ArticlesStress hyperglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview
Introduction
An unusually high prevalence of glucosuria in patients without diabetes who have acute myocardial infarction was noted as far back as 1931.1 Since then, up to half of these patients with acute myocardial infarction have been recognised as having raised blood glucose concentrations.2, 3 Moreover, a positive association between hyperglycaemia at the time of the event and mortality from myocardial infarction has been noted.4
Although the mechanisms underlying this association are not fully understood, evidence that use of insulin to lower glucose concentrations decreases mortality in patients with diabetes who have myocardial infarction5 suggests that hyperglycaemia is not simply an epiphenomenon of the stress response mediated by cortisol and noradrenaline. In patients who have had myocardial infarction, the lack of insulin associated with hyperglycaemia may lead to a decrease of glycolytic substrate for cardiac muscle and excessive free fatty acids. These changes may reduce myocardial contractility at increased oxygen cost, lead to pump failure, and promote arrythmias.6 Consequently, hyperglycaemia at the time of myocardial infarction in patients with and without diabetes may be an important and potentially modifiable risk factor for poor outcome.
We systematically searched for, reviewed, and assessed published evidence on the association between stress hyperglycaemia and in-hospital mortality and congestive heart failure in patients with and without diabetes, admitted with myocardial infarction.
Section snippets
Selection of articles
Two independent researchers did a computerised MEDLINE search of published articles (from 1966 to October, 1998). One researcher was assisted by a medical librarian experienced in literature searches. We searched by the subject headings “blood glucose” and “myocardial infarction”, text words “hyperglycemia”, “euglycemia”, and “hypoglycemia”, and methodology terms (including subject headings “incidence”, “mortality”, “follow-up studies”, “cohort studies”, and “prognosis”, and text words “natural
Results
The two MEDLINE searches yielded 49 and 217 citations, respectively. From the titles, abstracts, or both, 49 of the 266 citations were thought to be relevant by one or both of the searchers (κ=0·77), and the full text of these articles was retrieved. After review of the full text, 19 articles from the MEDLINE search were judged relevant (for agreement between searchers κ=0·83). Two additional relevant articles were found by searching the bibliographies; the Science Citation Index search yielded
Discussion
We showed that patients without diabetes who have stress hyperglycaemia on admission for acute myocardial infarction are at increased risk of in-hospital mortality and congestive heart failure or cardiogenic shock. Several possible mechanisms may explain this observation.
First, hyperglycaemia is a reflection of relative insulin deficiency, which is associated with increased lipolysis and excess circulating free fatty acids; this effect may be exaggerated in cases of acute stress such as
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