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Impact of hba1 c

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hbaic is associated with increased cardiovascular morbidity or mortality even before the diagnosis of diabetes...a patient with hba1c 0f 5.5% normal being 4.0-5.5% is prone for the acute cardiac …

hbaic is associated with increased cardiovascular morbidity or mortality even before the diagnosis of diabetes...a patient with hba1c 0f 5.5% normal being 4.0-5.5% is prone for the acute cardiac states,the article is published in JAPI,JUN 2011...
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  • 1. IMPACT OF HbA1c ON ACUTE CARDIAC STATESJAPI –JUNE 2011
    DR.PRAVEEN NAGULA
  • 2. INTRODUCTION
    DIABETES is a highly vascular disease with both macrovascular and microvascular complications.
    Macrovascular complications start before the patient has overt diabetes.
    Hyperglycemia accelerates the process of atherosclerosis by the formation of glycatedproteins,AGES—increased endothelial dysfunction.
    HBA1C is a good marker of glycated proteins.
    FRAMINGHAM study cardiovascular mortality is twice in diabetic men ,four times in diabetic women.
    HBA1C > 7% - risk of cardiovascular events and death.
  • 3. The correlation between higher HbA1 c levels and increased cardiovascular morbidity occurs even before the diagnosis of clinical diabetes…
    Gerstein HC ,glycosylatedHb –finally ready for prime time as a cardiovascular risk factor –Ann Int Med 2004;141:475-6
  • 4. CORRELATION between HbA1C levels and the severity and complications of patients admitted with acute cardiac states to the ICU of CMC,ludhiana.
  • 5. 4 months
    Acute cardiac states –UA,STEMI,NSTEMI,DCM,HF,AH.
    Patients with sepsis,hemoglobinopathy,hypothyroidism were excluded.
    Inv done were HbA1C,Lipids,cardiac enzymes,ECG,ECHO.
    Followed up till discharge.
    Complications noted –arrhythmias,CF,cardiogenic shock
    HBA1C –diastat by biorad.
  • 6. Hb A combines with glucose at valine ,terminal of b chain.
    Blood glucose  HbA1c levels
    Why HbA1c levels are indicated –slow rate of combination with glucose.
    Normal 4-5.9%
    >9 % --poor control
    >12% --very poor control.
    <7% - goal in diabetes
    Diabetes –HBA1C >6.5% -- ADA guidelines,diabetes care ,2010
  • 7. 166 patients
    Group A –diabetes
    Group B –non diabetes
    44 cases in group A – developed the cardiac event < 5 yrs of diagnosis.
    Acute cardiac state as presenting complaint of diabetes – 19 cases.
    Orthopnea,pedal edema more in group A ,group B –angina.
    HTN,CAD h/o – group A ,smoking,positive family h/o in group B.
    DCM,HF more in group A.
  • 8. BLOOD SUGARS ,,HbA1c levels.
    RBS >200 mg/dl – 67 cases in group A,32 > 300
    GROUP B -25 cases had RBS >140 mg/dl ,5 cases > 200 mg/dl(stress hyperglycemia)
    Mean HBa1C levels – 8.4% ,5.7 % in group B.
    Fairly good control -- < 7% -- had cardiac events – 22 cases.
    First diagnosis of diabetes -- > 7% - 13 cases.
    Group b 26 cases > 5.6 -- 6%..pre diabetes.
  • 9. DISCUSSION
    EARLIER CAD.
    Extensive atherosclerosis.
    HTN (68% vs 50% ),hypertriglyceridemia(43.5% vs 20% )
    Low HDL lvels 78.3%,previous h/o CAD (53% vs 28.4%)
    Stress hyperglycemia – 140-300 mg/dl(500mg/dl)
    Hyperglycemia with normal HbA1c does not rule out the diagnosis of diabetes..follow up needed.
