Correlation between HbA1c on admission and blood glucose fluctuations and adverse events after coronary artery bypass grafting in non-diabetic patients_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

WANG Qianwei , SU Pixiong , GU Song , YAN Jun , ZHANG Xitao , GAO Jie , GUO Yulin , XIN Yue , GUO Dalei ,  LIU Yan

Department of Cardiothoracic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing Institute of Hypertension Disease, Beijing, 100020, P.R.China;

Corresponding author：

LIU Yan, Email: liuyanlhn@163.com

Keywords：

Non-diabetic patients; glycated hemoglobin; coronary artery bypass grafting; major adverse events; blood glucose fluctuation

DOI：

10.7507/1007-4848.201901012

Video：

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Objective To explore the relationship between glycated hemoglobin (HbA1c) level and blood glucose fluctuations after coronary artery bypass grafting (CABG) and adverse events in non-diabetic patients, thus providing theoretical support for intensive preoperative blood glucose management in patients undergoing CABG surgery.Methods A total of 304 patients undergoing CABG with or without valvular surgery from October 2013 to December 2017 were enrolled in this prospective, single-center, observational cohort study. We classified them into two different groups which were a low-level group and a high-level group according to the HbA1c level. There were 102 males and 37 females, aged 36–85 (61.5±9.5) years in the low-level group, and 118 males and 47 females aged 34–85 (63.1±9.4) years in the high-level group. The main results were different in hospital mortality and perioperative complications including in-hospital death, myocardial infarction, sternal incision infection, new stroke, new-onset renal failure and multiple organ failure. To assess the effects of confounding factors, multivariate logistic regression analysis was used.Results Postoperative blood glucose fluctuation was more pronounced in the high-level group than that in the low-level group before admission [0.8 (0.6, 1.2) mmol/L vs. 1.0 (0.8, 1.8) mmol/L, P<0.01]. This study also suggested that the incidence of major adverse events was significantly lower in the low-level group compared with the high-level group (P=0.001). Multivariate logistic regression analyses to correct the influence of other confounding factors showed that HbA1c (OR=2.773, P=0.002) and postoperative blood glucose fluctuations (OR=3.091, P<0.001) could still predict the occurrence of postoperative adverse events.Conclusion HbA1c on admission can effectively predict blood glucose fluctuations in 24 hours after surgery. Secondly, HbA1c on admission and postoperative blood glucose fluctuations can further predict postoperative adverse events. It is suggested that we control the patient's preoperative HbA1c at a low level, which is beneficial to control postoperative blood glucose fluctuation and postoperative adverse events.

Citation： WANG Qianwei, SU Pixiong, GU Song, YAN Jun, ZHANG Xitao, GAO Jie, GUO Yulin, XIN Yue, GUO Dalei, LIU Yan. Correlation between HbA1c on admission and blood glucose fluctuations and adverse events after coronary artery bypass grafting in non-diabetic patients. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2019, 26(10): 963-967. doi: 10.7507/1007-4848.201901012 Copy

