Pressmeddelande den 14 november 2016 Hjärtlungfonden
Internationella diabetesdagen den 14 november:
 
Oupptäckt sockerstörning ökar riskerna efter hjärtinfarkt
Hjärtpatienter med oupptäckt sockerstörning löper betydligt större risk att drabbas av en ny hjärtinfarkt eller stroke, visar en ny forskningsstudie med stöd från Hjärt-Lungfonden. Ett enkelt sockertest kan identifiera riskindivider, OGTT oralt glukos tolerans test – men det genomförs bara på vissa sjukhus i landet.
 
– Sockerstörningar kan leda till typ 2-diabetes och ökar risken för hjärt-kärlsjukdom. Det är glädjande att forskningen ger bättre kunskap om kopplingen mellan sjukdomarna.
 
Den kunskapen måste så snabbt som möjligt komma patienter i hela Sverige till del genom nya behandlingsriktlinjer, säger Kristina Sparreljung, generalsekreterare för Hjärt-Lungfonden.
 
I dag har 450 000 svenskar diabetes, varav de flesta typ 2. Personer med diabetes är överrepresenterade bland de som drabbas av hjärtinfarkt, och löper efter hjärtinfarkten en ökad risk för stroke, hjärtsvikt och ytterligare hjärtinfarkter.
 
Den nya forskningsstudien, med stöd av Hjärt-Lungfonden, visar att även personer med tidigare okända sockerstörningar löper ökad risk för komplikationer när de har drabbats av en hjärtinfarkt.
 
Ett sockertest efter en hjärtinfarkt kan identifiera de som har oupptäckt sockerstörning, och ge möjlighet för vården att påbörja förebyggande behandling för att undvika ytterligare hjärtinfarkter. Metoder för att förhindra en andra hjärtinfarkt är bland annat att stödja personer att förändra levnadsvanor som rökning och fysisk inaktivitet, samt att sätta in blodfettssänkande och blodproppsförebyggande läkemedel.
 
– Uppåt hälften av de som drabbas av hjärtinfarkt har en sockerstörning utan att veta om det. Ett enkelt sockertest skulle vara mycket värdefullt, eftersom det signalerar ogynnsam prognos och ger möjligheten att påverka sitt blodsocker och sin risk. I dag är det bara vissa sjukhus som gör de här testerna och det ingår inte i de nationella riktlinjerna, säger Viveca Ritsinger, forskare på Karolinska Institutet.
 
Hjärt-kärlkomplikationer är den vanligaste dödsorsaken hos personer med diabetes. Kopplingen mellan sjukdomarna är tydlig, däremot förstår man ännu inte de exakta mekanismerna. Avhandlingen visar att dagens behandlingsmetoder behöver kompletteras med nya strategier. Om forskningen kan lösa gåtan om hur diabetes och hjärtsjukdom hänger ihop så skulle tusentals hjärtinfarkter kunna förhindras i Sverige varje år.
 
Viveca Ritsingers avhandling:
- Causes and mechanisms for an adverse outcome in patients with glucose abnormalities and cardiovascular disease – epidemiological and biochemical analyses
 
Causes and mechanisms of an adverse outcome in patients with glucose abnormalities and cardiovascular disease : epidemiological and biochemical analyses
 
Author: Ritsinger, Viveca
Date: 2016-11-18
Location: Kirurgisalen, A6:04, Karolinska University Hospital, Solna
Time: 09.00
Department: Inst för medicin, Solna / Dept of Medicine, Solna
 
Abstract
Background: Diabetes and previously undetected glucose abnormalities are common in patients with acute myocardial infarction (AMI). It is well established that patients with diabetes have a higher mortality rate after coronary events than patients without diabetes but the complication pattern in a contemporary perspective, the impact of glucose control and whether unknown glucose abnormalities affect the longterm prognosis is less well studied. Data on the prognostic implications of adipokines in patients with prevalent coronary heart disease are contradictory and long-term outcome studies are lacking.
 
Aims: To identify high-risk individuals and study long-term prognosis by
1. Investigating the lasting effect of intensified, insulin-based glucose control on mortality after AMI in patients with diabetes.
2. Analysing mortality and morbidity patterns after AMI in patients with newly discovered glucose abnormalities.
3. Investigating complication patterns after a first percutaneous coronary intervention.
4. Analysing the significance of adiponectin and leptin as biomarkers of cardiovascular complications. Glucose control and mortality after AMI: 306 patients with AMI and diabetes were randomised to intensified insulin-based glycaemic control while 314 served as controls in the DIGAMI-study. During a mean follow-up of 7.3 years 90% of the study population died. The median survival was 2.3 years longer in patients receiving intensified insulin-based glycaemic control after AMI (7.0 years) compared to patients in the control group (4.7 years).
 
