Association Between Glycemic Gap and In-hospital Outcomes in Aneurysmal Subarachnoid Hemorrhage

Introduction: Glycemic gap (GG), as determined by the difference between glucose and the hemoglobin A1c (HbA1c)-derived estimated average glucose (eAG), is associated with poor outcomes in various clinical settings. There is a paucity of data describing GG and outcomes after aneurysmal subarachnoid hemorrhage (aSAH). Our main objectives were to evaluate the association of admission glycemic gap (aGG) with in-hospital mortality and with poor composite outcome and to compare aGG's predictive value to admission serum glucose. Secondary outcomes were the associations between aGG and neurologic complications including vasospasm and delayed cerebral ischemia following aSAH.Methods: We retrospectively reviewed 119 adult patients with aSAH admitted to a single tertiary care neuroscience ICU. Spearman method was used for correlation for non-normality of data. Area under the curve (AUC) for Receiver Operating Characteristic (ROC) curve was used to estimate prediction accuracy of aGG and admission glucose on outcome measures. Multivariable analyses were conducted to assess the value of aGG in predicting in-hospital poor composite outcome and death.Results: Elevated aGG at or above 30 mg/dL was identified in 79 (66.4%) of patients. Vasospasm was not associated with the elevated aGG. Admission GG correlated with admission serum glucose (r = 0.94, p < 0.01), lactate (r = 0.41, p < 0.01), procalcitonin (r = 0.38, p < 0.01), and Hunt and Hess score (r = 0.51, p < 0.01), but not with HbA1c (r = 0.02, p = 0.82). Compared to admission glucose, aGG had a statistically significantly improved accuracy in predicting inpatient mortality (AUC mean ± SEM: 0.77 ± 0.05 vs. 0.72 ± 0.06, p = 0.03) and trended toward statistically improved accuracy in predicting poor composite outcome (AUC: 0.69 ± 0.05 vs. 0.66 ± 0.05, p = 0.07). When controlling for aSAH severity, aGG was not independently associated with delayed cerebral ischemia, poor composite outcome, and in-hospital mortality.Conclusion: Admission GG was not independently associated with in-hospital mortality or poor outcome in a population of aSAH. An aGG ≥30 mg/dL was common in our population, and further study is needed to fully understand the clinical importance of this biomarker.

Abstract 1122‐000119: Impact of Diabetes on Pass‐Number in Intracranial Thrombectomy for Large Vessel Occlusion Acute Ischemic Stroke

Introduction : Admission hyperglycemia is associated with poor functional outcomes, greater hemorrhagic risk and mortality after endovascular therapy (EVT) for large vessel occlusion (LVO) acute ischemic stroke (AIS). Diabetes is also linked with intracranial atherosclerosis. In this study, we examine whether underlying diabetes is associated with increased pass number requirements, as a possible etiology for worsened clinical outcomes in these patients. Methods : From our prospectively maintained multi‐institutional registry across 4 comprehensive stroke centers, we identified patients with LVO AIS undergoing EVT, for whom admission glucose, HbA1c as well as complete procedural details and 90 day outcome measures (mRS) had been captured. Diabetes was defined using HbA1c cutoff of ≥ 6.5% consistent with American Diabetes Association definitions. Admission hyperglycemia was defined as serum glucose on admission of >140 mg/dL. The primary outcome was number of EVT passes required for TICI ≥2b in diabetic vs. non‐diabetic patients. Results : Among 512 patients that met inclusion criteria, median age was 68 [IQR 58‐78], 254 (49.6%) were female, and median NIHSS was 16 [IQR 11‐20]. Median HbA1c was 5.8% (range 2.5‐14%), and 136 (26.6%) were diabetic. Mean admission glucose was greater in diabetic patients (122±30.7 vs. 199±79.8 mg/dL, non‐diabetic vs. diabetic, p<0.01). Admission hyperglycemia and HbA1≥6.5 were associated with lower rates of 90 day mRS 0–2 (24.0% vs 42.7%, hyperglycemia vs. no hyperglycemia, p<0.01; 28.7% vs. 39.1%, diabetes vs. no diabetes, p = 0.03). However, diabetics and patients presenting with hyperglycemia did not appear to require a higher number of passes to achieve TICI 2b or greater (1.83 vs 1.88, p = 0.69, 1.82 vs 1.88, p = 0.56, respectively) and had comparable first pass recanalization rates (56 vs 53%, p = 0.50, 56 vs 54, p = 0.72). Conclusions : Presentation hyperglycemia and diabetes were both associated with worsened clinical outcomes, but not with increased pass numbers or procedural time in EVT. These findings suggest alternative means by which clinical outcomes are worsened in this population.

