Multidisciplinary intervention for control of diabetes in patients undergoing coronary artery bypass graft (CABG) (original) (raw)

2003, Cardiovascular Surgery

https://doi.org/10.1016/S0967-2109(03)00019-X

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Abstract

In Israel, as elsewhere, diabetes mellitus is highly prevalent among patients undergoing coronary artery bypass graft (CABG). The bulk of evidence, derived retrospectively, suggests that poor control of diabetes predisposes to complications of CABG and increases mortality; but the findings in a number of studies fail to support that impression.

Glycated Hemoglobin as a Predictor of the Length of Hospital Stay in Patients Following Coronary Bypass Graft Surgery in the Saudi Population

Brazilian Journal of Cardiovascular Surgery

Objective: The diabetic population has a high prevalence of coronary artery disease, and frequently patients with diabetes undergo coronary artery bypass graft (CABG) surgery. Elevated glycated hemoglobin (HbA1c) in diabetics is shown to be associated with morbidity and mortality, but the association of HbA1c with postoperative length of hospital stay (LOS) has conflicting results. In this study, we aim to identify if elevated HbA1c levels are associated with prolonged LOS after CABG surgery. Methods: A retrospective chart review study was performed, using a total of 305 patients who were referred for CABG surgery. HbA1c levels were measured before the day of surgery. Patients were classified into two groups according to HbA1c levels: <7% and ≥7%. A LOS of more than 14 days was proposed as an extended LOS. HbA1c and the LOS relationship were assessed using appropriate statistical methods. Results: Patients who had diabetes mellitus comprised 81.6% of our studied population. Sixty-four percent had HbA1c levels ≥ 7%. There was no significant difference in the total LOS in HbA1c <7% compared to HbA1c ≥7% patients (P=0.367). Conclusion: Our study results rejected the proposed hypothesis that elevated HbA1c levels ≥7% would be associated with prolonged hospital stay following CABG surgery in a Saudi population.

Elevated preoperative hemoglobin A1c level is predictive of adverse events after coronary artery bypass surgery

The Journal of Thoracic and Cardiovascular Surgery, 2008

Objective: Diabetes mellitus has been associated with an increased risk of adverse outcomes after coronary artery bypass grafting. Hemoglobin A1c is a reliable measure of long-term glucose control. It is unknown whether adequacy of diabetic control, measured by hemoglobin A1c, is a predictor of adverse outcomes after coronary artery bypass grafting. Methods: Of 3555 consecutive patients who underwent primary, elective coronary artery bypass grafting at a single academic center from April 1, 2002, to June 30, 2006, 3089 (86.9%) had preoperative hemoglobin A1c levels obtained and entered prospectively into a computerized database. All patients were treated with a perioperative intravenous insulin protocol. A multivariable logistic regression model was used to determine whether hemoglobin A1c, as a continuous variable, was associated with in-hospital mortality, renal failure, cerebrovascular accident, myocardial infarction, and deep sternal wound infection after coronary artery bypass grafting. Receiver operating characteristic curve analysis identified the hemoglobin A1c value that maximally discriminated outcome dichotomies. Results: In-hospital mortality for all patients was 1.0% (31/3089). An elevated hemoglobin A1c level predicted in-hospital mortality after coronary artery bypass grafting (odds ratio 1.40 per unit increase, P 5 .019). Receiver operating characteristic curve analysis revealed that hemoglobin A1c greater than 8.6% was associated with a 4-fold increase in mortality. For each unit increase in hemoglobin A1c, there was a significantly increased risk of myocardial infarction and deep sternal wound infection. By using receiver operating characteristic value thresholds, renal failure (threshold 6.7, odds ratio 2.1), cerebrovascular accident (threshold 7.6, odds ratio 2.24), and deep sternal wound infection (threshold 7.8, odds ratio 5.29) occurred more commonly in patients with elevated hemoglobin A1c. Conclusion: Elevated hemoglobin A1c level was strongly associated with adverse events after coronary artery bypass grafting. Preoperative hemoglobin A1c testing may allow for more accurate risk stratification in patients undergoing coronary artery bypass grafting.

