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


CONCLUSIONS
Optimal glucose control highly reduces EuroSCORE expected mortality in diabetic patients undergoing myocardial revascularization, especially in moderate- to high-risk patients.
D'Alessandro
Cosimo
C
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. cosimodalessandro@wanadoo.fr
Leprince
Pascal
P
Golmard
Jean Louis
JL
Ouattara
Alexandre
A
Aubert
Stéphane
S
Pavie
Alain
A
Gandjbakhch
Iradj
I
Bonnet
Nicolas
N
D000368:Aged; D003327:Coronary Disease / Q000150:complications* / Q000601:surgery*; D048909:Diabetes Complications / Q000517:prevention & control*; D003920:Diabetes Mellitus / Q000188:drug therapy* / Q000451:nursing; D005260:Female; D006801:Humans; D007328:Insulin / Q000008:administration & dosage*; D008297:Male; D016343:Monitoring, Intraoperative; D009204:Myocardial Revascularization / Q000401:mortality*; D019990:Perioperative Care / Q000379:methods*; D011446:Prospective Studies
D007328:Insulin