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2-Hour Post-Load Glucose Increases Predictability of GRACE Score
Study Questions:
What is the impact of 2-hour post-load plasma glucose (2h-PG) on the GRACE (Global Registry of Acute Coronary Events) risk score (GRS)–based prognostic models in acute coronary syndrome (ACE) patients without known diabetes mellitus (DM)?
Methods:
The investigators conducted a retrospective cohort study of 1,056 acute coronary event (ACE) survivors without known DM who had fasting plasma glucose (FPG) and 2h-PG measured predischarge. Death and nonfatal myocardial infarction (MI) were recorded as major adverse cardiac events (MACE) during follow-up. GRS for discharge to 6 months was calculated. Cox proportional-hazards regression was used to identify predictors of event-free survival. The predictive value of 2h-PG alone and combined with GRS was estimated using likelihood ratio test, Akaike’s information criteria, continuous net reclassification improvement (NRI>0), and integrated discrimination improvement (IDI).
Results:
During 40.8 months of follow-up, 235 MACE (22.3%) occurred, more frequently in the upper 2h-PG quartiles. Two-hour PG, but not FPG, adjusted for GRS, independently predicted MACE (hazard ratio, 1.091; 95% confidence interval, 1.043-1.142; p = 0.0002). Likelihood ratio test showed that 2h-PG significantly improved the prognostic models including GRS (χ2 = 20.56, 1 df; p = 0.000). Models containing GRS and 2h-PG yielded lowest corrected Akaike’s information criteria, compared to that with only GRS. Two-hour PG, when added to GRS, improved net reclassification significantly (NRIe>0 6.4%, NRIne>0 24%, NRI>0 0.176; p = 0.017 at final follow-up). Two-hour PG improved integrated discrimination of models containing GRS (IDI of 0.87%, p = 0.008 at final follow-up).
Conclusions:
The authors concluded that 2h-PG, but not FPG, is an independent predictor of adverse outcome after ACE even after adjusting for the GRS.
Perspective:
This study reports that 2h-PG, but not FPG, independently predicts prognosis after ACS after adjusting for the GRS, and improves the ability of models containing GRS to predict long-term adverse events after an ACS in patients without known DM. However, other studies have suggested that in patients without known diabetes, FPG, adjusted for the GRS, predicted mortality after MI and improved the prognostic models containing GRS. Two-hour PG should at least be considered as a marker of post-MI prognosis in these patients, but given the limitations of an observational longitudinal cohort study using retrospective analysis, the study findings need to be prospectively validated.
Keywords: Acute Coronary Syndrome, Blood Glucose, Diabetes Mellitus, Disease-Free Survival, Fasting, Metabolic Syndrome, Myocardial Infarction, Primary Prevention
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