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Glucose level may predict CV risk after noncardiac surgery, regardless of diabetes status
Elevated casual or fasting glucose levels measured before noncardiac surgery may predict risk for myocardial injury and death in the days after surgery regardless of diabetes status, according to study findings published in Lancet Diabetes & Endocrinology.
“Although the mechanisms remain unclear, glucose concentrations show a continuous relation with future cardiovascular disease in patients with or without diabetes and in the general population, beginning at concentrations well below those used to define diabetes,” Zubin Punthakee, MD, of the Population Health Research Institute at McMaster University, Hamilton, Ontario, Canada, and colleagues wrote. “These associations have been observed in ambulatory settings and specialized hospital settings; however, the relation between preoperative glucose concentration and morbidity in patients undergoing a broad range of non-cardiac surgeries has not been systematically studied in large numbers of patients.”
In a prospective analysis, Punthakee and colleagues analyzed data from 11,954 patients aged at least 45 years who required at least one overnight hospital admission for noncardiac surgery between August 2006 and January 2011, as part of the GlucoVISION study, conducted at 12 centers in eight countries (mean age, 66 years; 51% women). Primary outcome was myocardial injury in the 3 days after noncardiac surgery, defined as any troponin T value of 0.03 ng/mL or more. Secondary outcome was time to death within the first 30 days after surgery from any cause.
Researchers used logistic regression analysis to assess the relationship between preoperative, casual or fasting glucose concentrations and myocardial injury within 3 days of noncardiac surgery, and 30-day mortality risk using Cox proportional regression models in people with and without diabetes.
Within the cohort, 2,809 patients (23%) had diabetes. In the 3 days after noncardiac surgery, 813 patients (7%) experienced a myocardial injury and 249 patients (2%) died in the 30 days after surgery.
Researchers found that patients with diabetes were nearly twice as likely to experience myocardial injury after noncardiac surgery (OR = 1.98; 95% CI, 1.7-2.3) and had increased risk for death within 30 days of surgery (OR = 1.41; 95% CI, 1.08-1.86) vs. patients without diabetes. However, in patients with and without diabetes, researchers found that casual glucose concentrations were associated with risk for both myocardial injury after noncardiac surgery (adjusted HR = 1.06; 95% CI, 1.04-1.09 per 1 mmol/L increment in glucose) and risk for death within 30 days (adjusted HR = 1.13; 95% CI, 1.05-1.23 per mmol/L). Additionally, researchers noted a progressive relationship between unadjusted fasting glucose concentration and risk for both myocardial injury (OR = 1.14; 95% CI, 1.08-1.2 per mmol/L) and death within 30 days (HR = 1.1; 95% CI, 1.02-1.19 per mmol/L) driven by the effect in the subgroup without diabetes (P = .025 for interaction).
For patients without diabetes, researchers found that a casual glucose level of at least 6.86 mmol/L and a fasting glucose level of at least 6.41 mmol/L predicted risk for myocardial injury in the 3 days after noncardiac surgery, with ORs of 1.71 (95% CI, 1.36-2.15) and 2.71 (95% CI, 1.85-3.98), respectively.
“These relations are particularly evident for casual glucose concentrations and for people without known diabetes before surgery,” the researchers wrote. “Moreover, for casual glucose concentrations, these associations cannot be explained by other common cardiac risk factors.”
The researchers noted that there is potential clinical utility in the consideration of preoperative glucose concentrations.
“Surgeons and cardiologists, internists and anesthetists who consult on surgical patients can easily obtain glucose measurements in a matter of minutes and can now assess the incremental risk using empirically determined glucose thresholds, even after considering all the other known preoperative and prognostic factors. These results have the potential to enhance conversations about prognosis and decision making before going to surgery.” – by Regina Schaffer
Disclosures: Punthakee reports he has received grants or personal or advisory fees from Amgen, Astra Zeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lilly, Janssen, Lexicon, Merck, Novo Nordisk, Pfizer and Sanofi. Please see the study for the other authors’ relevant financial disclosures.