Hyperglycemia predicts mortality after CABG: postoperative hyperglycemia predicts dramatic increases in mortality after coronary artery bypass graft surgery

Journal of Diabetes and its Complications, 2008

Risk of morbidity and mortality after coronary artery bypass graft surgery (CABG) is higher in patients with clinical diabetes mellitus (DM). We evaluated whether outcomes are affected by postoperative hyperglycemia in CABG patients independent of preoperative DM diagnosis. A total of 2297 consecutive CABG patients were studied. The first glucose value after surgery completion (mean 15 min) was tested as a predictor of outcome. Primary outcome variables were prolonged ventilation (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;24 h), deep sternal wound infection, renal failure, permanent stroke, any reoperation, length of stay (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;14 days) and mortality. All outcomes except for prolonged ventilation and length of stay were tracked out to 30 days postoperatively. Patients were stratified by glycemic control: Low (glucose &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;80), normal (referent, glucose 80-110), high (glucose 111-200) and very high (glucose &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;200 mg/dl). Multivariable logistic regression was used to determine the independent predictive value of glycemic groups, adjusted for outcome specific risk scores from the Society of Thoracic Surgeons model. Patient distribution among groups low through very high were 44 (1.9%), 476 (20.7%), 1425 (62.0%) and 352 (15.3%). Greater complication rates were noted in the very high group when compared with the referent group: prolonged ventilation (adjusted odds ratio (OR)=2.66, P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.001), length of stay &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;14 days (adjusted OR=2.06, P=.004) and mortality (adjusted OR=7.71, P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.001). Patients with blood glucose values &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;200 mg/dl immediately after CABG had an increased risk of complications, including mortality, independent of a clinical diagnosis of DM. This study documents the high risk associated with early postoperative hyperglycemia in this group, suggesting the need for prospective trials of glycemic control.

The prevalence of elevated hemoglobin A1c in patients undergoing coronary artery bypass surgery

Journal of Cardiothoracic Surgery, 2008

Background: Diabetes mellitus has become a major health issue in the United States and contributes to morbidity and mortality from coronary artery disease. Despite lifestyle changes and medications that have been shown to decrease complications and death, many persons have poor glycemic control. The purpose of this study is to determine the prevalence of elevated Hemoglobin A1c levels, a marker of glycemic control in patients presenting for coronary artery bypass surgery, and to determine if risk factors for diabetes mellitus could identify those patients with an elevated hemoglobin A1c. Methods: All patients undergoing coronary artery bypass surgery had hemoglobin A1c levels determined immediately preoperatively. Proportions were used to describe the number of patients with elevated levels. Linear regression and receiver operator characteristic curves were used to evaluate the accuracy of risk factors to identify patients with elevated levels. Results: 83 of 87 (95%) diabetic patients had elevated A1c levels (≥ 6.0%), with 55 of 87 (63%) having inadequate control-A1c levels ≥ 7.0. 93 of 163 (57%) non-diabetic patients had elevated A1c levels (≥ 6.0%), with 19 (12%) having levels ≥ 7.0%. Risk factors for diabetes mellitus poorly predicted which patient had elevated A1c levels. Conclusion: The prevalence of elevated hemoglobin levels in patients undergoing coronary artery bypass surgery is high and routine measurement should be done to permit institution of lifestyle modifications and medication changes that decrease complications and death from diabetes mellitus.

