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Effect of glycaemic control on complications following cardiac surgery: literature review

Journal of Cardiothoracic Surgery volume 13, Article number: 10 (2018) Cite this article

Abstract

Introduction

No uniform consensus in the UK or Europe exists, for glycaemic management of patients with Diabetes or pre-diabetes undergoing cardiac surgery.

Objective

[i] Determine the relationship between glycaemic control and cardiac surgical outcomes; [ii] Compare current vs gold standard management of patients with Diabetes or pre-diabetes undergoing cardiac surgery.

Methods

Searches of MEDLINE, NHS Evidence and Web of Science databases were completed. Articles were limited to those in English, German and French. No date limit was enforced.13,232 articles were identified on initial literature review, and 50 relevant papers included in this review.

Results

No national standards for glycaemic control prior to cardiac surgery were identified. Upto 30% of cardiac surgical patients have undiagnosed Diabetes. Cardiac surgical patients without Diabetes with pre-operative hyperglycaemia have a 1 year mortality double that of patients with normoglyacemia, and equivalent to patients already diagnosed with Diabetes. Pre- and peri-operative hyperglycaemia is associated with worse outcomes. Evidence regarding tight glycaemic control vs moderate glycaemic control is conflicting. Tight control may be more effective in patients without Diabetes with pre−/peri-operative hyperglycaemia, and moderate control appears more effective in patients with pre-existing Diabetes. Patients with well controlled Diabetes may achieve comparable outcomes to patients without Diabetes with similar glycaemic control.

Conclusions

Pre / peri-operative hyperglycaemia is associated with worse outcomes in both patients with, and without Diabetes undergoing CABG. This review supports the pre-operative screening, and optimisation of glycaemic control in patients undergoing cardiac surgery. Optimal glycaemic management remains unclear and clear guidelines are needed.

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Background

Diabetes is a common life-long health condition and a major risk factor for coronary artery disease. Latest estimates show a global prevalence of 382 million in 2013, with a projected rise to 592 million by 2035 [1]. Average annual increases in insulin dependent Diabetes of 3% worldwide and 4% in Europe [2] are reported. In the United Kingdom [UK] there are currently 3.2 million people diagnosed with Diabetes, while another 630,000 remain undiagnosed [1]. Approximately 26 million [8%] people suffer from Diabetes in the United States [US] population, while an estimated additional 7 million are undiagnosed [3]. Due to the slow onset of non-insulin dependent Diabetes, and long pre-detection period, up to one-half of cases may be undiagnosed [1], and an estimated 80 million US citizens are considered to have pre-diabetes, pre-disposing them to an increased risk of developing overt Diabetes.

UK and worldwide data shows that the proportion of people with Diabetes undergoing isolated CABG surgery has increased by 33% in recent years to 25–40% [4]. These patients face increased morbidity and mortality following cardiac surgery and represent a sizeable medico-economic predicament worldwide. Specific UK guidelines and standards exist regarding medical management of Diabetes and risk implications for cardiovascular disease [5]. In the US guidelines for the glycaemic management of patients with Diabetes, or pre-diabetes undergoing cardiac surgery have been available for nearly a decade. Surprisingly however, no uniform consensus in the UK or Europe exists for the glycaemic management of these patients.

This literature review considers the care and outcomes of patients with Diabetes and pre-diabetes undergoing cardiac surgery. The main purpose of this article is to: a] identify current standards of care of patients with Diabetes / pre-diabetes undergoing cardiac surgery and b] address the question; “what is best glycaemic management of patients with Diabetes / pre-diabetes undergoing cardiac surgery?”. Based on the reviewed published literature related to the care and outcomes of patients with Diabetes and pre-diabetes undergoing cardiac surgery, it is clear that there is a lack of evidence against which institutions can benchmark their glycaemic management.

Methods

Literature review

In pursuit of clinical evidence regarding management and outcomes of patients with Diabetes or pre-diabetes undergoing cardiac surgery, an extensive search was performed using the MEDLINE, NHS Evidence and Web of Science databases. The search criteria were: [“Diabetes” OR “hyperglycaemia” OR “hypoglycaemia” OR “HbA1c” OR “pre-diabetes” OR “glycaemic control” OR “glucose” OR “blood glucose” OR “insulin”] in title/abstract AND [“cardiac surgery” OR “surgery” OR “coronary artery bypass grafting” OR “CABG” OR “cardiovascular”] in title/abstract. Articles were limited to those in English, German and French. No date limit was enforced.

In total 13,232 articles were initially identified. Duplicates and false positives were removed. Following examination of the remaining titles and abstracts only 148 articles were regarded of relevance to the topic of review. Reference lists of these articles were also screened for any further relevant papers. Fifty papers from this search have been included in this review.

