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Hyperglycemia Increases New-Onset Atrial Fibrillation in Patients with Acute ST-Elevation Myocardial Infarction

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Hyperglycemia Increases New-Onset Atrial Fibrillation in Patients with Acute ST-Elevation Myocardial Infarction Original ArticleHyperglycemia Predicts AF in STEMIs Acta Cardiol Sin 2012;28:279-285 Arrhythmia and Electrophysiology Hyperglycemia Increases New-Onset Atrial Fibrillation in Patients with Acute ST-Elevation Myocardial Infarction Hong-Pin Hsu,1 Yu-Lan Jou,1 Tao-Cheng Wu,2,3 Ying-Hwa Chen,2,3 Shao-Song Huang,2,3 Yenn-Jiang Lin,2,3 Li-Wei Lo,2,3 Yu-Feng Hu,2,3 Ta-Chuan Tuan,3 Shih-Lin Chang2,3 and Shih-Ann Chen2,3 Background: Atrial fibrillation (AF) is a frequent complication of acute myocardial infarction, and is often accompanied by an increased morbidity and mortality. The aim of this study was to investigate the predictors and outcome of new-onset AF occurring after acute ST-elevation myocardial infarction (STEMI). Methods: A total of 307 patients with acute STEMI from May 2007 to June 2009 were included in our study. Of those patients, 57 patients experienced new-onset AF during their hospitalization in the coronary care unit with continuous ECG monitoring. The primary endpoint was the occurrence of AF during the hospitalization. The secondary endpoint was the all-cause mortality during a 12-month follow-up period. Results: Two hundred eighty three patients (92.2%) received revascularization during the hospitalization. The patients with new-onset AF after the acute STEMI were older, with lower diastolic blood pressure, higher initial fasting glucose, lower lipid level, and a higher incidence of coronary artery disease history when compared to those without new-onset AF. In a multivariable analysis, the initial fasting glucose level (p = 0.025, OR = 1.007, 95% CI = 1.001~1.012) was an independent predictor of the occurrence of new-onset AF after acute STEMI. New-onset AF was associated with a higher all-cause mortality rate during the follow-up (p = 0.001). Conclusion: A higher initial fasting glucose level was an independent predictor of the occurrence of AF in patients with acute STEMI, which may be associated with a poor prognosis. Key Words: Atrial fibrillation · Hyperglycemia · Myocardial infarction INTRODUCTION and associated with an increased mortality and morbid- ity.1,2 Those patients with AMI who developed AF were Atrial fibrillation (AF) is the most frequently occur- at a greater risk for an acute stroke and mortality during ring supraventricular tachycardia during an acute myo- their hospitalization than those without it.3 On the other cardial infarction (AMI), with an incidence of 6-21%, hand, ventricular tachyarrhythmias are also an important cause of sudden cardiac death in patients with AMI. The patients with ventricular tachyarrhythmias had higher Received: June 9, 2011 Accepted: July 13, 2012 low-density lipoprotein cholesterol (LDL-C) levels and a 1Division of Cardiology, Department of Internal Medicine, Taipei lower blood pressure on their initial arrival, suggesting 2 City Hospital; Division of Cardiology, Taipei Veterans General that dyslipidemia may impose a higher risk of develop- Hospital; 3Department of Medicine and Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University ing tachyarrhythmias in the acute phase of ST-segment School of Medicine, Taipei, Taiwan. elevation myocardial infarction (STEMI).4 However, the Address correspondence and reprint requests to: Dr. Shih-Lin Chang, relationship of new-onset AF to the clinical biochemical Division of Cardiology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan. Tel: 886-2-2875-7156; Fax: markers and outcome in the patients with acute STEMI 886-2-2873-5656; E-mail: [email protected] is still not fully clarified. The purpose of this study was 279 Acta Cardiol Sin 2012;28:279-285 Hong-Pin Hsu et al. to determine the predictors of the risk of developing total creatine kinase (CK) level was < 200 IU/L. new-onset AF in the clinical setting of acute STEMI, and AF was detected by the 12-lead ECGs recorded dur- to try to elucidate the relationship between new-onset ing the entire hospital course and the 24 hour continuous AF and the clinical outcome. ECG monitoring in the CCU. The ECG monitor auto- matically detected and recorded any non-sustained or sustained supraventricular and ventricular arrhythmias PATIENTS AND METHODS after the myocardial infarction, and the recording was further confirmed by the CCU doctor. All of the 12-lead A retrospective study was designed and we enrolled ECGs acquired during the hospitalization were con- those patients admitted to Taipei Veterans General Hos- firmed by the cardiologists. Patients who had AF epi- pital of Taiwan due to acute STEMI from May 2007 to sodes in the past were excluded from the study. June 2009. A total of 307 consecutive patients without The serum lipids, including the total cholesterol any documented AF prior to admission were included in (TC), LDL-C, high-density lipoprotein cholesterol this study based on the registration of the