IMPACT OF HbA1c ON

ACUTE CARDIAC STATESJAPI –JUNE 2011

DR.PRAVEEN NAGULA

INTRODUCTION

DIABETES is a highly vascular disease with both macrovascular and microvascular complications.

Macrovascular complications start before the patient has overt diabetes.

Hyperglycemia accelerates the process of atherosclerosis by the formation of glycated proteins,AGES—increased endothelial dysfunction.

HBA1C is a good marker of glycated proteins.FRAMINGHAM study cardiovascular mortality is twice in diabetic

men ,four times in diabetic women.HBA1C > 7% - risk of cardiovascular events and death.

The correlation between higher HbA1 c levels and increased cardiovascular morbidity occurs even before the diagnosis of clinical diabetes…

Gerstein HC ,glycosylated Hb –finally ready for prime time as a cardiovascular risk factor –Ann Int Med 2004;141:475-6

CORRELATION between HbA1C levels and the severity and complications of patients admitted with acute cardiac states to the ICU of CMC,ludhiana.

4 monthsAcute cardiac states –UA,STEMI,NSTEMI,DCM,HF,AH.Patients with sepsis,hemoglobinopathy,hypothyroidism were

excluded.Inv done were HbA1C,Lipids,cardiac enzymes,ECG,ECHO.Followed up till discharge.Complications noted –arrhythmias,CF,cardiogenic shockHBA1C –diastat by biorad.

Hb A combines with glucose at valine ,terminal of b chain.Blood glucose HbA1c levelsWhy HbA1c levels are indicated –slow rate of combination with

glucose.Normal 4-5.9%>9 % --poor control>12% --very poor control.<7% - goal in diabetesDiabetes –HBA1C >6.5% -- ADA guidelines,diabetes care ,2010

166 patientsGroup A –diabetesGroup B –non diabetes44 cases in group A – developed the cardiac event < 5 yrs of

diagnosis.Acute cardiac state as presenting complaint of diabetes – 19

cases.Orthopnea,pedal edema more in group A ,group B –angina.HTN,CAD h/o – group A ,smoking,positive family h/o in group B.DCM,HF more in group A.

BLOOD SUGARS ,,HbA1c levels.

RBS >200 mg/dl – 67 cases in group A,32 > 300GROUP B -25 cases had RBS >140 mg/dl ,5 cases > 200

mg/dl(stress hyperglycemia)Mean HBa1C levels – 8.4% ,5.7 % in group B.Fairly good control -- < 7% -- had cardiac events – 22 cases.First diagnosis of diabetes -- > 7% - 13 cases.Group b 26 cases > 5.6 -- 6%..pre diabetes.

DISCUSSION

EARLIER CAD.Extensive atherosclerosis.HTN (68% vs 50% ),hypertriglyceridemia(43.5% vs 20% )Low HDL lvels 78.3%,previous h/o CAD (53% vs 28.4%)Stress hyperglycemia – 140-300 mg/dl(500mg/dl)Hyperglycemia with normal HbA1c does not rule out the

diagnosis of diabetes..follow up needed.Hyperglycemia mortality. In AMIHb A1c > 7% --more UA,STEMI,DCM,AH,TVD,re infarction

BERTONI et al

from 1994 to 1999 151,738 beneficiaries with diabetes who were age 65 years, RESULTS — Heart failure was prevalent in 22.3% in 1994. Among individuals

without heartfailure in 1994, the heart failure incidence rate was 12.6 per 100 person-years (95% CI 12.5–12.7 per 100 person-years).

Incidence was similar by sex and race and increased significantly with age and diabetes-related comorbidities.

Over 60 months, incident heart failure among older adults with diabetes was associated with high mortality—32.7 per 100 person-years compared with 3.7 per 100 person-years amongthose with diabetes who remained heart failure free.

CONCLUSIONS — These data demonstrate alarmingly high prevalence, incidence, andmortality for heart failure in individuals with diabetes. Prevention of heart failure should be research and clinical priority

LU et al

STRONG HEART STUDYAmerican indians American Diabetes Association guidelines for glycaemic

control were used: good, A1c < 7%; fair, 7–7.9%; and poor, ≥ 8%.

9 years of follow-upshowed that diabetic individuals with poor baseline

glycaemic control had significantly increased proportions of overall CVD and CHD (P = 0.001) during the 9 years of follow-up, compared with those who had good or fair control.

hyperglycemia

ApoptosisMyocyte necrosis – systolic,diastolic dysfunction.Diabetic cardiomyopathy is related directly to hyperglycemia. Cell

death such as apoptosis plays a critical rolein cardiac pathogenesis. Whether hyperglycemia induces myocardial apoptosis, leading to diabetic cardiomyopathy, remains unclear. We tested the hypothesis that apoptotic cell death occurs in the diabetic myocardium through mitochondrial cytochrome c–mediated caspase-3 activation pathway.

Diabetic mice producedby streptozotocin and H9c2 cardiac myoblast cells exposed to high levels of glucose were used. In the hearts of diabetic mice, apoptotic cell death occurred.

UKPDS study

Intensive glycemic control HBA1C < 7% -- 16% reduction in MI

In this study HbA1c - CARDIOVASCULAR disease – 5.7% - more than normal.Mean HbA1c LEVELS IN ASIA -- Mean A1C was 5.5 0.4%, range 4.0 – 6.8%. MACROVASCULAR complications take place at lower blood glucose levels --

jama 1990.These results indicate that prediabetic subjects have an atherogenic

pattern of risk factors (possibly caused by obesity, hyperglycemia, and especially hyperinsulinemia), which may be present for many years and may contribute to the risk of macrovascular disease as much as the duration of clinical diabetes itself.

HbA1C < 5% - LOWEST RATES OF CV mortality.1% increase in HbA1C – 2.5 TIMES risk of CVD. – selvin et alindependent of age, body mass index, waist-to-hip ratio, systolic

bloodpressure, serum cholesterol concentration, cigarette smoking, and history of cardiovascular disease.

HbA1c levels

5 % -97mg/dl (76–120)6% - 126mg/dl (100–152)7% - 154 mg/dl (123–185)

drawbacksSmall groupAngiography not done in allPatients died within few hours were not included.

Take home message

UA,STEMI,DCM,HF cardiomyopathy,reinfarction - HbA1C > 7%.DIABETES to be diagnosed early and for detection of CAD lower

levels of HbA1c than present >6.5%.Every 1 % increase in HbA1c over 4.6% - 2.5 times risk of CVD.Hyperglycemia induces apoptosis,necrosis –SD,DDHyperglycemia mortality in AMI.Stress hyperglycemia – 140-300 mg/dl.Orthopnea and pedal edema more common in diabetes.CAD may be presenting symptom of diabetes.HbA1c levels to be

monitored.

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