Results – Literature review

Diabetes and hyperglyacemia

Diabetes

It is established for over a decade that patients with Diabetes undergoing isolated CABG surgery are faced with a higher incidence of operation-related morbidity, mortality and post-procedural angina recurrence [6, 7]. Numerous studies show that patients with Diabetes have a significantly greater risk [up to 44%] of readmission following discharge after CABG [6, 8,9,10,11,12]. This finding is also supported by most recent British national data [13]. Despite this, no specific guidance exists in the UK or Europe, as to the optimal level, or method of achieving adequate glycaemic control in patients undergoing cardiac surgery. In the US, guidelines have been available for almost a decade [12].

Hyperglycaemia

Distinct from Diabetes, isolated hyperglycaemia is a long established marker of adverse outcome and increased LOS in numerous diverse clinical settings, in both patients with, and without Diabetes. Effects appear to be “dose-dependent”, as longer duration and higher levels of hyperglycaemia are both associated with increased morbidity and mortality [14]. This relationship is also apparent in patients undergoing CABG surgery [15], following acute myocardial infarction [MI] [16], severe trauma, ischaemic stroke, and in critically ill medical [17,18,19] and peri-operative neurosurgical patients within the ITU environment. Treatment of hyperglycaemia shows clinical outcome benefit [17, 18, 20], however the optimal range and duration of glycaemic control is unclear and remains controversial.

Pre-operative hyperglycaemia in surgical patients

At present no specific guidance exists in the UK or Europe, regarding the detection and management of pre-operative hyperglycaemia in patients undergoing cardiac surgery.

The prevalence of hyperglycaemia amongst hospitalised patients is reported as high as 38%. Newly discovered in-hospital hyperglycaemia is associated with a higher mortality rate [16%] compared with hyperglycaemia for patients with known Diabetes [21, 22], increased short-term morbidity, and also short and long-term mortality following non-cardiac surgery [23, 24].

A retrospective analysis of 60,000 patients undergoing elective non-cardiac surgery from the Cleveland Clinic showed that pre-operative hyperglycaemia [random BG ≥12 mmol/l at pre-operative assessment] in patients without an established diagnosis of Diabetes increased 1 year mortality [23]. Diabetic status significantly altered this relationship and for a given level of pre-operative hyperglycaemia; the risk of 1 year mortality was lower in the Diabetes patient group compared with non-diabetes. A similar relationship was demonstrated between pre-admission hyperglycaemia and increased in-hospital mortality in the ITU setting [25], with therapeutic glycaemic control showing benefit in only those without a diagnosis of Diabetes [18]. These findings prompted the authors to suggest that A] pre-operative hyperglycaemia should be given greater consideration in patients without Diabetes than those already diagnosed with Diabetes, and B] the expected benefits of adequate glycaemic control may be determined by the pre-operative diagnosis of Diabetes [23]. This suggestion may be regarded as counter-intuitive, but emphasises the need to “glucose screen” all patients undergoing cardiac surgery, something that is currently not routine practice in the UK.

In another large study, over 20% of ~ 34,000 non-cardiac surgical patients were hyperglycaemic on admission [fasting BG > 6.1 mmol/l] without having a prior pre-operative diagnosis of Diabetes. In over half of these patients, a subsequent provisional diagnosis of Diabetes was made [26]. Hatzakorzian et al., in a much smaller study of non-cardiac surgical patients showed a prevalence of pre-operative hyperglycaemia of greater than 25% [27]. A study of 7310 patients by Lauruschkat et al. [28], showed that the prevalence of undiagnosed Diabetes in patients undergoing CABG to be 29.6%. This was associated with increased rate of adverse outcomes, including those of cardiac resuscitation, re-intubation and prolonged ventilation. Anderson et al., in a study of 1895 patients undergoing CABG showed that patients not known to have Diabetes, but with an elevated pre-operative fasting BG [≥ 5.6 mmol/l] had double their expected 1-year mortality, and this was equivalent to patients known to have Diabetes [29]. Key studies relating to the effects of hyperglycaemia on outcomes are summarised in Table 1.

Table 1 Impact of newly discovered hyperglycaemia on the outcome of patients admitted to hospital
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Pre-operative HbA1c

In a prospective study of 3555 CABG patients, an HbA1c ≥ 8.6% [70 mmol/l] was shown to be an independent risk factor for early adverse outcomes and mortality [10]. The same group when conducting a study of 3201 patients demonstrated an HbA1c ≥ 7.0% [53 mmol/l] to be associated with decreased 5 year survival following CABG, compared to patients having a value < 7.0% [53 mmol/l]. More importantly, patients with well controlled Diabetes [HbA1c < 7.0%], could achieve comparable outcomes to those patients without a diagnosis of Diabetes [30]. Alserius et al., also demonstrated significantly reduced 3-year survival, and elevated rates of early superficial wound infection to be associated with HbA1c ≥ 6.0% [42 mmol/l] following CABG [31]. However, two studies [32, 33] have failed to show a relationship between HbA1c and LOS, significant early adverse outcomes, or long-term survival following CABG.