coronary care (HDL-C), triglyceride (TG), and fasting glucose level unit (CCU) of Taipei Veterans General Hospital. The were sampled on the morning after the day of admission, outcome within 12 months after discharge was acquired and all patients generally should fast for at least 8 hours by the medical records of the hospital and telephone before checking those biochemical data. The C-reactive communication with family members. protein (CRP) level was checked immediately upon the The patients included in this study met the following patient’s arrival at our emergency room. criteria for acute STEMI: (1) chest pain of ³ 30 minutes Hypertension was defined as a systolic blood pres- in duration; (2) electrocardiograph (ECG) showing sure (SBP) of ³ 140 mmHg and/or diastolic pressure ST-segment elevation of ³ 0.1mVintwoormoreleads; (DBP) of ³ 90 mmHg with more than two readings dur- and (3) elevated creatine kinase-MB (CK-MB) isoen- ing a resting state, according to the criteria of the Joint zymes or troponin-I within 24 hours of the chest pain. National Committee-VII (JNC-VII),6 or those who had Most of these patients were treated with a primary per- taken antihypertensive medications during their daily cutaneous coronary intervention (PCI), coronary artery life. Diabetes mellitus (DM) was defined according to the bypass graft (CABG) surgery, or medical control and American Diabetes Association criteria,7 or as those who then an elective PCI according to the guidelines pub- used oral hypoglycemic agents or insulin for blood sugar lished by the American College of Cardiology/American control. A past history of coronary artery disease (CAD) Heart Association (ACC/AHA).5 All the patients were was defined according to the results of the previous coro- initially admitted to the CCU, with follow-up cardiac nary angiography (CAG) or non-invasive stress imaging. enzyme tests and 12 lead ECGs taken every 6 hours to The left atrial (LA) diameter and left ventricular trace the ST-T change after the acute STEMI. Con- ejection fraction (LVEF) were determined by echocar- tinuous ECG, blood pressure and oximetry monitoring diography during the hospitalization. The culprit lesion were performed in all the study patients when they were was identified by correlating the coronary angiography in the CCU. The medications used during the hospital with the ST-segment elevation on the admission ECG, course, such as aspirin, clopidogrel, anticoagulants, an- and the regional wall motion abnormality in the left giotensin converting enzyme (ACE) inhibitors, angio- ventriculography. Coronary artery stenosis of > 50% in tensin receptor blockers, beta-antagonists, lipid-lower- diameter was regarded as significant. The number of dis- ing agents, and intravenous or sublingual nitroglycerin eased arteries was determined accordingly. The hemo- were all administered as recommended by the ACC/ dynamic status included the SBP, DBP, and heart rate, AHA guidelines and were continued after discharge which were recorded immediately after arrival at the from the hospital unless there was any contraindication emergency room. for the patients. The patients were transferred to an ordi- nary ward if they became hemodynamically stable, no Statistical analyses symptoms of ongoing ischemia were observed, and the Data are expressed as the mean ± standard deviation. Acta Cardiol Sin 2012;28:279-285 280 Hyperglycemia Predicts AF in STEMIs Chi-square and Fisher’s exact tests were used for cate- CAD into the multivariable analysis, the initial fasting gorical data. Student’s t tests were used for continuous glucose level [odds ratio (OR) = 1.007, confidence inter- data. A univariate analysis of the various clinical vari- val (CI) = 1.001~1.012, p = 0.025] was an independent ables was performed to determine the predictors of predictor of the occurrence of new-onset AF after acute new-onset AF occurring after acute STEMI. The vari- STEMI (Table 2). ables selected to be tested in the multivariate analysis After a follow-up of 12 months, the patients with (logistic regression) were those with p values of < 0.1 in new-onset AF had a higher all-cause mortality rate the univariate models. The survival rate and cumulative (39.1% vs. 16.0%, p = 0.001) (Figure 1) and a higher survival curve between the two groups were analyzed by rate of cardiovascular death (28.1% vs. 13.6%, p = 0.01) a Kaplan-Meier method and log-rank test. The compari- than those without AF. The causes of cardiovascular son of the all-cause mortality between the sinus rhythm death included recurrent myocardial infarction (2 pa- and AF groups was further adjusted by age with a Cox tients), decompensated heart failure (35 patients), and regression analysis. A p value of < 0.05 was considered ventricular arrhythmias (13 patients). The non-cardio- statistically significant. vascular deaths included septic shock (5 patients) and malignant neoplasms (2 patients). Because there was a significant difference in the age between new-onset AF RESULTS and non-AF, the age was adjusted in a Cox regression model to compare the mortality of these two groups.
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