired glucose tolerance are common in patients with an acute myocardial infarction. These abnormalities can be detected early in the postinfarction period. Our results suggest that fasting and postchallenge hyperglycaemia in the early phase of an acute myocardial infarction could be used as early markers of high-risk individuals.

n-3 fatty acids and cardiovascular outcomes in patients with dysglycemia

BACKGROUND The use of n-3 fatty acids may prevent cardiovascular events in patients with recent myocardial infarction or heart failure. Their effects in patients with (or at risk for) type 2 diabetes mellitus are unknown. METHODS In this double-blind study with a 2-by-2 factorial design, we randomly assigned 12,536 patients who were at high risk for cardiovascular events and had impaired fasting glucose, impaired glucose tolerance, or diabetes to receive a 1-g capsule containing at least 900 mg (90% or more) of ethyl esters of n-3 fatty acids or placebo daily and to receive either insulin glargine or standard care. The primary outcome was death from cardiovascular causes. The results of the comparison between n-3 fatty acids and placebo are reported here. RESULTS During a median follow up of 6.2 years, the incidence of the primary outcome was not significantly decreased among patients receiving n-3 fatty acids, as compared with those receiving placebo (574 patients [9.1%] vs. 581 patients [9.3%]; hazard ratio, 0.98; 95% confidence interval [CI], 0.87 to 1.10; P=0.72). The use of n-3 fatty acids also had no significant effect on the rates of major vascular events (1034 patients [16.5%] vs. 1017 patients [16.3%]; hazard ratio, 1.01; 95% CI, 0.93 to 1.10; P=0.81), death from any cause (951 [15.1%] vs. 964 [15.4%]; hazard ratio, 0.98; 95% CI, 0.89 to 1.07; P=0.63), or death from arrhythmia (288 [4.6%] vs. 259 [4.1%]; hazard ratio, 1.10; 95% CI, 0.93 to 1.30; P=0.26). Triglyceride levels were reduced by 14.5 mg per deciliter (0.16 mmol per liter) more among patients receiving n-3 fatty acids than among those receiving placebo (P<0.001), without a significant effect on other lipids. Adverse effects were similar in the two groups. CONCLUSIONS Daily supplementation with 1 g of n-3 fatty acids did not reduce the rate of cardiovascular events in patients at high risk for cardiovascular events. (Funded by Sanofi; ORIGIN ClinicalTrials.gov number, NCT00069784.).

Abnormal glucose tolerance - a common risk factor in patients with acute myocardial infarction in comparison with population-based controls

Background.  A high prevalence of newly detected diabetes and impaired glucose tolerance (abnormal glucose tolerance) was recently reported in patients with acute myocardial infarction. It is important to verify whether this finding is specific for the patients or attributable to the population, from which they were recruited.

Oral Glucose Tolerance Test: A Reliable Tool for Early Detection of Glucose Abnormalities in Patients With Acute Myocardial Infarction in Clinical Practice : A report on repeated oral glucose tolerance tests from the GAMI Study

OBJECTIVE—Previously undetected glucose abnormalities are common in patients with acute myocardial infarction (AMI). We evaluated long-term reliability of early glucometabolic classification of patients with AMI by repeated oral glucose tolerance tests (OGTTs). RESEARCH DESIGN AND METHODS—A glucometabolic OGTT-based classification was obtained in 122 patients by measuring capillary whole-blood glucose. The classification was performed on three occasions, before hospital discharge and 3 and 12 months thereafter. RESULTS—At discharge, 34, 31, and 34% were classified as having normal glucose tolerance, impaired glucose tolerance (IGT), or type 2 diabetes, respectively, and 93% of all patients with type 2 diabetes were still classified with type 2 diabetes (n = 27) or IGT (n = 12) after 12 months. The agreements between the OGTTs at discharge and 3 and 12 months were κ = 0.35, P < 0.001, and κ = 0.43, P < 0.001, respectively. CONCLUSIONS—The outcome of an OGTT performed in AMI patients at hospital discharge reliably informs on long-term glucometabolic state.

Basal glucometabolic status has an impact on long-term prognosis following an acute myocardial infarction in non-diabetic patients

Abstract. Tenerz Å, Nilsson G, Forberg R, Öhrvik J, Malmberg K, Berne C, Leppert J (Central Hospital, Västerås; Karolinska Hospital, Stockholm; and University Hospital, Uppsala; Sweden) Basal glucometabolic status has an impact on long‐term prognosis following an acute myocardial infarction in non‐diabetic patients. J Intern Med 2003; 254: 494–503.