Arguably, the predictive value of pre-operative HbA1c in cardiac surgical patients without Diabetes is less well studied. Hudson et al., in a retrospective observational study of 1474 elective patients showed an HbA1c of ≥ 6% [42 mmol/l] in almost a third of patients [31%]. This was associated with elevated intra-operative BG values, a known predictor of adverse outcomes [34], and in isolation, was shown to be an independent predictor of 30-day mortality [35]. Other studies of patients not known to have Diabetes and undergoing percutaneous coronary, vascular or cardiac [4] surgical interventions, also demonstrated a strong association between the pre-procedural elevated HbA1c [30–58%], and risk of early adverse events. These findings suggest that pre-operative HbA1c assessment will be useful as a screening tool in all patients undergoing cardiac surgery, both those with and without Diabetes.

Peri and post-operative hyperglycaemia

Intra-operative hyperglycaemia during cardiopulmonary bypass is an independent risk factor for mortality and morbidity in patients with and without Diabetes [34, 36]. Insulin resistance rather than impaired secretion is considered responsible for this [36]. However, it remains unclear whether hyperglycaemia per se, as opposed to increased insulin resistance, drives adverse outcomes. Furnary et al., proposed that improvement in underlying impaired myocardial glycometabolism was one of the predominant mechanisms underlying the favourable effects of insulin therapy, rather than pure achievement of euglycaemia [8, 9] and this has been subsequently supported by other studies [37, 38]. Overall, peri-operative control of hyperglycaemia via continuous insulin infusion was associated with decreased incidence of deep sternal wound infection, shortened hospital LOS, reduced rates of recurrent ischaemia, improved long-term survival and significantly decreased morbidity [8, 11], in a large number of cardiac surgical patients [> 8000]. As such, it is now a globally accepted standard practice of care, although the precise stringency of control i.e. tight vs. moderate, timing and duration of intravenous therapy remain matters of debate [7, 12].

Atrial fibrillation in patients with diabetes

The relationship between Diabetes status and post-operative AF requires clearer definition. Most studies do not show any clear association [6], however, some studies show a decreased AF incidence in patients with elevated pre-operative HbA1c [10, 33, 39]. These studies reflect outcomes from a non-UK population, involving pre-dominantly off pump CABG surgery. The potential protective mechanisms of an elevated HbA1c on post-operative AF are unclear. Kinoshita et al. [39], propose that one plausible explanation is that patients with elevated HbA1c require more insulin for adequate glycaemic control, a therapy which is shown to reduce post-operative AF [8, 40]. In support, Lazar et al. have also demonstrated tighter glycaemic control via intravenous insulin to lower incidence of post-operative AF [11].

CABG vs non-CABG cardiac surgery

The majority of evidence reviewed in this paper relates to CABG surgery as opposed to non-CABG surgery. Studies including non-CABG cardiac surgery did not clearly delineate outcomes relating to type of surgery, with the majority of patients having undergone CABG. Therefore it is difficult to draw firm conclusions regarding the relationship between deranged glycaemic control, outcomes and precise type of surgery. It is intuitive to think that the effects of deranged glycaemic control on outcomes, would be most prominent following CABG surgery as opposed to non-CABG surgery, due to the well-recognised and established effects on lipid metabolism, endothelial cell function, coronary artery disease, as well as arterial vascular properties / function although, this remains to be proven. Future studies should focus on defining whether deranged glycaemic control has differing effects on outcomes depending on type of surgery.

Optimal glycaemic care and barriers to standardisation

A critical factor hindering the establishment of clearly defined glycaemic control guidelines is the lack of consensus on what optimal treatment actually is [7, 14]. Brief consensus was reached following 2001, when the Leuven Surgical Trial demonstrated reduced 1-year mortality among critically ill patients when BG levels were tightly controlled between 4.4–6.1 mmol/l as compared to 10.0–11.1 mmol/l [17]. This study instigated an era of tight glycaemic control for all critically ill patients including cardiac surgical patients. The aim of tight control was reinforced by further studies showing beneficial effects of intensive insulin therapy in surgical, medical [18, 20] and cardiac surgical patients [8, 38]. The Portland Diabetic Project provided strong evidence of the adverse effects of hyperglycaemia in patients with Diabetes undergoing cardiac surgery, using an 8.3 mmol/l cut off target value [8, 38].

The concept of tight glycaemic control in critically ill patients was called into question with the publication of the NICE-SUGAR Study [37]. This study of 6104 patients failed to reproduce the findings of the Leuven Surgical Trial, and in fact demonstrated increased 90-day, all-cause mortality after surgery in the tight control group [37]. In support of these findings more recent studies in CABG patients have either failed to demonstrate beneficial effects with tight control [41,42,43,44], or shown superior beneficial effects with moderate control [7.0–9.9 mmol/l] [45].

