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Clinical significance of glycated hemoglobin in acute coronary syndrome patients from the CCC-ACS project

Findings from a multicenter retrospective observational study

Klinische Bedeutung des glykierten Hämoglobins bei Patienten mit akutem Koronarsyndrom aus dem CCC-ACS-Projekt

Ergebnisse einer retrospektiven Multizenter-Beobachtungsstudie

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Abstract

Background

Blood glucose levels are associated with the prognosis of patients with acute coronary syndrome (ACS). Glycated hemoglobin (HbA1c) reflects the average blood glucose level. The purpose of the study was to evaluate HbA1c as a prognostic indicator for ACS.

Methods

In total, 27,337 ACS patients from the CCC-ACS (Improving Care for Cardiovascular Disease in China - Acute Coronary Syndrome) project were enrolled in this study and divided into three groups according to HbA1c level: Group I, HbA1c level <5.7%; Group II, HbA1c level 5.7–6.4%; Group III, HbA1c level ≥6.5%. The primary outcome was an in-hospital major adverse cardiovascular event (MACE), such as all-cause death, recurrent myocardial infarction, acute or subacute stent thrombosis, heart failure, cardiogenic shock, or cardiac arrest. Baseline data and effectiveness outcome were compared among patients in the three groups.

Results

Group III had the highest MACE incidence (13.4% [Group III] vs. 8.7% [Group I] and 10.5% [Group II], p < 0.001). In the logistic regression, there was a statistically significant difference in HbA1c level between the groups (odds ratio [OR]: 1.110, 95% confidence interval [CI]: 1.008–1.133, p < 0.001). In the receiver operating characteristic curve, the area under the curve for MACE was 0.560 (95% CI: 0.550–0.571, p < 0.001); the cut-off value for the HbA1c level was 6.38%.

Conclusion

The HbA1c level was associated with the risk of MACEs in ACS patients with or without diabetes.

Trial Registration clinicaltrials.gov, NCT02306616. Registered 3 December 2014—Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02306616.

Zusammenfassung

Hintergrund

Der Blutzuckerspiegel steht in einem Zusammenhang mit der Prognose von Patienten mit akutem Koronarsyndrom (ACS). Das glykierte Hämoglobin (HbA1c) ist ein Marker für den durchschnittlichen Blutzuckerspiegel. Ziel der vorliegenden Studie war es, HbA1c als prognostischen Indikator des ACS zu untersuchen.

Methoden

In die vorliegende Studie wurden 27.337 ACS-Patienten aus dem CCC-ACS-Projekt (Improving Care for Cardiovascular Disease in China – Acute Coronary Syndrome) einbezogen und nach ihrem HbA1c-Wert in 3 Gruppen eingeteilt: Gruppe I mit einem HbA1c-Wert <5,7 %; Gruppe II mit einem HbA1c-Wert von 5,7–6,4 %; Gruppe III mit einem HbA1c-Wert ≥6,5 %. Primärer Endpunkt war ein schweres kardiovaskuläres unerwünschtes Ereignis im Krankenhaus (MACE), wie Tod aus sämtlichen Ursachen, Rezidiv eines Herzinfarkts, akute oder subakute Stentthrombose, Herzinsuffizienz, kardiogener Schock oder Herzstillstand. Die Ausgangsdaten und das Ergebnis hinsichtlich der Wirksamkeit wurden zwischen den Patienten in den 3 Gruppen verglichen.

Ergebnisse

Die höchste MACE-Inzidenz bestand in Gruppe III (13,4 % [Gruppe III] vs. 8,7 % [Gruppe I] und 10,5 % [Gruppe II]; p < 0,001). Im Rahmen der logistischen Regression gab es zwischen den Gruppen eine statistisch signifikante Differenz beim HbA1c-Wert (Odds Ratio, OR: 1,110; 95 %-Konfidenzintervall, 95 %-KI: 1,008–1,133; p < 0,001). In der Receiver-Operating-Characteristic-Kurve betrug die Fläche unter der Kurve für MACE 0,560 (95 %-KI: 0,550–0,571; p < 0,001); der Grenzwert für den HbA1c-Wert lag bei 6,38 %.

Schlussfolgerung

Der HbA1c-Wert weist einen Zusammenhang mit dem Risiko für MACE bei ACS-Patienten mit oder ohne Diabetes mellitus auf. Studienregistrierung: clinicaltrials.gov, NCT02306616. Registrierung 3. Dezember 2014 – retrospektiv registriert, https://clinicaltrials.gov/ct2/show/NCT02306616.