Admission Glucose Levels and Associated Risk for Heart Failure After Myocardial Infarction in Patients Without Diabetes

Background Dysglycemia at acute myocardial infarction (AMI) is common and is associated with mortality. Information on other outcomes is less well explored in patients without diabetes in a long‐term perspective. We aimed to explore the relationship between admission glucose level and long‐term outcomes in patients with AMI without diabetes in a nationwide setting. Methods and Results Patients without diabetes (n=45 468) with AMI registered in SWEDEHEART (Swedish Web–System for Enhancement and Development of Evidence‐Based Care in Heart Disease Evaluated According to Recommended Therapies) and admission glucose ≤11 mmol/L (≤198 mg/dL) were followed for outcomes (AMI, heart failure, stroke, renal failure, and death) between 2012 and 2017 (mean follow‐up time 3.3±1.7 years). The association between categorized glucose levels and outcomes was assessed in adjusted Cox proportional hazards regression analyses (glucose levels 4.0–6.0 mmol/L [72–109 mg/dL] as reference). Further nonfatal complications and their associated mortality were explored (patients without events served as a reference). A glucose level of 7.8–11.0 mmol/L (140–198 mg/dL) was associated with hospitalization for heart failure (hazard ratio [HR] 1.40 [95% CI, 1.30–1.51], P <0.001), renal failure (1.17; 1.04–1.33, P =0.009), and death (1.31; 1.20–1.43, P <0.001), but not with recurrent myocardial infarction (0.99; 0.92–1.07, P =0.849) or stroke (1.03; 0.88–1.19, P =0.742). Renal failure had the strongest association with future mortality (age‐adjusted HR 4.93 [95% CI, 4.34–5.60], P <0.001), followed by heart failure (3.71; 3.41–4.04, P <0.001), stroke (3.39; 2.94–3.91, P <0.001), and myocardial infarction (2.08; 1.88–2.30, P <0.001). Conclusions Elevated glucose levels at AMI admission identifies patients without diabetes at increased risk of long‐term complications: in particular, hospitalization for heart and renal failure. These results emphasize that glucose levels at admission could be useful in risk assessment after myocardial infarction.

Admission glucose level and short-term mortality in older patients with acute myocardial infarction: results from the KORA Myocardial Infarction Registry

Study objectivesTo investigate the association between admission blood glucose levels and 28-day mortality as well as in-hospital complications in older patients with incident acute myocardial infarction (AMI) undergoing modern treatment.MethodsFrom a German population-based regional MI registry, 5530 patients (2016 women), aged 65–84 years, hospitalised with an incident AMI between 1 January 2009 and 31 December 2016 were included in the study. Multivariable logistic regression models were used to assess the associations between admission blood glucose and 28-day mortality as well as in-hospital complications after AMI. Analyses stratified according to age, diabetes and type of infarction (ST-elevation MI (STEMI)/non-STEMI) were conducted.ResultsThe adjusted ORs for the association between admission blood glucose and 28-day mortality in young-old (65–74 years) and old (75–84 years) patients with AMI were 1.40 (95% CI: 1.21 to 1.62) and 1.21 (95% CI: 0.98 to 1.50) per 1 SD increase in admission blood glucose, respectively. Furthermore, higher admission blood glucose was related to case fatality irrespective of the diabetes status and type of infarction only in the under-75 group. For the patients aged 75–84 years, it was only true for those without diabetes and STEMI. Admission blood glucose was also associated with major cardiac complications in both age groups.ConclusionAdmission blood glucose was significantly associated with 28-day case fatality in patients with AMI aged 65–74 years but not 75–84 years; furthermore, in both age groups there was an increased risk of major complications. It seems that admission glucose may play a rather minor role in terms of case fatality in higher aged patients with AMI.

