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Frequency of Undiagnosed Diabetes Mellitus in Patients With Acute Coronary Syndrome

2005; Elsevier BV; Volume: 96; Issue: 3 Linguagem: Inglês

10.1016/j.amjcard.2005.03.076

1879-1913

Darcy Green Conaway, James H. O’Keefe, Kimberly J. Reid, John A. Spertus,

Cardiovascular Function and Risk Factors

In a prospective cohort of patients who had acute coronary syndrome, we used a simple fasting plasma glucose to identify previously unrecognized diabetes mellitus. A total of 57% of patients who had acute coronary syndrome had abnormal glucose metabolism; ∼66% of those who met criteria for new diabetes were not diagnosed or treated as such by the physicians who managed them. In a prospective cohort of patients who had acute coronary syndrome, we used a simple fasting plasma glucose to identify previously unrecognized diabetes mellitus. A total of 57% of patients who had acute coronary syndrome had abnormal glucose metabolism; ∼66% of those who met criteria for new diabetes were not diagnosed or treated as such by the physicians who managed them. To date, no study has described practice patterns in evaluating high-risk patients who have acute coronary syndrome (ACS) for the diagnosis of diabetes mellitus (DM). Because DM is considered by many to be a coronary atherosclerotic disease equivalent,1Adult Treatment Panel IIIExecutive summary of the 3rd report of the National Cholesterol Expert Panel on detection, evaluation, and treatment of elevated blood cholesterol in adults (ATPIII).JAMA. 2001; 285: 2486-2497Crossref PubMed Scopus (24729) Google Scholar it follows that 1 way to "catch" some of these undiagnosed patients is to screen patients who present with an ACS with a simple fasting plasma glucose (FPG) test. We sought to (1) describe the prevalence of DM, recognized and unrecognized, among a cohort of patients who presented with an ACS and (2) offer ways to expedite the process of the diagnosis of DM. Patients were prospectively enrolled into an ACS registry at 2 hospitals in Kansas City, Missouri, the Mid America Heart Institute and Truman Medical Center. There were 10,911 consecutive patients who were admitted between March 1, 2001 and October 31, 2002, had a troponin blood test ordered, and were screened for a possible ACS. Standard definitions were used to diagnose ACS in patients who had acute myocardial infarction2Morrow D.A. Antman E.M. Charlesworth A. Cairns R. Murphy S.A. de Lemos J.A. Giugliano R.P. McCabe C.H. Braunwald E. TIMI risk score for ST-elevation myocardial infarction: a convenient, bedside, clinical score for risk assessment at presentation. An intravenous nPA for treatment of infarcting myocardium early II trial substudy.Circulation. 2000; 102: 2031-2037Crossref PubMed Scopus (1209) Google Scholar or unstable angina.3Braunwald E. Unstable angina. A classification.Circulation. 1989; 80: 410-414Crossref PubMed Scopus (1255) Google Scholar Those who had acute myocardial infarction were defined by a positive troponin blood test result in the setting of symptoms or electrocardiographic changes (ST-segment elevation and non-ST-segment elevation changes) consistent with myocardial infarction. Unstable angina was diagnosed if the patient had a negative troponin blood test result and any 1 of the following characteristics: new-onset angina ( 20 minutes) angina at rest, recent ( 40, 6.8% for recognized vs 6.1% for unrecognized) and a lack of previous angina (18.2% for recognized vs 39.0% for unrecognized, p = 0.017). Importantly, we found a substantial number of patients who had high FPG levels (252 of 878, 29%), thus qualifying them for a diagnosis of impaired fasting glucose level. None of these patients received such a diagnosis (Figure 2).Figure 2Among 1,199 patients who presented with ACS, 321 (27%) had known DM on admission. After excluding these, an additional 126 of 878 patients (14%) met criteria for a diagnosis of new-onset DM. Another 252 of 878 patients (29%) received a new diagnosis of impaired fasting glucose metabolism.View Large Image Figure ViewerDownload (PPT)Figure 3Of 126 patients who presented with ACS and met the criteria for new DM with a high FPG level, 44 of 126 (35%) were recognized as having DM by physicians. In the remaining 82 (65%), DM remained undiagnosed on hospital discharge.View Large Image Figure ViewerDownload (PPT) Of the 1,199 enrolled patients who had ACS, FPG levels were not available for 278. We included these patients with those who had "normal glucose metabolism" (Figure 1). This undoubtedly resulted in under-representation of patients who had abnormal glucose metabolism. This study confirms previous trials that suggested that DM is often unrecognized and uncontrolled in patients who present with an acute myocardial infarction.4Norhammar A. Tenerz A. Nilsson G. Hamsten A. Efendic S. Ryden L. Malmberg K. Glucose metabolism in patients with acute myocardial infarction and no previous diagnosis of diabetes mellitus a prospective study.Lancet. 2002; 359: 2140-2144Abstract Full Text Full Text PDF PubMed Scopus (948) Google Scholar Using a simple FPG test, we found that 14% of patients (n = 126) who did not have a previous diagnosis of DM and presented with ACS met criteria for a new diagnosis of DM. Although many patients met criteria for diagnosis, only 35% (n = 44) were actually given a diagnosis and treated for their DM. The remaining 65% (n = 82) were left undiagnosed and, hence, untreated on discharge. In addition, we identified another 252 patients who met criteria for impaired FPG, i.e., insulin resistance or prediabetes. Patients who have DM or the metabolic syndrome are at markedly higher risk for recurrent cardiovascular events after ACS.5Tenerz A. Norhammar A. Silveira A. Hamsten A. Nilsson G. Ryden L. Malmberg K. Diabetes, insulin resistance, and the metabolic syndrome in patients with acute myocardial infarction without previously known diabetes.Diabetes Care. 2003; 26: 2770-2776Crossref PubMed Scopus (115) Google Scholar There are several limitations worth noting in this study. First, the use of FPG values to diagnose DM in the setting of an ACS is controversial, because the stress of a serious medical illness or major surgery can temporarily increase glucose levels. However, a recent study has suggested that most patients who have DM that is newly diagnosed during hospitalization for ACS continue to have increased glucose levels after 3 months.5Tenerz A. Norhammar A. Silveira A. Hamsten A. Nilsson G. Ryden L. Malmberg K. Diabetes, insulin resistance, and the metabolic syndrome in patients with acute myocardial infarction without previously known diabetes.Diabetes Care. 2003; 26: 2770-2776Crossref PubMed Scopus (115) Google Scholar This study showed that ∼33% of the cohort had new DM and another 33% had impaired FPG metabolism. After performing a glucose tolerance test in an outpatient setting 3 months later, nearly all patients continued to show abnormal glucose metabolism. Second, our study population consisted predominantly of white men from the Midwest of the United States and thus may not be representative of other populations. The ACS cohort in this study comprised patients from 2 hospitals, an inner-city teaching institution and a private tertiary care hospital.