The recent randomised controlled GLUCO-CABG trial of 302 patients showed no difference in outcomes between intensive or conventional moderate glucose control in CABG patients with Diabetes [46]. However, in patients without Diabetes intensive glucose control was associated with lower complication rate. This reinforces the idea from the Portland Diabetic Project and Cleveland Clinic group of the importance of Diabetic status [pre/peri-operative hyperglycaemia in patients with and without Diabetes] [38]. Possibly a lower BG target is needed for patients without Diabetes, whereas a higher target is permissible for those with Diabetes.

The recently published American multicentre study of 4316 cardiac surgical patients by Greco et al., [47] showed that, increasing hyperglycaemia above 180 mg/dl [10 mmol/l] in patients without Diabetes was associated with worsening outcomes. However, this relationship did not hold for patients with non-insulin treated Diabetes. Adding further complexity, this study demonstrated that in insulin treated group allowing BGs above 180 mg/dl [10 mmol/l] was beneficial, with worsening outcomes when “better” control was achieved.

Inducing unnecessary and dangerous hypoglycaemic events with insulin, historically represented another issue driving reluctance to employ stringent BG control protocols. However, these events are now recognised as being rare and avoidable [3, 46], provided BG is frequently monitored.

The lack of consensus amongst the studies we have analysed in this review may be due to the heterogeneity with regards to treatment of hyperglycaemia, glycaemic control protocols, glucose measurement protocols, the glucose metrics employed, their validity and relevance, as well as the individual population demographics. The best metric of glycaemic control remains a matter of debate, and many have been utilised. Average BG over 3 days [3-BG] is considered a good measure [38, 48]. Studies show that metrics incorporating glucose values over longer time periods have greater prognostic relevance in comparison to isolated glucose measurements from just the first 24 or 48-h of an index event e.g. surgical operation or hospitalisation [49]. Metrics of variability/complexity of the circadian glucose pattern are also proposed to be of greater importance than actual BG levels [50].

Future targeted therapies

The multiple proposed detrimental downstream pathways of hyperglycaemia / insulin resistance, and positive effects of insulin therapy following cardiac surgery are largely unknown and require further detailed definition [3]. They are not the focus of this review, but they are of importance with respect to the development of future targeted therapies. Altered free fatty acid metabolism, endothelial dysfunction, reduced nitric oxide bioavailability and accumulation of reactive oxygen species are implicated [3]. So too is protein kinase C-dependent vasoconstriction, vascular inflammation and platelet aggregation; as well as advanced glycation products [AGE] driven pro-inflammatory cascades [3]. In addition to the metabolic benefits, improved myocardial recovery following myocardial ischemia and direct improvement of contractile function are thought to occur with insulin therapy. Increasing evidence now suggests that reduction in BG variability, rather than absolute levels, to be a major determinant of the beneficial effects of insulin therapy [50]. Other proposed beneficial mechanisms include; membrane stabilization, anti-arrhythmic effects, improved glucose utilization, improved cardiac output via vasodilation and lowering of total peripheral resistance, and improved immune function [3].

Improving clinical outcomes

The detrimental effects of hyperglycaemia and Diabetes on cardiac surgery outcomes are well recognised. Despite that, clear treatment guidance is still lacking in UK and Europe and this has to be addressed. It is vital for all disciplines associated with the care of cardiac surgical patients, to engage in addressing the discrepancy in quality of outcomes observed in patients with poor glycaemic control. By looking into this discrepancy in outcomes, a decision needs to be made as to whether this discrepancy is A] acceptable, B] modifiable, and if so how, and C] is enough currently being done to minimise, or potentially abolish it. We feel that the current dogma stating that “patients with Diabetes have worse outcomes than patients without Diabetes following cardiac surgery” is potentially wrong, as these patients are currently not receiving best therapy, and this dogma must be challenged.

Proposal’s for quality service improvement

The extensive evidence reviewed in this article provides a sufficient mandate to commence a national / international initiative to standardise and improve the quality of glycaemic control in patients undergoing cardiac surgery in UK and Europe.

In the US, a national initiative to improve post-operative glycaemic control in cardiac patients has already commenced in the form of a Surgical Care Improvement Project [SCIP] [21, 48]. This initiative involves collection and analysis of specific performance measures relating to glycaemic control in all participating cardiac centres, with subsequent public reporting of outcomes and compliance. In addition the Society of Thoracic Surgeons [STS] have published detailed US practice guidelines relating to pre-, intra- and post-operative glycaemic management of patients with and without Diabetes undergoing cardiac surgery; Table 2 [12]. The STS practice guidelines include: A] active control of BGs < 180 mg/dl[10 mmol/l] for all patients during the intra- and post-operative period B] all patients with Diabetes receive an insulin infusion in the operating room and for at least 24 h postoperatively C] pre-operative HbA1c measurement in all patients with Diabetes and those at high risk of post-operative hyperglycaemia, to optimise glycaemic management, and identify patients requiring more aggressive glycaemic control, D] pre-discharge in-patient education of all patients with Diabetes and E] appropriate follow up and communication with primary care physician.

