高血糖和低血糖对AMI病人临床预后的预测
2009-12-03 19:53:47 来源：丁香园 作者： 评论：0 点击：
Background—In patients with acute myocardial infarction (AMI), hyperglycemia predicts death, but the prognostic significance of hypoglycemia is controversial.
背景 对于急性心肌梗死病人，高血糖是死亡预测因素之一，但是低血糖的预测意义存在争议。
方法与结果 我们对30536位经过两组大规模葡萄糖-胰岛素-钾治疗试验的急性心肌梗死病人进行了事后分析以评估高血糖和低血糖对预后的预测意义。入院时，入院后6小时以及24小时的血糖水平，以及30天死亡率被记录下来。在入院时以及入院后血糖的分离多变量cox模型中，我们对比了低血糖( 70 mg/dL)和高血糖( 140 mg/dL)与正常血糖(>70 and <140 mg/dL)的预测价值。并通过定义低血糖为 60 mg/dL以及建立糖尿病或胰岛素（葡萄糖-胰岛素-钾）分配状态的重要分组重复分析结果。结果显示高分位和低分位的入院血糖都预计增加30天死亡率。但对于入院后血糖，这U型关系变得不明显，因此只有高血糖更有预测性。
Methods and Results—We evaluated the prognostic significance of hypoglycemia and hyperglycemia in 30 536 AMI patients in a post hoc analysis of 2 large trials of glucose-insulin-potassium therapy in AMI. Glucose levels on admission and at 6 and 24 hours after admission, as well as 30-day mortality, were documented. In separate multivariable Cox models for admission and postadmission glucose, we compared the prognostic value of hypoglycemia ( 70 mg/dL) and hyperglycemia ( 140 mg/dL) with normoglycemia (>70 and <140 mg/dL). Analyses were repeated with hypoglycemia defined as glucose 60 mg/dL and in key subgroups based on diabetes or insulin (glucose-insulin-potassium) allocation status. Both high and low percentiles of admission glucose predicted increased 30-day mortality. However, for postadmission glucose, this U-shaped relationship was attenuated so that only high and not low glucose levels remained prognostic.
高血糖( 140 mg/dL)与正常血糖相比，包括入院时（调整后危险比率 1.43，95%可信区间 1.32- 1.56，P<0.0001）和入院后（调整后危险比率 1.47，95%可信区间 1.31- 1.66，P<0.0001），预测了死亡。相反，低血糖（ 70 mg/dL），包括入院时（调整后危险比率 1.16，95%可信区间 0.84- 1.62，P=0.37）和入院后（调整后危险比率 0.96，95%可信区间 0.72- 1.26，P=0.75）都不具有预测性。
Hyperglycemia ( 140 mg/dL), both on admission (adjusted hazard ratio 1.43, 95% confidence interval 1.32 to 1.56, P<0.0001) and after admission (adjusted hazard ratio 1.47, 95% confidence interval 1.31 to 1.66, P<0.0001), predicted death compared with normoglycemia. In contrast, hypoglycemia (glucose 70 mg/dL) on admission was not prognostic (adjusted hazard ratio 1.16, 95% confidence interval 0.84 to 1.62, P=0.37), nor was postadmission hypoglycemia (adjusted hazard ratio 0.96, 95% confidence interval 0.72 to 1.26, P=0.75).
重新定义低血糖为 60 mg/dL，和仅限于分析糖尿病患者（占总体的18%）的探索性分析显示了一致的结果，入院后低血糖更常见于胰岛素治疗病人（6.9%），未治疗病人（3.4%），但均不可预测死亡率
Exploratory analyses that redefined hypoglycemia as glucose 60 mg/dL showed consistent results, as did analyses restricted to diabetic patients (18% of the study population). Postadmission hypoglycemia was more common in insulin (glucose-insulin-potassium)–treated patients (6.9%) than in untreated patients (3.4%) but did not predict mortality in either subgroup.
Conclusions—Both admission and postadmission hyperglycemia predict 30-day death in AMI patients. In contrast, only hypoglycemia on admission predicted death, and this relationship dissipated after admission. These data suggest hypoglycemia may not be a direct mediator of adverse outcomes in AMI patients.