Preoperative Glycosylated Hemoglobin: A Risk Factor for Patients Undergoing Coronary Artery Bypass

The Annals of thoracic surgery, 2017

The prevalence of diabetes in the population of patients presenting with coronary artery disease continues to rise. The aim of this study was to assess whether high Glycosylated hemoglobin (HbA1c) was associated with adverse outcomes in patients undergoing elective coronary artery bypass grafting. A retrospective observational study on prospectively collected data in 4,678 patients undergoing elective, isolated coronary artery bypass graft procedures in a single institution over a 4-year period was conducted. Patients were grouped into those with adequate preoperative control of hyperglycemia (HbA1c <6.5%) and those with suboptimal control (HbA1c ≥6.5%). Multivariable analysis using HbA1c as a binary independent variable was undertaken in the whole group. A subgroup analysis in diabetic patients and in nondiabetic patients was performed. The effect of HbA1c on outcomes at higher levels (HbA1c ≥8.0% and HbA1c ≥9.0%) was also assessed. A total of 4,678 patients (mean age, 58.8; mal...

Koroner Arter Bypass Cerrahisi Geçiren Hastalarda 3'lü Karışım ve 4'lü Yoğun İnsülin Tedavilerinin Karşılaştırılması

Marmara Medical Journal, 2012

Objective: Insulin therapy initiated after coronary artery bypass graft (CABG) surgery has decreased long-term mortality. The aim was to compare the effectiveness of prandial premixed therapy (PPT) using insulin thrice daily and basal-bolus therapy (BBT) on patients having CABG surgery. Patients and Methods: Thirty-four patients having CABG surgery were included. Fasting blood glucose (FBG), postprandial blood glucose (PPBG), hemoglobin A1c (HbA1c) and hemoglobin levels were determined preoperatively and at the first week postoperatively when the patients were randomized to either PPT or BBT. Initial measurements were repeated at the end of three months. Results: Seventeen patients (F/M:9/8; 61.5±8.5 years) were assigned on a random basis to the mixed insulin arm and 17 patients (F/M:10/7; 57.4±9.2 years) to the basal-bolus arm. FBG, PPBG and HbA1c levels of both groups (7.6±0.8 % vs 6.7±0.5 % in the BBT and 7.3±0.7 % vs 7.3±1.0 % in the PPT group) at the end of the 3 months were not different than at the time of randomization. The percentage of patients reaching HbA1c levels below 6.0%, 6.5% and 7.0% were higher in the BBT group compared to the PPT group. Conclusion: For patients who had undergone CABG surgery, BBT provided more patients with HbA1c levels below the target than did PPT.

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Implication of preoperative glycosylated hemoglobin level on short term outcomes in diabetic patients undergoing coronary artery bypass grafting

International Surgery Journal, 2020

INTRODUCTION The post-operative morbidity and mortality are increased by five-to-ten folds in diabetics. 1 The glycosylation of the red blood cells is regulated by blood glucose level; considering the life span of RBC (90-120 days) the circulating blood glucose level and continuous cell turnover lead to formation of HbA1c. Thus, the HbA1c level indicates about the glycemic status of the patient over a period of previous three to four months. In fact, HbA1c gives more information than a blood sugar reading taken at a single time that may change depending on the metabolic demand and short-term dietary changes. Currently, HbA1c is considered gold standard to monitor the glycemic control in diabetics. 2 The objective of the study was to depict the implication of preoperative HbA1c level on short term outcomes after CABG in two groups (HbA1c≤7 and HbA1c>7) of the diabetic patients. METHODS We studied 218 diabetic postoperative CABG patients retrospectively after having approval from the institutional ethical committee. It was an observational ABSTRACT Background: Diabetes mellitus is one of the significant risk factors for adverse outcomes after coronary artery bypass surgery. The glycosylated haemoglobin i.e. HbA1c is a reliable diagnostic test to know the long-term glycemic status. The objective of the study is to investigate the implication of preoperative HbA1c level on short term outcomes after coronary artery bypass grafting (CABG). Method: Total 218 patients were studied, and the data were collected retrospectively. Patients are distributed into group 1 with HbA1c≤7 (good glycemic control) and group 2 with HbA1c>7 (poor glycemic control). The parameters studied for short term outcomes were revision due to bleeding, duration of mechanical ventilation, cerebrovascular accident (CVA), atrial fibrillation (AF), renal failure requiring dialysis, infective complications like sternal and leg wound infection, mediastinitis, pneumonia, urinary tract infection (UTI), sepsis; length of ICU stay and in-hospital mortality. Result: In comparison to group 1, patients of group 2 showed statistically significant more morbidity in view of short-term outcomes in this study. Conclusion: HbA1c>7 is associated with statistically significant adverse short-term outcomes after CABG.