Waist circumference alone predicts insulin resistance as good as the metabolic syndrome in elderly women.

BACKGROUND Insulin resistance (IR) is a risk factor for diabetes and atherosclerotic diseases. The metabolic syndrome (MetS) reflects IR. Waist circumference (WC) is the most easily registered component of MetS. The objective was to compare WC alone with MetS as defined by the National Cholesterol Education Program (NCEP) and the International Diabetes Federation (IDF) for their abilities to predict IR in elderly without known diabetes. METHODS The study included 223 women and 210 men comprising 70% of a random sample of 75-year-olds from a general population. IR was conventionally defined as the gender-specific upper quartile of the Homeostasis Model Assessment-Insulin Resistance (HOMA-IR) index in individuals without known diabetes. RESULTS 1) The positive association between WC and IR is stronger in women than in men. 2) WC >88 cm alone is nearly as good as MetS, using NCEP criteria, in predicting IR in women. 3) According to the ROC curve, the optimal cut-off point for WC predicting IR was between 96 and 97 cm (men) and between 88 and 89 cm (women). The relative risk of IR was 5.6 (95% CI: 3.1-11.9) for women with WC >88 cm and 1.9 (1.5-2.8) for men with WC >96 cm. 4) The NCEP criteria predicts IR significantly better than the IDF criteria. CONCLUSION WC >88 cm in women indicates a high likelihood of IR and is almost as good as MetS defined using the NCEP criteria in predicting IR. MetS defined using the NCEP criteria predicts IR better than MetS defined using the IDF criteria.

Sustained prognostic implications of newly detected glucose abnormalities in patients with acute myocardial infarction: Long-term follow-up of the Glucose Tolerance in Patients with Acute Myocardial Infarction cohort

Objective: To investigate long-term prognostic importance of newly discovered glucose disturbances in patients with acute myocardial infarction (AMI). Methods: During 1998–2001, consecutive patients with AMI (n = 167) and healthy controls (n = 184) with no previously known diabetes were investigated with an oral glucose tolerance test (OGTT). Patients and controls were separately followed up for cardiovascular events (first of cardiovascular mortality/AMI/stroke/heart failure) during a decade. Results: In all, 68% of the patients and 35% of the controls had newly detected abnormal glucose tolerance (AGT). Cardiovascular event (n = 72, p = 0.0019) and cardiovascular mortality (n = 31, p = 0.031) were more frequent in patients with newly detected AGT. Regarding patients, a Cox proportional-hazard regression analysis identified AGT (hazard ratio (HR): 2.30; 95% confidence interval (CI): 1.24–4.25; p = 0.008) and previous AMI (HR: 2.39; CI: 1.31–4.35; p = 0.004) as prognostically important. Conclusion: An OGTT at discharge after AMI disclosed a high proportion of patients with previously unknown AGT which had a significant and independent association with long-term prognosis.

Elevated levels of adipokines predict outcome after acute myocardial infarction : a long-term follow-up of the glucose tolerance in patients with acute myocardial infarction cohort

Objective: Adiponectin and leptin are associated with insulin resistance and cardiovascular disease. Information on the prognostic value after an acute myocardial infarction is still conflicting. Methods: Patients (n = 180) without known diabetes and with admission glucose of <11 mmol/L admitted for an acute myocardial infarction in 1998–2000 were followed for mortality and cardiovascular events (first of cardiovascular mortality/acute myocardial infarction/stroke/heart failure) until the end of 2011 (median: 11.6 years). Plasma adiponectin and leptin were related to outcome in Cox proportional-hazard regression analyses. Results: Median age was 64 years and 69% were male. Total mortality was 34% (n = 61) and 44% (n = 80) experienced a cardiovascular event. Adiponectin at discharge predicted cardiovascular events (hazard ratio; 95% confidence interval; 1.45; 1.02–2.07, p = 0.038), total mortality (2.53; 1.64–3.91, p < 0.001) and cancer mortality (3.64; 1.51–8.74, p = 0.004). After adjustment for age, sex, body mass index, previous myocardial infarction and heart failure, adiponectin predicted total mortality (1.79; 1.07–3.00, p = 0.027) but not cardiovascular events. High levels of leptin were associated with cardiovascular events during the first 7 years, after which the association was attenuated. Leptin did not predict total mortality. Conclusion: In patients with acute myocardial infarction but without previously known diabetes, high levels of adiponectin at discharge predicted total mortality. The present results support the hypothesis that high rather than low levels of adiponectin predict mortality after acute myocardial infarction.