Lipska Kasia J, Venkitachalam Lakshmi, Gosch Kensey, Kovatchev Boris, Van den Berghe Greet, Meyfroidt Geert, Jones Philip G, Inzucchi Silvio E, Spertus John A, DeVries J Hans, Kosiborod Mikhail
Department of Internal Medicine, Yale University, New Haven, CT, USA.
Circ Cardiovasc Qual Outcomes. 2012 Jul 1;5(4):550-7. doi: 10.1161/CIRCOUTCOMES.111.963298. Epub 2012 Jun 12.
Mean blood glucose (BG) during acute myocardial infarction (AMI) is an important predictor of inpatient mortality but does not capture glucose variability (GV), which has been shown to be independently associated with mortality in critically ill patients. Whether GV is associated with in-hospital mortality during AMI, after accounting for mean BG, is unknown.
We analyzed 18 563 consecutive patients with AMI with ≥3 BGs in the first 48 hours admitted to 61 US hospitals from 2000 to 2008. Five different GV metrics were compared for their ability to predict in-hospital mortality (range, standard deviation, mean amplitude of glycemic excursions, mean absolute glucose change, and average daily risk range) using hierarchical logistic regression models that sequentially adjusted for mean BG, hypoglycemia (<70 mg/dL), and multiple patient characteristics. In unadjusted analyses, range and average daily risk range had the highest C-indices (0.620 for range, 0.635 for average daily risk range; both P<0.0001). Greater GV was associated with higher mortality for all metrics (eg, mortality was 3.8%, 5.5%, 7.1%, and 11.3% for increasing quartiles of range, P<0.0001); however, the association between GV and mortality for each metric was no longer significant after multivariable adjustment. In contrast, mean BG remained an important predictor of survival (P<0.001, all models).
Although greater GV is associated with increased risk of in-hospital mortality in patients with AMI in unadjusted analyses, GV is no longer independently predictive after controlling for multiple patient factors, including mean BG. These findings suggest that GV does not provide additional prognostic value above and beyond already recognized risk factors for mortality during AMI.
急性心肌梗死（AMI）期间的平均血糖（BG）是住院死亡率的重要预测指标，但未涵盖血糖变异性（GV），而血糖变异性已被证明与危重症患者的死亡率独立相关。在考虑平均BG后，GV是否与AMI期间的院内死亡率相关尚不清楚。
我们分析了2000年至2008年期间美国61家医院收治的18563例连续AMI患者，这些患者在入院后的头48小时内有≥3次BG测量值。使用分层逻辑回归模型，依次对平均BG、低血糖（<70mg/dL）和多个患者特征进行调整，比较了五种不同的GV指标预测院内死亡率的能力（范围、标准差、血糖波动平均幅度、平均绝对血糖变化和平均每日风险范围）。在未调整的分析中，范围和平均每日风险范围的C指数最高（范围为0.620，平均每日风险范围为0.635；均P<0.0001）。所有指标中，更大的GV与更高的死亡率相关（例如，范围四分位数增加时，死亡率分别为3.8%、5.5%、7.1%和11.3%，P<0.0001）；然而，多变量调整后，每个指标的GV与死亡率之间的关联不再显著。相比之下，平均BG仍然是生存的重要预测指标（所有模型中P<0.001）。
虽然在未调整的分析中，更大的GV与AMI患者院内死亡风险增加相关，但在控制包括平均BG在内的多个患者因素后，GV不再具有独立预测性。这些发现表明，在AMI期间，GV在已公认的死亡风险因素之外，并未提供额外的预后价值。