结论 入院时和入院后高血糖均可预测急性心肌梗死病人30天死亡率。相反，只有入院时低血糖可以预测死亡，而这种预测关系在入院后即消失。这些数据提示低血糖可能不是AMI病人不良预后的直接调节因素。
背景 对于急性心肌梗死病人，高血糖是死亡预测因素之一，但是低血糖的预测意义存在争议。
方法与结果 我们对30536位经过两组大规模葡萄糖-胰岛素-钾治疗试验的急性心肌梗死病人进行了事后分析以评估高血糖和低血糖对预后的预测意义。入院时，入院后6小时以及24小时的血糖水平，以及30天死亡率被记录下来。在入院时以及入院后血糖的分离多变量cox模型中，我们对比了低血糖( 70 mg/dL)和高血糖( 140 mg/dL)与正常血糖(>70 and <140 mg/dL)的预测价值。并通过定义低血糖为 60 mg/dL以及建立糖尿病或胰岛素（葡萄糖-胰岛素-钾）分配状态的重要分组重复分析结果。结果显示高分位和低分位的入院血糖都预计增加30天死亡率。但对于入院后血糖，这U型关系变得不明显，因此只有高血糖更有预测性。
Methods and Results—We evaluated the prognostic significance of hypoglycemia and hyperglycemia in 30 536 AMI patients in a post hoc analysis of 2 large trials of glucose-insulin-potassium therapy in AMI. Glucose levels on admission and at 6 and 24 hours after admission, as well as 30-day mortality, were documented. In separate multivariable Cox models for admission and postadmission glucose, we compared the prognostic value of hypoglycemia ( 70 mg/dL) and hyperglycemia ( 140 mg/dL) with normoglycemia (>70 and <140 mg/dL). Analyses were repeated with hypoglycemia defined as glucose 60 mg/dL and in key subgroups based on diabetes or insulin (glucose-insulin-potassium) allocation status. Both high and low percentiles of admission glucose predicted increased 30-day mortality. However, for postadmission glucose, this U-shaped relationship was attenuated so that only high and not low glucose levels remained prognostic.
高血糖( 140 mg/dL)与正常血糖相比，包括入院时（调整后危险比率 1.43，95%可信区间 1.32- 1.56，P<0.0001）和入院后（调整后危险比率 1.47，95%可信区间 1.31- 1.66，P<0.0001），预测了死亡。相反，低血糖（ 70 mg/dL），包括入院时（调整后危险比率 1.16，95%可信区间 0.84- 1.62，P=0.37）和入院后（调整后危险比率 0.96，95%可信区间 0.72- 1.26，P=0.75）都不具有预测性。
Hyperglycemia ( 140 mg/dL), both on admission (adjusted hazard ratio 1.43, 95% confidence interval 1.32 to 1.56, P<0.0001) and after admission (adjusted hazard ratio 1.47, 95% confidence interval 1.31 to 1.66, P<0.0001), predicted death compared with normoglycemia. In contrast, hypoglycemia (glucose 70 mg/dL) on admission was not prognostic (adjusted hazard ratio 1.16, 95% confidence interval 0.84 to 1.62, P=0.37), nor was postadmission hypoglycemia (adjusted hazard ratio 0.96, 95% confidence interval 0.72 to 1.26, P=0.75).
重新定义低血糖为 60 mg/dL，和仅限于分析糖尿病患者（占总体的18%）的探索性分析显示了一致的结果，入院后低血糖更常见于胰岛素治疗病人（6.9%），未治疗病人（3.4%），但均不可预测死亡率
Exploratory analyses that redefined hypoglycemia as glucose 60 mg/dL showed consistent results, as did analyses restricted to diabetic patients (18% of the study population). Postadmission hypoglycemia was more common in insulin (glucose-insulin-potassium)–treated patients (6.9%) than in untreated patients (3.4%) but did not predict mortality in either subgroup.
Conclusions—Both admission and postadmission hyperglycemia predict 30-day death in AMI patients. In contrast, only hypoglycemia on admission predicted death, and this relationship dissipated after admission. These data suggest hypoglycemia may not be a direct mediator of adverse outcomes in AMI patients.
结论 入院时和入院后高血糖均可预测急性心肌梗死病人30天死亡率。相反，只有入院时低血糖可以预测死亡，而这种预测关系在入院后即消失。这些数据提示低血糖可能不是AMI病人不良预后的直接调节因素。
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