1.	Doenst T, Wijeysundera D, Karkouti K, et al. Hyperglycemia during cardiopulmonary bypass is an independent risk factor for mortality in patients undergoing cardiac surgery. J Thorac Cardiovasc Surg, 2005, 130(4): 1144.
2.	Alserius T, Anderson RE, Hammar N, et al. Elevated glycosylated haemoglobin (HbA1c) is a risk marker in coronary artery bypass surgery. Scand Cardiovasc J, 2008, 42(6): 392-398.
3.	Schmeltz LR, DeSantis AJ, Thiyagarajan V, et al. Reduction of surgical mortality and morbidity in diabetic patients undergoing cardiac surgery with a combined intravenous and subcutaneous insulin glucose management strategy. Diabetes Care, 2007, 30(4): 823-828.
4.	McAlister FA, Man J, Bistritz L, et al. Diabetes and coronary artery bypass surgery: an examination of perioperative glycemic control and outcomes. Diabetes Care, 2003, 26(5): 1518-1524.
5.	Galindo RJ, Fayfman M, Umpierrez GE. Perioperative management of hyperglycemia and diabetes in cardiac surgery patients. Endocrinol Metab Clin North Am, 2018, 47(1): 203-222.
6.	Buehler L, Fayfman M, Alexopoulos AS, et al. The impact of hyperglycemia and obesity on hospitalization costs and clinical outcome in general surgery patients. J Diabetes Complications, 2015, 29(8): 1177-1182.
7.	Székely A, Levin J, Miao Y, et al. Impact of hyperglycemia on perioperative mortality after coronary artery bypass graft surgery. J Thorac Cardiovasc Surg, 2011, 142(2): 430-437.
8.	Frisch A, Chandra P, Smiley D, et al. Prevalence and clinical outcome of hyperglycemia in the perioperative period in noncardiac surgery. Diabetes Care, 2010, 33(8): 1783-1788.
9.	American Diabetes Association. 2. Classification and diagnosis of diabetes: standards of medical care in diabetes—2018. Diabetes Care, 2018, 41(Suppl 1): S13-S27.
10.	中华医学会糖尿病学分会. 中国2型糖尿病防治指南(2017年版). 中华糖尿病杂志, 2018, 10(1): 4.
11.	McGinn JT Jr, Shariff MA, Bhat TM, et al. Prevalence of dysglycemia among coronary artery bypass surgery patients with no previous diabetic history. J Cardiothorac Surg, 2011, 6: 104.
12.	Duncan AE, Abd-Elsayed A, Maheshwari A, et al. Role of intraoperative and postoperative blood glucose concentrations in predicting outcomes after cardiac surgery. Anesthesiology, 2010, 112(4): 860-871.
13.	Lazar HL, Chipkin SR, Fitzgerald CA, et al. Tight glycemic control in diabetic coronary artery bypass graft patients improves perioperative outcomes and decreases recurrent ischemic events. Circulation, 2004, 109(12): 1497-1502.
14.	Jung HS. Clinical implications of glucose variability: chronic complications of diabetes. Endocrinol Metab (Seoul), 2015, 30(2): 167-174.
15.	Gatti G, Perrotti A, Reichart D, et al. Glycated hemoglobin and risk of sternal wound infection after isolated coronary surgery. Circ J, 2016, 81(1): 36-43.
16.	Verdoia M, Schaffer A, Barbieri L, et al. Glycosylated hemoglobin and the risk of periprocedural myocardial infarction in non-diabetic patients. J Diabetes Complications, 2015, 29(4): 517-522.
17.	Halkos ME, Puskas JD, Lattouf OM, et al. Elevated preoperative hemoglobin A1c level is predictive of adverse events after coronary artery bypass surgery. J Thorac Cardiovasc Surg, 2008, 136(3): 631-640.
18.	Gumus F, Polat A, Sinikoglu SN, et al. Use of a lower cut-off value for HbA1c to predict postoperative renal complication risk in patients undergoing coronary artery bypass grafting. J Cardiothorac Vasc Anesth, 2013, 27(6): 1167-1173.
19.	Subramaniam B, Lerner A, Novack V, et al. Increased glycemic variability in patients with elevated preoperative HbA1C predicts adverse outcomes following coronary artery bypass grafting surgery. Anesth Analg, 2014, 118(2): 277-287.
20.	Egi M, Bellomo R, Stachowski E, et al. Variability of blood glucose concentration and short-term mortality in critically ill patients. Anesthesiology, 2006, 105(2): 244-252.
21.	Bardia A, Khabbaz K, Mueller A, et al. The association between preoperative hemoglobin A1C and postoperative glycemic variability on 30-day major adverse outcomes following isolated cardiac valvular surgery. Anesth Analg, 2017, 124(1): 16-22.
22.	王锦, 吴海鹰, 张红仙, 等. 血糖变异性对脓毒症28d死亡率临床影响. 昆明医科大学学报, 2014, 35(1): 98-101.
23.	Lee SH, Han K, Cho H, et al. Variability in metabolic parameters and risk of dementia: a nationwide population-based study. Alzheimers Res Ther, 2018, 10(1): 110.
24.	Ceriello A, Esposito K, Piconi L, et al. Oscillating glucose is more deleterious to endothelial function and oxidative stress than mean glucose in normal and type 2 diabetic patients. Diabetes, 2008, 57(5): 1349-1354.
25.	Casqueiro J, Casqueiro J, Alves C. Infections in patients with diabetes mellitus: A review of pathogenesis. Indian J Endocrinol Metab, 2012, 16 Suppl 1: S27-S36.
26.	Koh GC, Peacock SJ, van der Poll T, et al. The impact of diabetes on the pathogenesis of sepsis. Eur J Clin Microbiol Infect Dis, 2012, 31(4): 379-388.