Table 2 Summary of the US STS guidelines for glycaemic control during adult cardiac surgery (2008)
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It is inevitable that practice and outcomes around the UK and Europe in relation to patients with Diabetes or pre-diabetes varies between individual treatment centres. However, the formation of national guidelines, standardisation of care, centralised reporting and open sharing of glycaemic performance data is critical to improving future standards of care. Formation of this structure along with a national glycaemic SCIP would also serve to incentivise service improvement. An example of such a novel potential European SCIP is shown in Table 3. In addition the novel care pathway utilised in our unit is shown in Table 4. 

Table 3 Potential Steps for Facilitating Service Improvement in Diabetic / Pre-diabetic Patients Undergoing Cardiac Surgery
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Table 4 Oxford Heart Centre Diabetes Care Pathway
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Future studies

Future studies need to A] define the optimal level, duration and timing of glycaemic control of patients undergoing cardiac surgery B] quantify any potential benefit derived from pre-operative glycaemic control optimisation C] define the optimal glucose metrics for glycaemic control assessment and validate their positive predictive value for adverse events and D] mechanistically interrogate and identify potential therapeutic targets that improve outcomes in patients with Diabetes, pre-diabetes and those with peri-operative hyperglycaemia and E] aim to define the precise relationship between and deranged glycaemic control and outcomes following types of cardiac surgery; CABG vs non-CABG.

Establishing a new culture in which widespread detailed measurement, reporting and analysis of glycaemic control in relation to patient outcomes will enhance our understanding, help to identify and direct avenues for research and ultimately improve practice and outcomes in these patients.

Conclusions

The incidence of diagnosed Diabetes continues to rise, and in addition high levels of undiagnosed Diabetes and pre-diabetes are reported in surgical patients. Poor glycaemic control is associated with adverse outcomes following cardiac surgery, and the evidence suggests that pre-operative hyperglycaemia in patients without Diabetes carries greater clinical significance; than in patients already with diagnosed Diabetes. These results suggest that implementation of routine pre-operative glycaemic screening should be performed in all patients. There is conflicting evidence regarding the precise stringency of glycaemic control that should be employed in these patients i.e. tight vs. moderate control; and this requires clearer definition. Patients with Diabetes with good glycaemic control can achieve similar outcomes to patients without Diabetes undergoing cardiac surgery. As such, the current dogma stating that “diabetic patients have worse outcomes than non-diabetic patients following cardiac surgery” is potentially wrong. It is imperative that we generate national and European guidelines and standardise the care for patients with Diabetes/pre-diabetes undergoing cardiac surgery.

The main findings from this review are summarised in Table 5.

Table 5 The summary of the main findings of this review
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References

  1. Forouhi NG, Wareham NJ. Epidemiology of diabetes. Medicine [Abingdon ]. 2014;42(12):698–702.

    Google Scholar 

  2. Patterson CC, Dahlquist GG, Gyurus E, Green A, Soltesz G. Incidence trends for childhood type 1 diabetes in Europe during 1989-2003 and predicted new cases 2005-20: a multicentre prospective registration study. Lancet. 2009;373(9680):2027–33.

    Article  PubMed  Google Scholar 

  3. Reddy P, Duggar B, Butterworth J. Blood glucose management in the patient undergoing cardiac surgery: a review. World J Cardiol. 2014;6(11):1209–17.

    Article  PubMed  PubMed Central  Google Scholar 

  4. JT MG Jr, Shariff MA, Bhat TM, Azab B, Molloy WJ, Quattrocchi E, Farid M, Eichorn AM, Dlugacz YD, Silverman RA. Prevalence of dysglycemia among coronary artery bypass surgery patients with no previous diabetic history. J Cardiothorac Surg. 2011;6:104.

    Article  Google Scholar 

  5. Ryden L, Grant PJ, Anker SD, Berne C, Cosentino F, Danchin N, Deaton C, Escaned J, Hammes HP, Huikuri H, Marre M, Marx N, Mellbin L, Ostergren J, Patrono C, Seferovic P, Uva MS, Taskinen MR, Tendera M, Tuomilehto J, Valensi P, Zamorano JL. ESC guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the E. Diab Vasc Dis Res. 2014;11(3):133–73.

    Article  PubMed  Google Scholar 

  6. Thourani VH, Weintraub WS, Stein B, Gebhart SS, Craver JM, Jones EL, Guyton RA. Influence of diabetes mellitus on early and late outcome after coronary artery bypass grafting. Ann Thorac Surg. 1999;67(4):1045–52.

