Acute Glycemic Variability and Early Outcomes After Cardiac Surgery: A Meta-Analysis

Abstract

The influence of acute glycemic variability (GV) on early outcomes of patients after cardiac surgery remains not fully determined. We performed a systematic review and meta-analysis to evaluate the association between acute GV and in-hospital outcomes of patients after cardiac surgery. Relevant observational studies were obtained by search of electronic databases including Medline, Embase, Cochrane Library, and Web of Science. A randomized-effects model was selected to pool the data by incorporating the influence of potential heterogeneity. Nine cohort studies involving 16 411 patients after cardiac surgery were included in this meta-analysis. Pooled results showed that a high acute GV was associated with an increased risk of major adverse events (MAE) during hospitalization for patients after cardiac surgery [odds ratio [OR]: 1.29, 95% CI: 1.15 to 1.45, p<0.001, I22=38%]. Sensitivity analysis limited to studies of on-pump surgery and GV evaluated by coefficient of variation of blood glucose showed similar results. Subgroup analysis suggested that a high acute GV was related to an increased incidence of MAE in patients after coronary artery bypass graft, but not for those after isolated valvular surgery (p=0.04), and the association was weakened after adjustment of glycosylated hemoglobin (p=0.01). Moreover, a high acute GV was also related to an increased risk of in-hospital mortality (OR: 1.55, 95% CI: 1.15 to 2.09, p=0.004; I22=0%). A high acute GV may be associated with poor in-hospital outcomes in patients after cardiac surgery.

Key words

glycemic variability - cardiac surgery - adverse events - mortality - meta-analysis