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Abbreviations

ACEI:

Angiotensin-converting enzyme inhibitor

ACS:

Acute coronary syndrome

AMI:

Acute myocardial infarction

ARB:

Angiotensin receptor blocker

AUC:

Area under the curve

CAD:

Coronary atherosclerotic disease

CCC-ACS:

Improving Care for Cardiovascular Disease in China—Acute Coronary Syndrome

CI:

Confidence interval

CVD:

Cardiovascular disease

DM:

Diabetes mellitus

GFR:

Glomerular filtration rate

GRACE:

Global Registry of Acute Coronary Events

HbA1c:

Glycated hemoglobin

LDL‑C:

Low-density lipoprotein cholesterol

MACE:

Major adverse cardiovascular event

NSTE-ACS:

Non-ST-elevation ACS

NSTEMI:

Non-ST-elevation myocardial infarction

OR:

Odds ratio

PCI:

Percutaneous coronary intervention

ROC:

Receiver operating characteristic

SBP:

Systolic blood pressure

SD:

Standard deviation

STEMI:

ST-elevation myocardial infarction

UA:

Unstable angina

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Acknowledgements

We acknowledged all participating hospitals for their contributions to the CCC-ACS project (Table S1).

Funding

The Improving Care for Cardiovascular Disease in China CCC-ACS project is a collaborative study of the American Heart Association (AHA) and Chinese Society of Cardiology (CSC). The AHA was funded by Pfizer for the quality improvement initiative through an independent grant for learning and change. This work was also supported by the Cardiacare Sponsored Optimizing Antithrombotic Research Fund (BJUHFCSOARF201801-05) and Liaoning Provincial Key Research and Development Program (2018225001).

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Authors and Affiliations

  1. Department of Cardiology, General Hospital of Northern Theater Command, 110016, Shenyang, Liaoning, China

    Xin Zhao MD, PhD, Xiaozeng Wang MD, PhD, Guannan Ai MS, Yifei Liu MS, Pei Xu MS, Jiyuan Zhang MS & Yaling Han MD, PhD

  2. Department of Heart Center, First Hospital of Tsinghua University, 100016, Beijing, China

    Yi Kang MD

  3. Department of Cardiology, The Second Affiliated Hospital of Shenyang Medical College, 110016, Shenyang, Liaoning, China

    Xiaoxu Yang MS

  4. Jinzhou Medical University, 121001, Jinzhou, Liaoning, China

    Guannan Ai MS, Yifei Liu MS, Pei Xu MS & Jiyuan Zhang MS

  5. Department of Cardiology, Anqing Hospital Affiliated to Anhui Medical University, Anqing, Auhui, 246003, China

    Chonghuai Gu MS

  6. Department of Cardiology, Affiliated Hospital of Liaoning University of Traditional Chinese Medicine, 110032, Shenyang, China

    Yan Zhang PhD

  7. Department of Epidemiology, Beijing An zhen Hospital, 100000, Beijing, China

    Yongchen Hao PhD & Dong Zhao MD, PhD

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  1. Xin Zhao MD, PhD
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Consortia

CCC investigators

Contributions

YK and XZ conceptualized and designed the study; YK statistically analyzed the data; YK and XZ wrote the manuscript. XZ had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. All authors were involved in the analysis or interpretation of data. All authors read and approved the final manuscript. All authors gave final approval for this version to be published.

Corresponding author

Correspondence to Yaling Han MD, PhD.

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Conflict of interest

X. Zhao, Y. Kang, X. Wang, X. Yang, G. Ai, Y. Liu, P. Xu, J. Zhang, C. Gu, Y. Zhang, Y. Hao, D. Zhao, and Y. Han declare that they have no competing interests.

Institutional review board approval was granted for the aggregate dataset for research and quality improvement by the Ethics Committee of Beijing An Zhen Hospital, Capital Medical University. Participating sites were granted a waiver of patient consent under the common rule. Thirty-nine sites received institutional review board approval from their own ethics committees, with the other 111 sites accepting central ethics approval. The study is listed at www.clinicaltrials.gov (NCT02306616).

Additional information

Xin Zhao and Yi Kang contributed equally to the manuscript.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the CCC-ACS project.

Code availability

The statistical analyses were used the IBM SPSS program (Version 23.0).

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Zhao, X., Kang, Y., Wang, X. et al. Clinical significance of glycated hemoglobin in acute coronary syndrome patients from the CCC-ACS project. Herz 46 (Suppl 2), 287–294 (2021). https://doi.org/10.1007/s00059-020-04999-9

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  • DOI: https://doi.org/10.1007/s00059-020-04999-9

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