Sugar Is Not Always Sweet: Exploring the Relationship Between Hyperglycemia and COVID-19 in a Predominantly African American Population

Introduction: A relationship between hyperglycemia and outcomes in patients with COVID-19 has been proposed, however there is a paucity of literature on this. In this study, we examined the effect of admission glucose in diabetics and non-diabetics on outcomes in patients hospitalized with COVID-19. Our study uniquely examines this association in a largely African American cohort, a population disproportionately affected by COVID-19. Methods: In this retrospective cohort study, we analyzed all adults admitted with COVID-19 to a designated COVID hospital in Brooklyn, NY from March 1 to May 15, 2020. Diabetics were compared to non-diabetics, and were further stratified based on admission glucoses of 140 and 180 mg/dL. Diagnosis of diabetes was based on history and/or Hba1c &gt; 6.5%. Univariate, multiple and logistic regressions were used for analyses, examining outcomes of mortality, intubation, ICU admission, acute kidney injury (AKI), and length of stay based on admission glucose levels, while controlling for age, gender, lab values (serum creatinine and WBC), and comorbidities including hypertension, cardiovascular disease, and obesity. Outcomes are presented as an adjusted odds ratio (OR) with 95% confidence interval (95% CI). Results: 708 patients were analyzed; 54% diabetics, 83.5% non-Hispanic Blacks, 51% male with a mean age of 68, BMI of 29 kg/m2 and crude mortality rate of 40%. The length of hospital stay was greater in diabetics than non-diabetics, (13±26 days vs 9.5±18.5 days, p&lt;0.05). Diabetics with an admission glucose &gt; 140 mg/dL (vs&lt;140 g/dL) had a 2.4-fold increased odds of both intubation and ICU admission (95% CI: 1.2, 4.5; 1.3, 4.6). Diabetics with admission glucoses &gt; 180 mg/dL (vs &lt;180 g/dL) had a 1.8-fold increased mortality (95% CI: 1.2, 2.9). Non-diabetics with admission glucoses &gt;140 mg/dL (vs&lt;140 g/dL) had a two-fold increased mortality (95% CI: 1.2, 3.5), 3.5-fold increased odds of ICU admission (95% CI: 1.8,6.6) and a 2.3-fold increased odds of both intubation and AKI (95% CI: 1.3, 4.2; 1.3,4.2). Non-diabetics with a glucose &gt;180 mg/dL (vs &lt;180 g/dL) had a four-fold increased mortality (95% CI: 1.8, 8.8), 2.7-fold increased odds of intubation (95% CI: 1.3, 5.6) and 2.9-fold increased odds of ICU admission (95% CI: 1.3, 6.2). Conclusion: Our results show hyperglycemia portends worse outcomes in diabetics and non-diabetics with COVID-19. Elevated admitting glucoses &gt;180 mg/dL increased odds of mortality four-fold in non-diabetics and 1.8- fold in diabetics. In COVID-19, diabetic patients had a 37% greater length of hospital stay than non-diabetics. Whether hyperglycemia is a marker or a cause of more severe COVID-19 is unknown. These findings suggest that patients presenting with hyperglycemia require closer observation and more aggressive therapies. This raises the testable hypothesis that intensive glucose control may improve outcomes in patients with COVID-19.

Personalized Consideration of Admission-Glucose Gap between Estimated Average and Initial Glucose Levels on Short-Term Stroke Outcome