    Article  CAS  PubMed  Google Scholar 

  7. Tsai LL, Jensen HA, Thourani VH. Intensive Glycemic control in cardiac surgery. Curr Diab Rep. 2016;16(4):25.

    Article  PubMed  Google Scholar 

  8. Furnary AP, Zerr KJ, Grunkemeier GL, Starr A. Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg. 1999;67(2):352–60.

    Article  CAS  PubMed  Google Scholar 

  9. Furnary AP, Gao G, Grunkemeier GL, Wu Y, Zerr KJ, Bookin SO, Floten HS, Starr A. Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2003;125(5):1007–21.

    Article  CAS  PubMed  Google Scholar 

  10. Halkos ME, Puskas JD, Lattouf OM, Kilgo P, Kerendi F, Song HK, Guyton RA, Thourani VH. Elevated preoperative hemoglobin A1c level is predictive of adverse events after coronary artery bypass surgery. J Thorac Cardiovasc Surg. 2008;136(3):631–40.

    Article  PubMed  Google Scholar 

  11. Lazar HL, Chipkin SR, Fitzgerald CA, Bao Y, Cabral H, Apstein CS. Tight glycemic control in diabetic coronary artery bypass graft patients improves perioperative outcomes and decreases recurrent ischemic events. Circulation. 2004;109(12):1497–502.

    Article  CAS  PubMed  Google Scholar 

  12. Lazar HL, McDonnell M, Chipkin SR, Furnary AP, Engelman RM, Sadhu AR, Bridges CR, Haan CK, Svedjeholm R, Taegtmeyer H, Shemin RJ. The Society of Thoracic Surgeons practice guideline series: blood glucose management during adult cardiac surgery. Ann Thorac Surg. 2009;87(2):663–9.

    Article  PubMed  Google Scholar 

  13. National Adult Cardiac Surgical Database Report. 2008. Available http://www.scts.org/_userfiles/resources/SixthNACSDreport 2008.

  14. Girish G, Agarwal S, Satsangi DK, Tempe D, Dutta N, Pratap H. Glycemic control in cardiac surgery: rationale and current evidence. Ann Card Anaesth. 2014;17(3):222–8.

    Article  CAS  PubMed  Google Scholar 

  15. Fish LH, Weaver TW, Moore AL, Steel LG. Value of postoperative blood glucose in predicting complications and length of stay after coronary artery bypass grafting. Am J Cardiol. 2003;92(1):74–6.

    Article  PubMed  Google Scholar 

  16. Capes SE, Hunt D, Malmberg K, Pathak P, Gerstein HC. Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients: a systematic overview. Stroke. 2001;32(10):2426–32.

    Article  CAS  PubMed  Google Scholar 

  17. Van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P, Bouillon R. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345(19):1359–67.

    Article  CAS  PubMed  Google Scholar 

  18. Van den Berghe G, Wilmer A, Milants I, Wouters PJ, Bouckaert B, Bruyninckx F, Bouillon R, Schetz M. Intensive insulin therapy in mixed medical/surgical intensive care units: benefit versus harm. Diabetes. 2006;55(11):3151–9.

    Article  CAS  PubMed  Google Scholar 

  19. Van den Berghe G. Intensive insulin therapy in the ICU--reconciling the evidence. Nat Rev Endocrinol. 2012;8(6):374–8.

    Article  CAS  PubMed  Google Scholar 

  20. Van den Berghe G, Wilmer A, Hermans G, Meersseman W, Wouters PJ, Milants I, Van WE, Bobbaers H, Bouillon R. Intensive insulin therapy in the medical ICU. N Engl J Med. 2006;354(5):449–61.

    Article  CAS  PubMed  Google Scholar 

  21. Stoodley L, Wung SF. Hyperglycemia after cardiac surgery: improving a quality measure. AACN Adv Crit Care. 2014;25(3):221–7.

    Article  PubMed  Google Scholar 

  22. Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002;87(3):978–82.

    Article  CAS  PubMed  Google Scholar 

  23. Abdelmalak BB, Knittel J, Abdelmalak JB, Dalton JE, Christiansen E, Foss J, Argalious M, Zimmerman R, Van den Berghe G. Preoperative blood glucose concentrations and postoperative outcomes after elective non-cardiac surgery: an observational study. Br J Anaesth. 2014;112(1):79–88.

    Article  CAS  PubMed  Google Scholar 

  24. Noordzij PG, Boersma E, Schreiner F, Kertai MD, Feringa HH, Dunkelgrun M, Bax JJ, Klein J, Poldermans D. Increased preoperative glucose levels are associated with perioperative mortality in patients undergoing noncardiac, nonvascular surgery. Eur J Endocrinol. 2007;156(1):137–42.

    Article  CAS  PubMed  Google Scholar 

  25. Whitcomb BW, Pradhan EK, Pittas AG, Roghmann MC, Perencevich EN. Impact of admission hyperglycemia on hospital mortality in various intensive care unit populations. Crit Care Med. 2005;33(12):2772–7.