Evaluation of Hemoglobin A1c Criteria to Assess Preoperative Diabetes Risk in Cardiac Surgery Patients

Diabetes Technology & Therapeutics, 2011

Objective: Hemoglobin A1c (A1C) has recently been recommended for diagnosing diabetes mellitus and diabetes risk (prediabetes). Its performance compared with fasting plasma glucose (FPG) and 2-h post-glucose load (2HPG) is not well delineated. We compared the performance of A1C with that of FPG and 2HPG in preoperative cardiac surgery patients. Methods: Data from 92 patients without a history of diabetes were analyzed. Patients were classified with diabetes or prediabetes using established cutoffs for FPG, 2HPG, and A1C. Sensitivity and specificity of the new A1C criteria were evaluated. Results: All patients diagnosed with diabetes by A1C also had impaired fasting glucose, impaired glucose tolerance, or diabetes by other criteria. Using FPG as the reference, sensitivity and specificity of A1C for diagnosing diabetes were 50% and 96%, and using 2HPG as the reference they were 25% and 95%. Sensitivity and specificity for identifying prediabetes with FPG as the reference were 51% and 51%, respectively, and with 2HPG were 53% and 51%, respectively. One-third each of patients with prediabetes was identified using FPG, A1C, or both. When testing A1C and FPG concurrently, the sensitivity of diagnosing dysglycemia increased to 93% stipulating one or both tests are abnormal; specificity increased to 100% if both tests were required to be abnormal. Conclusions: In patients before cardiac surgery, A1C criteria identified the largest number of patients with diabetes and prediabetes. For diagnosing prediabetes, A1C and FPG were discordant and characterized different groups of patients, therefore altering the distribution of diabetes risk. Simultaneous measurement of FGP and A1C may be a more sensitive and specific tool for identifying high-risk individuals with diabetes and prediabetes.

Determination of the value of glycated hemoglobin HbA1c and fructosamine in assessing the risk of perioperative complications after cardiac surgery in patients with type 2 diabetes

Kardiochirurgia i torakochirurgia polska = Polish journal of cardio-thoracic surgery, 2016

Patients with diabetes have a worse postoperative course and longer length of hospital stay after surgery. A good indicator of proper long-term (3 months) glycemic control is glycated hemoglobin (HbA1c), and fructosamine in the short term (2-3 weeks). To determine the degree of glycemic control evaluated preoperatively by HbA1c and/or fructosamine influence on the postoperative course of patients with diabetes undergoing coronary artery bypass grafting (CABG) in 2014-2015. Before the operation HbA1c (N < 7.0) and fructosamine (N < 280 µmol/l) were measured and depending on the results the respondents were divided into 4 groups: group I (n = 46) - normal both parameters; group II (n = 22) - high both values; group III (n = 4) - normal fructosamine/HbA1c high; group IV (n = 33) - high HbA1c/fructosamine normal. Statistical analysis was performed using the t-test assuming p < 0.05 to be statistically significant. One hundred and five patients were treated by CABG/OPCAB (39 fem...