    Hyperglycemia  mortality. In AMI
    Hb A1c > 7% --more UA,STEMI,DCM,AH,TVD,re infarction
  • 10. BERTONI et al
    from 1994 to 1999
    151,738 beneficiaries with diabetes who were age 65 years,
    RESULTS — Heart failure was prevalent in 22.3% in 1994. Among individuals without heartfailure in 1994, the heart failure incidence rate was 12.6 per 100 person-years (95% CI 12.5–12.7 per 100 person-years).
    Incidence was similar by sex and race and increased significantly with age and diabetes-related comorbidities.
    Over 60 months, incident heart failure among older adults with diabetes was associated with high mortality—32.7 per 100 person-years compared with 3.7 per 100 person-years amongthose with diabetes who remained heart failure free.
    CONCLUSIONS — These data demonstrate alarmingly high prevalence, incidence, andmortality for heart failure in individuals with diabetes. Prevention of heart failure should be research and clinical priority
  • 11. LU et al
    STRONG HEART STUDY
    American indians
    American Diabetes Association guidelines for glycaemic control were used: good, A1c < 7%; fair, 7–7.9%; and poor, ≥ 8%.
    9 years of follow-up
    showed that diabetic individuals with poor baseline glycaemic control had significantly increased proportions of overall CVD and CHD (P = 0.001) during the 9 years of follow-up, compared with those who had good or fair control.
  • 12. hyperglycemia
    Apoptosis
    Myocyte necrosis – systolic,diastolic dysfunction.
    Diabetic cardiomyopathy is related directly to hyperglycemia. Cell death such as apoptosis plays a critical rolein cardiac pathogenesis. Whether hyperglycemia induces myocardial apoptosis, leading to diabetic cardiomyopathy, remains unclear. We tested the hypothesis that apoptotic cell death occurs in the diabetic myocardium through mitochondrial cytochrome c–mediated caspase-3 activation pathway.
    Diabetic mice producedbystreptozotocin and H9c2 cardiac myoblast cells exposed to high levels of glucose were used. In the hearts of diabetic mice, apoptotic cell death occurred.
  • 13.
  • 14. UKPDS study
    Intensive glycemic control HBA1C < 7% -- 16% reduction in MI
    In this study HbA1c - CARDIOVASCULAR disease – 5.7% - more than normal.
    Mean HbA1c LEVELS IN ASIA -- Mean A1C was 5.5 0.4%, range 4.0 – 6.8%.
    MACROVASCULAR complications take place at lower blood glucose levels -- jama 1990.
    These results indicate that prediabetic subjects have an atherogenic pattern of risk factors (possibly caused by obesity, hyperglycemia, and especially hyperinsulinemia), which may be present for many years and may contribute to the risk of macrovascular disease as much as the duration of clinical diabetes itself.
  • 15. HbA1C < 5% - LOWEST RATES OF CV mortality.
    1% increase in HbA1C – 2.5 TIMES risk of CVD. – selvin et al
    independent of age, body mass index, waist-to-hip ratio, systolic bloodpressure, serum cholesterol concentration, cigarette smoking, and history of cardiovascular disease.
  • 16. HbA1c levels
    5 % -97mg/dl (76–120)
    6% - 126mg/dl (100–152)
    7% - 154 mg/dl (123–185)
  • 17.
  • 18. drawbacks
    Small group
    Angiography not done in all
    Patients died within few hours were not included.
  • 19. Take home message
    UA,STEMI,DCM,HF cardiomyopathy,reinfarction - HbA1C > 7%.
    DIABETES to be diagnosed early and for detection of CAD lower levels of HbA1c than present >6.5%.
    Every 1 % increase in HbA1c over 4.6% - 2.5 times risk of CVD.
    Hyperglycemia induces apoptosis,necrosis –SD,DD
    Hyperglycemia  mortality in AMI.
    Stress hyperglycemia – 140-300 mg/dl.
    Orthopnea and pedal edema more common in diabetes.
    CAD may be presenting symptom of diabetes.HbA1c levels to be monitored.
  • 20. Thank you