Impact of undetected glucose abnormalities on long-term outcome after AMI: Patients (n=167) with AMI and healthy controls (n=184) without previously known diabetes (included in the GAMI study) were investigated with an oral glucose tolerance test (OGTT) at the time of hospital discharge (patients) or at inclusion (controls). Cardiovascular events (cardiovascular mortality, AMI, heart failure and stroke) during 10 years of follow-up were more frequent in patients with abnormal glucose tolerance than in patients with normal glucose tolerance and in controls. Abnormal glucose tolerance at the OGTT was independently associated with future cardiovascular events after an AMI (HR 2.30; 95% CI 1.24-4.25, p=0.008) in contrast to HbA1c (p=0.81) and fasting blood glucose (p=0.52).
 
Long-term outcome after coronary artery disease and revascularisation: High event rates of mortality, heart failure, myocardial infarction and stroke were demonstrated after a first percutaneous coronary intervention in patients with diabetes followed up to five years after inclusion in the Swedish Coronary Angiography Angioplasty Registry (SCAAR) between 2006-2010 (n=58891, 19% with diabetes). Diabetes was an independent predictor for mortality and cardiovascular events. Insulin-treated patients were at a particularly high risk. Adiponectin and leptin as biomarkers for identifying high risk patients: In 180 patients with AMI and without diabetes (the GAMI cohort) elevated levels of adiponectin at discharge independently predicted mortality (HR 1.79; 95% CI 1.07-3.00, p=0.027) but not cardiovascular events the coming decade. High levels of leptin at day 2 were associated with cardiovascular events during the first seven years but did not predict mortality.
 
Conclusion: Diabetes and previously undetected glucose abnormalities are common in patients with coronary events and their presence has a negative influence on the prognosis. Despite improved longevity patients with diabetes are still at increased risk for mortality and cardiovascular complications. An OGTT, but not HbA1c, identifies patients with previously undetected glucose abnormalities at increased cardiovascular risk the next coming 10 years. These findings support that an OGTT should be considered as an important screening tool after AMI. High levels of adiponectin and leptin identifies patients with compromised outcome after AMI. Future studies are warranted to confirm their role as suitable biomarkers. Finally a close follow-up of patients with glucose abnormalities is advocated where multifactorial treatment is important to improve long-term survival after AMI. The present studies do also underline that new treatment strategies are highly warranted.
 
List of papers:
I. Ritsinger V, Malmberg K, Mårtensson A, Rydén L, Wedel H, Norhammar A. Intensified insulin-based glycaemic control after myocardial infarction improves long-term survival. Twenty-year follow-up of the Diabetes Mellitus Insulin Glucose Infusion in Acute Myocardial Infarction (DIGAMI) study. Lancet Diabetes Endocrinol 2014;2(8):627-33.

II. Ritsinger V, Tanoglidi E, Malmberg K, Näsman P, Rydén L, Tenerz Å, Norhammar A. Sustained prognostic implications of newly detected glucose abnormalities in patients with acute myocardial infarction: Long-term follow-up of the Glucose Tolerance in Patients with Acute Myocardial Infarction cohort. Diab Vasc Dis Res 2015;12(1):23-32.
Fulltext (DOI)

III. Ritsinger V, Saleh N, Lagerqvist B, Norhammar A. High event rate after a first percutaneous coronary intervention (PCI) in patients with diabetes. Results from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR). Circ Cardiovasc Interv 2015;8(6):e002328

IV. Ritsinger V, Brismar K, Malmberg K, Mellbin L, Näsman P, Rydén L, Söderberg S, Tenerz Å, Norhammar A. Elevated levels of adipokines predict outcome after acute myocardial infarction : a long-term follow up of the GAMI cohort. Diab Vasc Dis Res 2017; [Submitted]
URI: http://hdl.handle.net/10616/45254
 
Institution: Karolinska Institutet
Supervisor: Norhammar, Anna
Issue date: 2016-10-26
Publication year: 2016
ISBN: 978-91-7676-446-6
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