Impaired glucose tolerance – a new risk factor?

Diethelm Tschöpe* and Christoph Bode

Heart and Diabetes Center, North-Rhine Westfalia, Ruhr University, Bochum, Germany

* Correspondence to: Dr. Diethelm Tschöpe, Heart and Diabetes Center, North-Rhine Wetsfalia, Ruhr University, Bochum, Germany (E-mail: diethelm.tschoepe{at}ruhr-uni-bochum.de).

This editorial refers to "Newly detected abnormal glucose tolerance: an important predictor of long term outcome after myocandial infarction"{dagger} by M. Bartnik on page 1990.

Recently, a plethora of scientific papers have revealed the parallel impairment of carbohydrate metabolism in patients referred to hospitals along with acute ischaemic events.1 The most recent, the Euro Heart Survey, reports the finding that more than two thirds of those patients are affected.3 This shows that the physicians in charge, both emergency care cardiologists and diabetologists responsible for the long-term treatment of these patients have so far completely underestimated the disease condition. On the other hand, it has been clear for several years that more than 75% of patients with diabetes mellitus will die from cardiovascular events and this situation has not changed compared with the decline in cardiovascular mortality in the overall population. Thus, it seems that there is a broad interrelation of patients affected by coronary artery disease and patients affected by disturbances of the carbohydrate metabolism which could open therapeutic chances by early detection and appropriate treatment. This is both mandatory and needed when we consider the enormous economical impact which is driven by the exponentially increasing figures of patients with overt diabetes mellitus or early metabolism disturbances. Interestingly enough the available data provide circumstantial evidence that impaired glucose tolerance already contributes significantly to the overall cardiovascular risk2 but in turn may be even more frequent in patients referred with myocardial infarction than (non-diagnosed) diabetes mellitus. At this point, it appears that the disease process may start much earlier than the presentation for the diagnosis of diabetes mellitus suggesting that metabolic and vascular disease may run in parallel or may be derived from one driving pathophysiological mechanism ("common soil"). At this point however, it has not been clear for years what the exact role of impaired glucose tolerance is for the prognosis of this highest risk population of post-myocardial infarction (MI) patients, whereas diabetes mellitus has been clearly identified as a predictor of increased post-MI mortality both acutely and chronically. In this issue of the Journal, Bartnik et al.3 show, in a prospective clinical observation study, that impaired glucose tolerance in the early post MI-phase affects the longer term post-MI prognosis. The magnitude of this finding was particularly surprising as the hazard ratio stayed over four and was greatest for abnormal glucose tolerance, even after multivariate adjustment and exceeded the well known prognostic contributions of a previous MI and stroke (HR 3.38 and 3.68). These data are confirmatory for the assumption that even subtle disturbances of carbohydrate metabolism may affect the event and survival rates but also provide an attractive anchor for therapeutic intervention. If there is a causal link between impaired glucose tolerance and outcome of that magnitude, therapeutic improvements of metabolic control at this stage should be successful in achieving endpoint protection. However, this type of data, both in terms of magnitude and kind of successful metabolic intervention, is missing so far in this particular setting. However, this is urgently needed to clarify the status of impaired glucose tolerance from an indubitable risk marker to a conditional risk factor to be aggressively treated within a standard algorithm of care for this ever growing population of patients with acute coronary events. In this sense, the paper by Bartnik and colleagues merits clinical attention and may be looked upon as a call for future studies showing clinical endpoint reduction through metabolic intervention in the earliest stages of the disease.

Footnotes

{dagger} 10.1016/j.ehj.2004.09.021 Back

References

  1. Norhammar A, Tenerz Ä, Nilsson G, et al. Glucose metabolism in patients with acute myocardial infarction and no previous diagnosis of diabetes mellitus: a prospective study Lancet 2002;359:2140-2144.[CrossRef][ISI][Medline]
  2. The DECODE study group on behalf of the European Diabetes Epidemiology Group. Glucose tolerance and cardiovascular mortality. Arch Intern Med 2001;161:397–404.
  3. Bartnik M, RydĂ©n L, Ferrari R, et al. on behalf of the Euro Heart Investigators. The prevalence of abnormal glucose regulation in patients with coronary artery disease across Europe. Eur Heart J 2004;25:1990–1997.

Related articles in EHJ:

Newly detected abnormal glucose tolerance: an important predictor of long-term outcome after myocardial infarction
M. Bartnik, K. Malmberg, A. Norhammar, Å. Tenerz, J. Öhrvik, and L. Rydén
EHJ 2004 25: 1990-1997. [Abstract] [Full Text]  




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