Background: Poststroke hyperglycemia is associated with poor outcomes. Most prior studies used initial glucose as an indicator of poststroke hyperglycemia without considering glycemic control status at the time of stroke occurrence. We aimed to investigate the effect of an admission-glucose gap on short-term functional outcomes in acute ischemic stroke (AIS). Methods: We enrolled patients with AIS or transient ischemic attack who had been admitted within 7 days of symptom onset to three stroke centers from May 2016 to December 2019. The admission-glucose gap between estimated average glucose levels (eAG) and initial glucose level (eAG–initial glucose) was categorized into four groups. The short-term functional outcome was evaluated using the modified Rankin Scale (mRS) score at 3 months after stroke onset and was dichotomized. Results: Among 1332 included subjects, 548 (41.1%) had poor short-term functional outcomes. After adjusting for multiple variables, a severe negative glucose gap (eAG–initial glucose ≤ −50 mg/dL) was significantly associated with poor short-term functional outcome (OR, 1.573; 95% CI, 1.101–2.248). After dichotomizing glycemic control status, its significance was only maintained in the good glycemic control group (HbA1c < 6.5%) (OR, 1.914; 95% CI, 1.155–3.169). Conclusions: An elevated admission-glucose gap, in which the initial glucose level was much higher than the estimated glucose level was based on HbA1c, was associated with poor stroke prognosis. In addition to admission-glucose levels, glycemic control status at the time of stroke onset should be considered when predicting short-term stroke outcomes.

Hyperglycemia, inflammatory response and infarct size in obstructive acute myocardial infarction and MINOCA

Background Hyperglycemia has been associated with increased inflammatory indexes and larger infarct sizes in patients with obstructive acute myocardial infarction (obs-AMI). In contrast, no studies have explored these correlations in non-obstructive acute myocardial infarction (MINOCA). We investigated the relationship between hyperglycemia, inflammation and infarct size in a cohort of AMI patients that included MINOCA. Methods Patients with AMI undergoing coronary angiography between 2016 and 2020 were enrolled. The following inflammatory markers were evaluated: C-reactive protein, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and neutrophil-to-platelet ratio (NPR). Myocardial infarct size was measured by peak high sensitivity troponin I (Hs-TnI) levels, left-ventricular-end-diastolic-volume (LVEDV) and left ventricular ejection fraction (LVEF). Results The final study population consisted of 2450 patients with obs-AMI and 239 with MINOCA. Hyperglycemia was more prevalent among obs-AMI cases. In all hyperglycemic patients—obs-AMI and MINOCA—NLR, NPR, and LPR were markedly altered. Hyperglycemic obs-AMI subjects exhibited a higher Hs-TnI (p < 0.001), a larger LVEDV (p = 0.003) and a lower LVEF (p < 0.001) compared to normoglycemic ones. Conversely, MINOCA patients showed a trivial myocardial damage, irrespective of admission glucose levels. Conclusions Our data confirm the association of hyperglycemic obs-AMI with elevated inflammatory markers and larger infarct sizes. MINOCA patients exhibited modest myocardial damage, regardless of admission glucose levels.

Hyperglycemia, Inflammatory Response and Infarct Size in Obstructive Acute Myocardial Infarction and MINOCA

BackgroundHyperglycemia has been associated with increased inflammatory indexes and larger infarct sizes in patients with obstructive acute myocardial infarction (obs-AMI). In contrast, no studies have explored these correlations in non-obstructive acute myocardial infarction (MINOCA). We investigated the relationship between hyperglycemia, inflammation and infarct size in a cohort of AMI patients that included MINOCA.MethodsPatients with AMI undergoing coronary angiography between 2016 and 2020 were enrolled. The following inflammatory markers were evaluated: C-reactive protein, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and neutrophil-to-platelet ratio (NPR). Myocardial infarct size was measured by peak high sensitivity troponin I (Hs-TnI) levels, left-ventricular-end-diastolic-volume (LVEDV) and left ventricular ejection fraction (LVEF).ResultsThe final study population consisted of 2450 patients with obs-AMI and 239 with MINOCA. Hyperglycemia was more prevalent among obs-AMI cases. In all hyperglycemic patients - obs-AMI and MINOCA - NLR, NPR, and LPR were markedly altered. Hyperglycemic obs-AMI subjects exhibited a higher Hs-TnI (p < 0.001), a larger LVEDV (p = 0.003) and a lower LVEF (p < 0.001) compared to normoglycemic ones. Conversely, MINOCA patients showed a trivial myocardial damage, irrespective of admission glucose levels.ConclusionsOur data confirm the association of hyperglycemic obs-AMI with elevated inflammatory markers and larger infarct sizes. MINOCA patients exhibited modest myocardial damage, regardless of admission glucose levels.