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Starr-Wood Cardiac Group, Providence St. Vincent Hospital, 9155 SW Barnes Rd, Ste 240, Portland, OR 97225
(Email: tfurnary{at}starrwood.com).
Diabetes is one of the most important and prevalent comorbidities cardiac surgeons face in their patients. At 31%, diabetes ranks as the fourth most common disease state in the Society of Thoracic Surgeons database, falling in rank order only behind coronary artery disease (73%), dyslipidemia (69%), and hypertension (68%) [1]. Most cardiac surgical patients with diabetes have type II or adult-onset, insulin-resistant diabetes, which develops slowly over the years with gradually rising glucose levels over time. The diagnosis of type II diabetes has traditionally required the observation of elevated glucose levels that rise above a specified point that denotes pathologic glucose concentrations—those that cause a significant increase in microvascular complications such as retinopathy, nephropathy, and neuropathy.
However, because it is chronic hyperglycemia that induces the diabetes-specific pathologic microvascular complications that are correlated with its diagnosis and stratification, it follows that a simple marker of long-term glycemic exposure, such as hemoglobin (Hb) A1c, should be sufficient to definitively diagnose the presence of diabetes and grade its severity. Several studies have shown that the optimal cut point for detecting moderate retinopathy and other microvascular complications is an HbA1c value of 6.5%.
As such, the American Diabetes Association recently declared that the diagnosis of diabetes is definitively made if the HbA1c is greater than 6.5% [2]. Patients with an A1c between 6.0% and 6.5% should be considered at risk for developing diabetes, and preventative measures should be undertaken in patients with these values. It has further recommended that the terms previously used to describe subdiabetic glycemia—impaired fasting glucose, impaired glucose tolerance, prediabetes, and borderline diabetes—be phased out of use as clinical diagnostic states in favor of simple HbA1c measurements (Table 1).
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Those patients who do not carry the diagnosis of diabetes on admission, but have a high preoperative predictive probability of having newly diagnosed diabetes mellitus (fasting plasma glucose level > 126 mg/dL or an HbA1c > 6.0%) should be aggressively treated in the hospital the same as those who are admitted with the diagnosis of diabetes—with tight glycemic control for 3 full postoperative days. These patients should be referred to an endocrinologist or an astute primary care physician for glycemic testing, education, and management after discharge.
Those who have HbA1c values of 6.5% or higher should be told that they have diabetes and properly educated about the disease before leaving the hospital. Those patients who do not meet the diabetes threshold of 6.5%, but have elevated HbA1c levels of between 6.0% and 6.5% should receive preventative education and be placed on demonstratively effective therapeutic interventions after discharge designed to stop or delay the progression of their disease to frank diabetes. Those with HbA1c levels between 5.5% and 6.0% should be educated about their risks of progression to diabetes [2]. Open heart surgical patients who do not have diabetes (HbA1c < 5.5%) do not need to have their glucose levels managed or monitored after discharge.
The importance of this study, and the American Diabetes Association expert committee report on the role of HbA1c, is that they help us rapidly determine what to do, both in the hospital and after discharge, when hyperglycemia develops in patients who present for heart operations without the diagnosis of diabetes. It is important to our patients with diabetes, and impending diabetes, that we not ignore this important disease state. We should therefore manage dysglycemia with the same voracity as we currently manage hypertension and hypercholesterolemia after cardiac operations.
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