Publication History

Received: 20 April 2023

Accepted: 01 June 2023

Article published online:
04 July 2023

• References

• 1 Ware LR, Gilmore JF, Szumita PM. Practical approach to clinical controversies in glycemic control for hospitalized surgical patients. Nutr Clin Pract 2022; 37: 521-535
• 2 Girish G, Agarwal S, Satsangi DK. et al. Glycemic control in cardiac surgery: rationale and current evidence. Ann Card Anaesth 2014; 17: 222-228
• 3 Bundhun PK, Bhurtu A, Yuan J. Impact of type 2 diabetes mellitus on the long-term mortality in patients who were treated by coronary artery bypass surgery: A systematic review and meta-analysis. Medicine (Baltimore) 2017; 96: e7022
• 4 Bayfield NGR, Bibo L, Budgeon C. et al. Conventional glycaemic control may not be beneficial in diabetic patients following Ccardiac surgery. Heart Lung Circ 2022; 31: 1692-1698
• 5 Sindhvananda W, Poopuangpairoj W, Jaiprasat T. et al. Comparison of glucose control by added liraglutide to only insulin infusion in diabetic patient undergoing cardiac surgery: a preliminary randomized-controlled trial. Ann Card Anaesth 2023; 26: 63-71
• 6 Jin X, Wang J, Ma Y. et al. Association between perioperative glycemic control strategy and mortality in patients with diabetes undergoing cardiac surgery: a systematic review and meta-analysis. Front Endocrinol (Lausanne) 2020; 11: 513073
• 7 Chen Y, Zhang H, Hou X. et al. Glycemic control and risk factors for in-hospital mortality and vascular complications after coronary artery bypass grafting in patients with and without preexisting diabetes. J Diabetes 2021; 13: 232-242
• 8 Lowden E, Schmidt K, Mulla I. et al. Evaluation of outcomes and complications in patients who experience hypoglycemia after cardiac surgery. Endocr Pract 2017; 23: 46-55
• 9 Dell’Aquila AM, Ellger B. Perioperative glycemic control: what is worth the effort?. Curr Opin Anaesthesiol 2013; 26: 438-443
• 10 Lin J, Cai C, Xie Y. et al. Acute glycemic variability and mortality of patients with acute stroke: a meta-analysis. Diabetol Metab Syndr 2022; 14: 69
• 11 Li X, Zhang D, Chen Y. et al. Acute glycemic variability and risk of mortality in patients with sepsis: a meta-analysis. Diabetol Metab Syndr 2022; 14: 59
• 12 Zhang L, Li F, Liu HH. et al. Glycaemic variability and risk of adverse cardiovascular events in acute coronary syndrome. Diab Vasc Dis Res 2022; 19 14791641221137736
• 13 Jiao X, Wang H, Li M. et al. Glycemic variability and prognosis of patients with intracerebral hemorrhage: a meta-analysis. Horm Metab Res 2023; 55: 176-183
• 14 Ravi R, Balasubramaniam V, Kuppusamy G. et al. Current concepts and clinical importance of glycemic variability. Diabetes Metab Syndr 2021; 15: 627-636
• 15 Landoni G, Lomivorotov V, Silvetti S. et al. Nonsurgical strategies to reduce mortality in patients undergoing cardiac surgery: an updated consensus process. J Cardiothorac Vasc Anesth 2018; 32: 225-235
• 16 Duncan AE, Abd-Elsayed A, Maheshwari A. et al. Role of intraoperative and postoperative blood glucose concentrations in predicting outcomes after cardiac surgery. Anesthesiology 2010; 112: 860-871
• 17 Subramaniam B, Lerner A, Novack V. et al. Increased glycemic variability in patients with elevated preoperative HbA1C predicts adverse outcomes following coronary artery bypass grafting surgery. Anesth Analg 2014; 118: 277-287
• 18 Bardia A, Khabbaz K, Mueller A. et al. The association between preoperative hemoglobin A1C and postoperative glycemic variability on 30-day major adverse outcomes following isolated cardiac valvular surgery. Anesth Analg 2017; 124: 16-22
• 19 Clement KC, Suarez-Pierre A, Sebestyen K. et al. Increased glucose variability is associated with major adverse events after coronary artery bypass. Ann Thorac Surg 2019; 108: 1307-1313
• 20 Kim HJ, Shim JK, Youn YN. et al. Influence of preoperative hemoglobin A1c on early outcomes in patients with diabetes mellitus undergoing off-pump coronary artery bypass surgery. J Thorac Cardiovasc Surg 2020; 159: 568-576
• 21 Rangasamy V, Xu X, Susheela AT. et al. Comparison of glycemic variability indices: blood glucose, risk index, and coefficient of variation in predicting adverse outcomes for patients undergoing cardiac surgery. J Cardiothorac Vasc Anesth 2020; 34: 1794-1802
• 22 Liang M, Xiong M, Zhang Y. et al. Increased glucose variability is associated with major adverse events in patients with infective endocarditis undergo surgical treatment. J Thorac Dis 2021; 13: 653-663
• 23 Choi H, Park CS, Huh J. et al. Intraoperative glycemic variability and mean glucose are predictors for postoperative delirium after cardiac surgery: a retrospective cohort study. Clin Interv Aging 2022; 17: 79-95
• 24 You H, Hou X, Zhang H. et al. Effect of glycemic control and glucose fluctuation on in-hospital adverse outcomes after on-pump coronary artery bypass grafting in patients with diabetes: a retrospective study. Diabetol Metab Syndr 2023; 15: 20
• 25 Higgins J, Thomas J, Chandler J. et al. Cochrane handbook for systematic reviews of interventions version 6.2. The Cochrane Collaboration. 2021 www.training.cochrane.org/handbook
• 26 Page MJ, Moher D, Bossuyt PM. et al. PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews. BMJ 2021; 372: n160
• 27 Brooke BS, Schwartz TA, Pawlik TM. MOOSE reporting guidelines for meta-analyses of observational studies. JAMA Surg 2021; 156: 787-788
• 28 Wells GA, Shea B, O’Connell D. et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. 2010 http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp
• 29 Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med 2002; 21: 1539-1558
• 30 Egger M, Davey Smith G, Schneider M. et al. Bias in meta-analysis detected by a simple, graphical test. BMJ 1997; 315: 629-634
• 31 Breyton AE, Lambert-Porcheron S, Laville M. et al. CGMS and glycemic variability, relevance in clinical research to evaluate interventions in T2D, a literature review. Front Endocrinol (Lausanne) 2021; 12: 666008
• 32 Yoo JH, Kim JH. Time in range from continuous glucose monitoring: a novel metric for glycemic control. Diabetes Metab J 2020; 44: 828-839
• 33 Gabbay MAL, Rodacki M, Calliari LE. et al. Time in range: a new parameter to evaluate blood glucose control in patients with diabetes. Diabetol Metab Syndr 2020; 12: 22
• 34 Sakamoto M. Type 2 Diabetes and glycemic variability: various parameters in clinical practice. J Clin Med Res 2018; 10: 737-742
• 35 Nam K, Jeon Y, Kim WH. et al. Intraoperative glucose variability, but not average glucose concentration, may be a risk factor for acute kidney injury after cardiac surgery: a retrospective study. Can J Anaesth 2019; 66: 921-933
• 36 Li X, Zhou X, Wei J. et al. Effects of glucose variability on short-term outcomes in non-diabetic patients after coronary artery bypass grafting: a retrospective observational study. Heart Lung Circ 2019; 28: 1580-1586
• 37 Clement KC, Alejo D, DiNatale J. et al. Increased glucose variability is associated with atrial fibrillation after coronary artery bypass. J Card Surg 2019; 34: 549-554
• 38 Lin YJ, Lin LY, Peng YC. et al. Association between glucose variability and postoperative delirium in acute aortic dissection patients: an observational study. J Cardiothorac Surg 2021; 16: 82
• 39 Valente T, Arbex AK. Glycemic variability, oxidative stress, and impact on complications related to type 2 diabetes mellitus. Curr Diabetes Rev 2021; 17 e071620183816
• 40 Tossios P, Bloch W, Huebner A. et al. N-acetylcysteine prevents reactive oxygen species-mediated myocardial stress in patients undergoing cardiac surgery: results of a randomized, double-blind, placebo-controlled clinical trial. J Thorac Cardiovasc Surg 2003; 126: 1513-1520
• 41 Luo M, Kong X, Wang H. et al. Effect of dapagliflozin on glycemic variability in patients with type 2 diabetes under insulin glargine combined with other oral hypoglycemic drugs. J Diabetes Res 2020; 6666403
• 42 Solomon SD, McMurray JJV, Claggett B. et al. Dapagliflozin in heart failure with mildly reduced or preserved ejection fraction. N Engl J Med 2022; 387: 1089-1098
• 43 Kurniawaty J, Setianto BY, Supomo et al. The effect of low preoperative ejection fraction on mortality after cardiac surgery in Indonesia. Vasc Health Risk Manag 2022; 18: 131-137