1. Doenst T, Wijeysundera D, Karkouti K, et al. Hyperglycemia during cardiopulmonary bypass is an independent risk factor for mortality in patients undergoing cardiac surgery. J Thorac Cardiovasc Surg, 2005, 130(4): 1144.
2. Alserius T, Anderson RE, Hammar N, et al. Elevated glycosylated haemoglobin (HbA1c) is a risk marker in coronary artery bypass surgery. Scand Cardiovasc J, 2008, 42(6): 392-398.
3. Schmeltz LR, DeSantis AJ, Thiyagarajan V, et al. Reduction of surgical mortality and morbidity in diabetic patients undergoing cardiac surgery with a combined intravenous and subcutaneous insulin glucose management strategy. Diabetes Care, 2007, 30(4): 823-828.
4. McAlister FA, Man J, Bistritz L, et al. Diabetes and coronary artery bypass surgery: an examination of perioperative glycemic control and outcomes. Diabetes Care, 2003, 26(5): 1518-1524.
5. Galindo RJ, Fayfman M, Umpierrez GE. Perioperative management of hyperglycemia and diabetes in cardiac surgery patients. Endocrinol Metab Clin North Am, 2018, 47(1): 203-222.
6. Buehler L, Fayfman M, Alexopoulos AS, et al. The impact of hyperglycemia and obesity on hospitalization costs and clinical outcome in general surgery patients. J Diabetes Complications, 2015, 29(8): 1177-1182.
7. Székely A, Levin J, Miao Y, et al. Impact of hyperglycemia on perioperative mortality after coronary artery bypass graft surgery. J Thorac Cardiovasc Surg, 2011, 142(2): 430-437.
8. Frisch A, Chandra P, Smiley D, et al. Prevalence and clinical outcome of hyperglycemia in the perioperative period in noncardiac surgery. Diabetes Care, 2010, 33(8): 1783-1788.
9. American Diabetes Association. 2. Classification and diagnosis of diabetes: standards of medical care in diabetes—2018. Diabetes Care, 2018, 41(Suppl 1): S13-S27.
10. 中华医学会糖尿病学分会. 中国2型糖尿病防治指南(2017年版). 中华糖尿病杂志, 2018, 10(1): 4.
11. McGinn JT Jr, Shariff MA, Bhat TM, et al. Prevalence of dysglycemia among coronary artery bypass surgery patients with no previous diabetic history. J Cardiothorac Surg, 2011, 6: 104.
12. Duncan AE, Abd-Elsayed A, Maheshwari A, et al. Role of intraoperative and postoperative blood glucose concentrations in predicting outcomes after cardiac surgery. Anesthesiology, 2010, 112(4): 860-871.
13. Lazar HL, Chipkin SR, Fitzgerald CA, et al. Tight glycemic control in diabetic coronary artery bypass graft patients improves perioperative outcomes and decreases recurrent ischemic events. Circulation, 2004, 109(12): 1497-1502.
14. Jung HS. Clinical implications of glucose variability: chronic complications of diabetes. Endocrinol Metab (Seoul), 2015, 30(2): 167-174.
15. Gatti G, Perrotti A, Reichart D, et al. Glycated hemoglobin and risk of sternal wound infection after isolated coronary surgery. Circ J, 2016, 81(1): 36-43.
16. Verdoia M, Schaffer A, Barbieri L, et al. Glycosylated hemoglobin and the risk of periprocedural myocardial infarction in non-diabetic patients. J Diabetes Complications, 2015, 29(4): 517-522.
17. Halkos ME, Puskas JD, Lattouf OM, et al. Elevated preoperative hemoglobin A1c level is predictive of adverse events after coronary artery bypass surgery. J Thorac Cardiovasc Surg, 2008, 136(3): 631-640.
18. Gumus F, Polat A, Sinikoglu SN, et al. Use of a lower cut-off value for HbA1c to predict postoperative renal complication risk in patients undergoing coronary artery bypass grafting. J Cardiothorac Vasc Anesth, 2013, 27(6): 1167-1173.
19. Subramaniam B, Lerner A, Novack V, et al. Increased glycemic variability in patients with elevated preoperative HbA1C predicts adverse outcomes following coronary artery bypass grafting surgery. Anesth Analg, 2014, 118(2): 277-287.
20. Egi M, Bellomo R, Stachowski E, et al. Variability of blood glucose concentration and short-term mortality in critically ill patients. Anesthesiology, 2006, 105(2): 244-252.
21. Bardia A, Khabbaz K, Mueller A, et al. The association between preoperative hemoglobin A1C and postoperative glycemic variability on 30-day major adverse outcomes following isolated cardiac valvular surgery. Anesth Analg, 2017, 124(1): 16-22.
22. 王锦, 吴海鹰, 张红仙, 等. 血糖变异性对脓毒症28d死亡率临床影响. 昆明医科大学学报, 2014, 35(1): 98-101.
23. Lee SH, Han K, Cho H, et al. Variability in metabolic parameters and risk of dementia: a nationwide population-based study. Alzheimers Res Ther, 2018, 10(1): 110.
24. Ceriello A, Esposito K, Piconi L, et al. Oscillating glucose is more deleterious to endothelial function and oxidative stress than mean glucose in normal and type 2 diabetic patients. Diabetes, 2008, 57(5): 1349-1354.
25. Casqueiro J, Casqueiro J, Alves C. Infections in patients with diabetes mellitus: A review of pathogenesis. Indian J Endocrinol Metab, 2012, 16 Suppl 1: S27-S36.
26. Koh GC, Peacock SJ, van der Poll T, et al. The impact of diabetes on the pathogenesis of sepsis. Eur J Clin Microbiol Infect Dis, 2012, 31(4): 379-388.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Correlation between HbA1c on admission and blood glucose fluctuations and adverse events after coronary artery bypass grafting in non-diabetic patients

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