    Article  PubMed  Google Scholar 

  26. Abdelmalak B, Abdelmalak JB, Knittel J, Christiansen E, Mascha E, Zimmerman R, Argalious M, Foss J. The prevalence of undiagnosed diabetes in non-cardiac surgery patients, an observational study. Can J Anaesth. 2010;57(12):1058–64.

    Article  PubMed  Google Scholar 

  27. Hatzakorzian R, Bui H, Carvalho G, Shan WL, Sidhu S, Schricker T. Fasting blood glucose levels in patients presenting for elective surgery. Nutrition. 2011;27(3):298–301.

    Article  CAS  PubMed  Google Scholar 

  28. Lauruschkat AH, Arnrich B, Albert AA, Walter JA, Amann B, Rosendahl UP, Alexander T, Ennker J. Prevalence and risks of undiagnosed diabetes mellitus in patients undergoing coronary artery bypass grafting. Circulation. 2005;112(16):2397–402.

    Article  PubMed  Google Scholar 

  29. Anderson RE, Klerdal K, Ivert T, Hammar N, Barr G, Owall A. Are even impaired fasting blood glucose levels preoperatively associated with increased mortality after CABG surgery? Eur Heart J. 2005;26(15):1513–8.

    Article  CAS  PubMed  Google Scholar 

  30. Halkos ME, Lattouf OM, Puskas JD, Kilgo P, Cooper WA, Morris CD, Guyton RA, Thourani VH. Elevated preoperative hemoglobin A1c level is associated with reduced long-term survival after coronary artery bypass surgery. Ann Thorac Surg. 2008;86(5):1431–7.

    Article  PubMed  Google Scholar 

  31. Alserius T, Anderson RE, Hammar N, Nordqvist T, Ivert T. Elevated glycosylated haemoglobin [HbA1c] is a risk marker in coronary artery bypass surgery. Scand Cardiovasc J. 2008;42(6):392–8.

    Article  CAS  PubMed  Google Scholar 

  32. Knapik P, Ciesla D, Filipiak K, Knapik M, Zembala M. Prevalence and clinical significance of elevated preoperative glycosylated hemoglobin in diabetic patients scheduled for coronary artery surgery. Eur J Cardiothorac Surg. 2011;39(4):484–9.

    Article  PubMed  Google Scholar 

  33. Matsuura K, Imamaki M, Ishida A, Shimura H, Niitsuma Y, Miyazaki M. Off-pump coronary artery bypass grafting for poorly controlled diabetic patients. Ann Thorac Cardiovasc Surg. 2009;15(1):18–22.

    PubMed  Google Scholar 

  34. Gandhi GY, Nuttall GA, Abel MD, Mullany CJ, Schaff HV, Williams BA, Schrader LM, Rizza RA, McMahon MM. Intraoperative hyperglycemia and perioperative outcomes in cardiac surgery patients. Mayo Clin Proc. 2005;80(7):862–6.

    Article  PubMed  Google Scholar 

  35. Hudson CC, Welsby IJ, Phillips-Bute B, Mathew JP, Lutz A, Chad HG, Stafford-Smith M. Glycosylated hemoglobin levels and outcome in non-diabetic cardiac surgery patients. Can J Anaesth. 2010;57(6):565–72.

    Article  PubMed  Google Scholar 

  36. Doenst T, Wijeysundera D, Karkouti K, Zechner C, Maganti M, Rao V, Borger MA. Hyperglycemia during cardiopulmonary bypass is an independent risk factor for mortality in patients undergoing cardiac surgery. J Thorac Cardiovasc Surg. 2005;130(4):1144.

    Article  PubMed  Google Scholar 

  37. Finfer S, Chittock DR, Su SY, Blair D, Foster D, Dhingra V, Bellomo R, Cook D, Dodek P, Henderson WR, Hebert PC, Heritier S, Heyland DK, McArthur C, McDonald E, Mitchell I, Myburgh JA, Norton R, Potter J, Robinson BG, Ronco JJ. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360(13):1283–97.

    Article  PubMed  Google Scholar 

  38. Furnary AP, Wu Y, Bookin SO. Effect of hyperglycemia and continuous intravenous insulin infusions on outcomes of cardiac surgical procedures: the Portland diabetic project. Endocr Pract. 2004;10(Suppl 2):21–33.

    Article  PubMed  Google Scholar 

  39. Kinoshita T, Asai T, Suzuki T, Kambara A, Matsubayashi K. Preoperative hemoglobin A1c predicts atrial fibrillation after off-pump coronary bypass surgery. Eur J Cardiothorac Surg. 2012;41(1):102–7.

    PubMed  Google Scholar 

  40. Lazar HL, Chipkin S, Philippides G, Bao Y, Apstein C. Glucose-insulin-potassium solutions improve outcomes in diabetics who have coronary artery operations. Ann Thorac Surg. 2000;70(1):145–50.

