Background-In nondiabetic patients with ST-segment-elevation myocardial infarction, acute hyperglycemia is associated with adverse outcome. Whether this association is due merely to hyperglycemia as an acute stress response or whether longer-term glycometabolic derangements are also involved is uncertain. It was our aim to determine the association between both acute and chronic hyperglycemia (hemoglobin A 1c [HbA 1c ]) and outcome in nondiabetic patients with ST-segment-elevation myocardial infarction. Methods and Results-This observational study included consecutive patients (nϭ4176) without known diabetes mellitus admitted with ST-segment-elevation myocardial infarction. All patients were treated with primary percutaneous intervention. Both glucose and HbA 1c were measured on admission. Main outcome measure was total long-term mortality; secondary outcome measures were 1-year mortality and enzymatic infarct size. One-year mortality was 4.7%, and mortality after total follow-up (3.3Ϯ1.5 years) was 10%. Both elevated HbA 1c levels (PϽ0.001) and elevated admission glucose (PϽ0.001) were associated with 1-year and long-term mortality. After exclusion of early mortality (within 30 days), HbA 1c remained associated with long-term mortality (PϽ0.001), whereas glucose lost significance (Pϭ0.09). Elevated glucose, but not elevated HbA 1c , was associated with larger infarct size. After multivariate analysis, HbA 1c (hazard ratio, 1.2 per interquartile range; PϽ0.01), but not glucose, was independently associated with long-term mortality. Conclusions-In nondiabetic patients with ST-segment-elevation myocardial infarction, both elevated admission glucose and HbA 1c levels were associated with adverse outcome. Both of these parameters reflect different patient populations, and their association with outcome is probably due to different mechanisms. Measurement of both parameters enables identification of these high-risk groups for aggressive secondary risk prevention. (Circulation. 2011;124:704-711.)
IntroductionThe relationship between potassium regulation and outcome is not known. Our first aim in the present study was to determine the relationship between potassium level and variability in (ICU) stay and outcome. The second aim was to evaluate the impact of a computer-assisted potassium regulation protocol.MethodsWe performed a retrospective before-after study including all patients >15 years of age admitted for more than 24 hours to the ICU of our university teaching hospital between 2002 and 2011. Potassium control was fully integrated with computerized glucose control (glucose and potassium regulation program for intensive care patients (GRIP-II)). The potassium metrics that we determined included mean potassium, potassium variability (defined as the standard deviation of all potassium levels) and percentage of ICU time below and above the reference range (3.5 through 5.0 mmol/L). These metrics were determined for the first ICU day (early phase) and the subsequent ICU days (late phase; that is, day 2 to day 7). We also compared potassium metrics and in-hospital mortality before and after GRIP-II was implemented in 2006.ResultsOf all 22,347 ICU admissions, 10,451 (47%) patients were included. A total of 206,987 potassium measurements were performed in these patients. Glucose was regulated by GRIP-II in 4,664 (45%) patients. The overall in-hospital mortality was 22%. There was a U-shaped relationship between the potassium level and in-hospital mortality (P <0.001). Moreover, potassium variability was independently associated with outcome. After implementation of GRIP-II, in the late phase the time below 3.5 mmol/L decreased from 9.2% to 3.9% and the time above 5.0 mmol/L decreased from 6.1% to 5.2%, and potassium variability decreased from 0.31 to 0.26 mmol/L (all P <0.001). The overall decrease in in-hospital mortality from 23.3% before introduction of GRIP-II to 19.9% afterward (P <0.001) was not related to a specific potassium subgroup.ConclusionsHypokalemia, hyperkalemia and potassium variability were independently associated with increased mortality. Computerized potassium control clearly resulted in improved potassium metrics.
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