Strict glycemic control reduces EuroSCORE expected mortality in diabetic patients undergoing myocardial revascularization

D’Alessandro, Cosimo; Leprince, Pascal; Golmard, Jean Louis; Ouattara, Alexandre; Aubert, Stéphane; Pavie, Alain; Gandjbakhch, Iradj; Bonnet, Nicolas

doi:10.1016/j.jtcvs.2007.02.028

« Previous Next »The Journal of Thoracic and Cardiovascular Surgery
Volume 134, Issue 1 , Pages 29-37, July 2007

Strict glycemic control reduces EuroSCORE expected mortality in diabetic patients undergoing myocardial revascularization

Cosimo D’Alessandro, MD
- Institute of Cardiology, Division of Thoracic and Cardiovascular Surgery, Centre Hospitalier Universitaire Pitié-Salpêtrière, Assistance Publique–Hôpitaux de Paris, Université Pierre et Marie Curie-Paris, Paris, France
- Address for reprints: Cosimo D’Alessandro, MD, Division of Thoracic and Cardiovascular Surgery, Hôpital La Pitié-Salpêtrière, 47-83 Boulevard de l’Hôpital, 75 651 Paris Cedex 13, France.
Pascal Leprince, MD, PhD
- Institute of Cardiology, Division of Thoracic and Cardiovascular Surgery, Centre Hospitalier Universitaire Pitié-Salpêtrière, Assistance Publique–Hôpitaux de Paris, Université Pierre et Marie Curie-Paris, Paris, France
Jean Louis Golmard, PhD
- Department of Biostatistics, Centre Hospitalier Universitaire Pitié-Salpêtrière, Assistance Publique–Hôpitaux de Paris, Université Pierre et Marie Curie-Paris, Paris, France.
Alexandre Ouattara, MD, PhD
- Department of Anesthesia and Critical Care, Centre Hospitalier Universitaire Pitié-Salpêtrière, Assistance Publique–Hôpitaux de Paris, Université Pierre et Marie Curie-Paris, Paris, France
Stéphane Aubert, MD
- Institute of Cardiology, Division of Thoracic and Cardiovascular Surgery, Centre Hospitalier Universitaire Pitié-Salpêtrière, Assistance Publique–Hôpitaux de Paris, Université Pierre et Marie Curie-Paris, Paris, France
Alain Pavie, MD
- Institute of Cardiology, Division of Thoracic and Cardiovascular Surgery, Centre Hospitalier Universitaire Pitié-Salpêtrière, Assistance Publique–Hôpitaux de Paris, Université Pierre et Marie Curie-Paris, Paris, France
Iradj Gandjbakhch, MD
- Institute of Cardiology, Division of Thoracic and Cardiovascular Surgery, Centre Hospitalier Universitaire Pitié-Salpêtrière, Assistance Publique–Hôpitaux de Paris, Université Pierre et Marie Curie-Paris, Paris, France
Nicolas Bonnet, MD
- Institute of Cardiology, Division of Thoracic and Cardiovascular Surgery, Centre Hospitalier Universitaire Pitié-Salpêtrière, Assistance Publique–Hôpitaux de Paris, Université Pierre et Marie Curie-Paris, Paris, France

Received 27 July 2006; received in revised form 7 February 2007; accepted 19 February 2007.

Objective

We sought to evaluate the effect of a strict glycemic control protocol on a series of diabetic patients undergoing surgical myocardial revascularization.

Methods

Between January 2003 and June 2004, 300 diabetic patients undergoing myocardial revascularization received a local protocol of insulin administration (protocol, group P). Patients were divided into 2 risk classes, according to their additive EuroSCORE value: low–moderate risk (0–4) and moderate–high risk (>4). The logistic EuroSCORE algorithm was used to calculate the expected probability of death. A control group was selected, including a series of 300 consecutive diabetic patients (no protocol group, group NP) who underwent coronary artery bypass grafting between March 2001 and September 2002, just before the introduction of the protocol. A propensity analysis was performed to control for selection bias.

Results

Both groups showed similar EuroSCORE risk profiles: mean additive and logistic EuroSCORE values were 4.16 and 4.29 in group P versus 3.93 and 3.91 in group NP. Observed and expected mortalities of group P were 0.6% versus 1.8% (low–moderate risk), 2.5% versus 8.0% (moderate–high risk, P = .03), and 1.3% versus 4.3% (entire group, P = .01). Observed and expected mortalities of group NP were 1.6% versus 1.9% (low–moderate risk), 8.3% versus 7.5% (moderate–high risk), and 4.0% versus 3.9% (entire group). Logistic regression confirmed observed mortality in group P to be significantly lower than the expected logistic EuroSCORE mortality. After risk adjustment, the protocol allowed us to reduce the mortality odds by 72% (odds ratio, 0.282; 95% confidence interval, 0.092–0.859; P < .03). Subgroup analysis for moderate- to high-risk patients showed the protocol to improve mortality (odds ratio, 0.24; P < .05), whereas no significant improvement was found in low- to moderate-risk patients. Addition of the propensity score to the multivariable analysis did not significantly displace P values and odds ratios. Sensitivity analysis of patients who underwent coronary artery bypass grafting without additional procedures showed the protocol to maintain its protective effect (odds ratio, 0.15; P < .05).

Conclusion

Optimal glucose control highly reduces EuroSCORE expected mortality in diabetic patients undergoing myocardial revascularization, especially in moderate- to high-risk patients.

CTSNet classification: 17, 23

Abbreviations and Acronyms: BGL, blood glycemic level, CABG, coronary artery bypass grafting, COPD, chronic obstructive pulmonary disease, DM, diabetes mellitus, ICU, intensive care unit, ITA, internal thoracic artery, LVEF, left ventricular ejection fraction, O/E, observed/expected ratio, OR, odds ratio