    Article  CAS  PubMed  Google Scholar 

  41. Desai SP, Henry LL, Holmes SD, Hunt SL, Martin CT, Hebsur S, Ad N. Strict versus liberal target range for perioperative glucose in patients undergoing coronary artery bypass grafting: a prospective randomized controlled trial. J Thorac Cardiovasc Surg. 2012;143(2):318–25.

    Article  CAS  PubMed  Google Scholar 

  42. Mulla I, Schmidt K, Cashy J, Wallia A, Andrei AC, Johnson OD, Aleppo G, Li C, Grady KL, McGee E, Molitch ME. Comparison of glycemic and surgical outcomes after change in glycemic targets in cardiac surgery patients. Diabetes Care. 2014;37(11):2960–5.

    Article  CAS  PubMed  Google Scholar 

  43. Pezzella AT, Holmes SD, Pritchard G, Speir AM, Ad N. Impact of perioperative glycemic control strategy on patient survival after coronary bypass surgery. Ann Thorac Surg. 2014;98(4):1281–5.

    Article  PubMed  Google Scholar 

  44. Lazar HL, McDonnell MM, Chipkin S, Fitzgerald C, Bliss C, Cabral H. Effects of aggressive versus moderate glycemic control on clinical outcomes in diabetic coronary artery bypass graft patients. Ann Surg. 2011;254(3):458–63.

    Article  PubMed  Google Scholar 

  45. Bhamidipati CM, LaPar DJ, Stukenborg GJ, Morrison CC, Kern JA, Kron IL, Ailawadi G. Superiority of moderate control of hyperglycemia to tight control in patients undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2011;141(2):543–51.

    Article  PubMed  Google Scholar 

  46. Umpierrez G, Cardona S, Pasquel F, Jacobs S, Peng L, Unigwe M, Newton CA, Smiley-Byrd D, Vellanki P, Halkos M, Puskas JD, Guyton RA, Thourani VH. Randomized controlled trial of intensive versus conservative glucose control in patients undergoing coronary artery bypass graft surgery: GLUCO-CABG trial. Diabetes Care. 2015;38(9):1665–72.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  47. Greco G, Ferket BS, D’Alessandro DA, Shi W, Horvath KA, Rosen A, Welsh S, Bagiella E, Neill AE, Williams DL, Greenberg A, Browndyke JN, Gillinov AM, Mayer ML, Keim-Malpass J, Gupta LS, Hohmann SF, Gelijns AC, O'Gara PT, Moskowitz AJ. Diabetes and the Association of Postoperative Hyperglycemia with Clinical and Economic Outcomes in cardiac surgery. Diabetes Care. 2016;

  48. McDonnell ME, Alexanian SM, Junqueira A, Cabral H, Lazar HL. Relevance of the surgical care improvement project on glycemic control in patients undergoing cardiac surgery who receive continuous insulin infusions. J Thorac Cardiovasc Surg. 2013;145(2):590–4.

    Article  PubMed  Google Scholar 

  49. Kosiborod M, Inzucchi SE, Krumholz HM, Xiao L, Jones PG, Fiske S, Masoudi FA, Marso SP, Spertus JA. Glucometrics in patients hospitalized with acute myocardial infarction: defining the optimal outcomes-based measure of risk. Circulation. 2008;117(8):1018–27.

    Article  CAS  PubMed  Google Scholar 

  50. Ogawa S, Okawa Y, Sawada K, Goto Y, Yamamoto M, Koyama Y, Baba H, Suzuki T. Continuous postoperative insulin infusion reduces deep sternal wound infection in patients with diabetes undergoing coronary artery bypass grafting using bilateral internal mammary artery grafts: a propensity-matched analysis. Eur J Cardiothorac Surg. 2016;49(2):420–6.

    Article  PubMed  Google Scholar 

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  1. Oxford Heart Centre, John Radcliffe Hospital, Headley Way, Oxfordshire, OX3 9DU, UK

    M. Navaratnarajah, R. Rea, R. Evans, F. Gibson, C. Antoniades, A. Keiralla, M. Demosthenous, G. Kassimis & G. Krasopoulos

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Contributions

MN and RR were specifically involved in performing a through literature review and both made significant contributions to the writing of the paper. RE and FG were specifically involved in the vetting of the quality of the papers subject to review in this article and made significant contributions to the formatting and structure of this paper. CA was involved in the literature review and assessment of the quality of papers included in this paper and also made significant contributions to the writing of this paper. AK and MD performed the initial literature search and selection of relevant papers. GK and GK were responsible for the editing of the final submitted paper. All authors read and approved the final manuscript.

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Navaratnarajah, M., Rea, R., Evans, R. et al. Effect of glycaemic control on complications following cardiac surgery: literature review. J Cardiothorac Surg 13, 10 (2018). https://doi.org/10.1186/s13019-018-0700-2

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Keywords

Journal of Cardiothoracic Surgery

ISSN: 1749-8090

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