Elevated Glycosylated Hemoglobin is Harbinger of Adverse Short-Term Outcomes Following Coronary Artery Bypass Grafting

Pakistan Heart Journal, 2021

Objective: To determine the association of elevated HbA1c levels with length of ICU stay, prolonged mechanical ventilator and ionotropic support, and infections in diabetic patients undergoing CABG. Methodology: This Prospective cohort study was conducted at National Institute of Cardiovascular Diseases, Karachi. One hundred fifty eight (158) diabetic patients were enrolled fulfilling inclusion criteria. Data was classified into two groups, Exposed group: elevated HbA1c (≥7%) and Un-exposed group: HbA1c (<7%) and study outcomes in both groups were compared for any statistically significant difference. Results: Total 86.1% patients had prolonged ICU duration, 79.7% (p<0.001) had prolonged mechanical ventilator and 87.3% (p<0.001) patients with prolonged ionotropic support in Exposed group (elevated HbA1c). In Un-exposed group (controlled HbA1c), 44.3% patients had prolonged ICU duration, 12.7% patients had prolonged mechanical ventilator and 64.6% had prolonged ionotropic su...

Study of association of preoperative glycosylated haemoglobin level and outcome after cardiac surgery

Sri Lankan Journal of Anaesthesiology, 2020

Background: Diabetes mellitus involves 8.7% of the adult community in India, and its preponderance is rising. Diabetes is an independent risk factor for complications after open cardiac surgery. Poor glycaemic control, measured by glycosylated haemoglobin A1C (HbA1c), is associated with high incidence of micro and macroangiopathy. HbA1c reflects the patient's prevailing sugar control over the previous 120-150 days. Perioperative cardiac surgical risk scoring systems like Euro Score and STS scoring systems do not include HbA1c level as risk factor. We intended to study the correlation of preoperative HbA1c level and outcome after cardiac surgery. Methodology: A total of 350 patients who had undergone elective cardiac surgery were included. All patients were stratified into two groups, Group 1 with HbA1c level < 7%, Group 2 >7%. Intraoperative and postoperative adverse events were documented retrospectively. The two groups of patients were compared with regard to their demographic data, operation risk, mortality and morbidity. Results: Overall incidence of major adverse events (7.7%) and mortality (4.8%) were very low. Incidence of sternal wound infection and prolonged ventilator support (> 24hrs) were significant in group 2 compared to group 1(p values were 0.03 and 0.01 respectively). Conclusion: Preoperative HbA1c level may provide more accurate prognostic information about outcomes after all major open cardiac surgeries compared with a diabetes status alone.

Preoperative hemoglobin concentration as an independent predictor for outcome after coronary artery bypass grafting

Background: Preoperative anemia is accused for increased complications, morbidity and mortality following cardiac surgery. Due to the nature of cardiac patients who usually have poor myocardium reserve and multiple concomitant comorbidities, it is difficult to identify the role of preoperative hemoglobin (HB) concentration in the postoperative outcome. Accordingly, correction of low HB level prior to cardiac surgery still is a matter of debate. The aim of this work was to determine the impact of preoperative HB concentration on postoperative outcome following coronary artery bypass grafting (CABG). Methods: Data were collected on all patients who underwent CABG surgery in our hospital in the last three years. Preoperative Anemia was defined as HB level below 12 gm/dl. Accordingly, three groups were identified: low, normal and high preoperative HB. Postoperative bleeding, red blood cells transfused, myocardial injury, infection rate, lengths of ventilation, renal injury and length of stay in intensive care unit (ICU) were recorded. Results: We recruited 804 patients in our study. Preoperative anemia were identified in 159 patients assigned in group I. Patients in this group had postoperative blood transfusion in 69% of patients and postoperative bleeding > One liter in 31.6% of patients with P-value of 0.006,0.096 respectively. It showed higher postoperative infection rate in 9.5% of patients (P-value 0.49) and higher length of stay in ICU in 43.3% of patients (P value 0.003). Group II was 481 patients who had HB (12.1e15 gm/dl) showed the shortest postoperative hospital stay in 56.1% of patients, P value 0.0001. Group III, 164 patients had HB more than 15.1 gm./dl. No cases of ICU readmission were recorded. Conclusion: Preoperative HB level can be used as an indicator of outcome after cardiac surgery. Preoperative anemia should be optimized before CABG.

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