3 research outputs found
Diabetes mellitus and coronary artery surgery : Clinical and epidemiological studies
Objectives: Assess early and late mortality and incidence of acute
myocardial infarction (AMI) after coronary artery bypass grafting (CABG)
in patients with and without diabetes mellitus (DM) in relation to type
of treatment. Analyse mortality after CABG in patients with and without
DM to examine if any difference was influenced by changes in prognosis
related to time-period. Measure glycosylated haemoglobin 1 (HbA1c) before
CABG to determine correlation to postoperative outcome. Determine if the
use of thoracic epidural analgesia (TEA) during and after CABG reduced
insulin requirements and hyperglycaemia in patients with and without DM.
Seek novel markers for morbidity and hospital stay after CABG by using
gene expression techniques.
Methods and Results: The risk of early mortality (≤30 days) was increased
in patients with insulin-treatment (odds ratio [OR] 4.6, 95% Confidence
Interval [CI], 2.5-8.4) and in those on oral antidiabetic drugs (OR 2.0,
95% CI 1.0-3.8), but not in diet treated patients compared with patients
without DM among 6727 patients who had CABG during 1980-1995. At 10 years
the relative risk of death or AMI was 1.8 (95% CI 1.5-2.2) in
insulin-treated patients and 1.4 (95% CI 1.2-1.7) in patients on oral
drugs but there was no increased risk in diet treated patients compared
with patients without DM. Survival at 10 years without AMI was 40% in
patients with insulin-treatment, 48% if on oral drugs, 59% if diet
managed, compared with 66% in patients without DM.
Early mortality was 3.4% in patients with DM versus 1.8% in patients
without DM (OR 2.0, 95% CI 1.4-2.7) among 12,557 patients who had CABG
during 1970-2003. Early mortality was reduced in patients operated on
2000-03 compared with 1970-89 in patients with DM (OR 0.3, 95% CI
0.1-0.9) and in those without DM (OR 0.4, 95% CI 0.2-0.7). Five-year
mortality was 14.6% in patients with DM versus 8.3% in those without DM
(hazard ratio 1.8, 95% CI 1.5-2.0). Five-year mortality was reduced 40%
in patients operated on 2000-03 compared to 1970-89 in patients with and
without DM.
Superficial sternal wound infection after CABG occurred in 13,9% of
patients with preoperative HbA1c level ≥6% versus in 5,5% if HbA1c <6%
(p=0.007). Mortality at an average of 3.5 years after CABG was 18.9% in
patients with HbA1c ≥6% compared with 4.1% if HbA1c <6% (p<0.001, hazard
ratio 5.4, 95% CI 3.0-10.0).TEA was used during and three days after CABG
in half of 44 patients with DM and 60 without DM. TEA reduced mean blood
glucose (BG) and insulin requirements (p<0.02) during the initial 24
hours in patients without DM whereas in patients with DM mean BG level
was reduced (p=0.017) with unchanged insulin requirements. TEA did not
attenuate hyperglycaemia during the first three postoperative days or
diminish the increased fasting BG on the third postoperative day in
patients without DM. Metabolic gene expression profiles were analysed in
biopsies obtained during CABG in 66 patients. Patients with DM and not
diagnosed DM had prolonged hospitalization time. Levels of the
anti-inflammatory gene dual-specificity phosphatase 1 (DUSP1) in skeletal
muscle differed in patients with normal (≤8 days) versus long
hospitalization (>8 days, p=0.003).
Conclusions: DM was associated with an increased risk of early and late
mortality. Early and late mortality was reduced in patients with and
without DM operated on more recently but the mortality disadvantage
associated with DM was not eliminated. HbA1c level ≥6% was associated
with increased risk ofwound infection and higher mortality at three years
after CABG. TEA improved glucose homeostasis minimally during the initial
24 postoperative hours but did not attenuate hyperglycaemia during
subsequent three postoperative days. Levels of DUSP1 expression predicted
hospitalization time and may be of use to predict outcome after CABG