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      Oral Hypoglycemics: Increased Postoperative Mortality in Coronary Risk Patients


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          Background: Diabetes mellitus (DM), particularly if insulin-dependent, is a predictor of increased perioperative risk, whereas stringent metabolic control with insulin is beneficial in the critically ill. Methods: The impact of oral hypoglycemics (OH) vs. insulin on outcome was determined as a secondary retrospective analysis of a cohort study in patients with coronary artery disease (CAD) and DM undergoing major non-cardiac surgery. Primary end-point was 2-year all-cause mortality; secondary endpoints were perioperative myocardial ischemia and 2-year cardiac mortality. Results: Of 173 patients, DM was diagnosed in 42 (24%) based on pre-existing treatment with OH (15%) or insulin (9%). During follow-up, 40/173 (23%) patients died. All-cause mortality was similar in the non-diabetic (20%) and insulin groups (19%) but significantly higher in the OH group (42%; p = 0.025). Cardiac mortality tended to be higher in the OH group compared with the insulin and non-diabetic groups (27 vs. 19% and 11%, respectively; p = 0.066). Multivariate analysis revealed renal failure (odds ratio [OR] = 4.9, 95% confidence interval [CI] = 1.8–13.0), treatment with OH (OR = 3.3, 95% CI = 1.2–9.0), peripheral vascular surgery (OR = 2.7, 95% CI = 1.2–6.0), and prior diuretic therapy (OR = 2.6, 95% CI = 1.1–5.7) being independently associated with 2-year all-cause death. No difference existed in postoperative ischemia among the different groups. Conclusions: Long-term mortality after major non-cardiac surgery is elevated in patients with CAD and diabetes mellitus only if they are treated with OH, but not if they are treated with insulin. Further evaluation of the impact of perioperative anti-diabetic treatment on morbidity and mortality in CAD is warranted.

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          Most cited references 8

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          Outcome benefit of intensive insulin therapy in the critically ill: Insulin dose versus glycemic control.

          Maintenance of normoglycemia with insulin reduces mortality and morbidity of critically ill patients. Here we report the factors determining insulin requirements and the impact of insulin dose vs. blood glucose control on the observed outcome benefits. A prospective, randomized, controlled trial. A 56-bed predominantly surgical intensive care unit in a tertiary teaching hospital. A total of 1,548 patients were randomly assigned to either strict normalization of blood glucose (80-110 mg/dL) with insulin infusion or the conventional approach, in which insulin is only given to maintain blood glucose levels at 180-200 mg/dL. It was feasible and safe to achieve and maintain blood glucose levels at 20 IU/hr). Between day 7 and 12, insulin requirements decreased by 40% on stable caloric intake. Brief, clinically harmless hypoglycemia occurred in 5.2% of intensive insulin-treated patients on median day 6 (2-14) vs. 0.8% of conventionally treated patients on day 11 (2-10). The outcome benefits of intensive insulin therapy were equally present regardless of whether patients received enteral feeding. Multivariate logistic regression analysis indicated that the lowered blood glucose level rather than the insulin dose was related to reduced mortality (p <.0001), critical illness polyneuropathy (p <.0001), bacteremia (p =.02), and inflammation (p =.0006) but not to prevention of acute renal failure, for which the insulin dose was an independent determinant (p =.03). As compared with normoglycemia, an intermediate blood glucose level (110-150 mg/dL) was associated with worse outcome. Normoglycemia was safely reached within 24 hrs and maintained during intensive care by using insulin titration guidelines. Metabolic control, as reflected by normoglycemia, rather than the infused insulin dose, was related to the beneficial effects of intensive insulin therapy.
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            Oral Antihyperglycemic Therapy for Type 2 Diabetes

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              Helicobacter pylori eradication in long-term users of non-steroidal anti-inflammatory drugs


                Author and article information

                S. Karger AG
                May 2007
                29 January 2007
                : 107
                : 4
                : 296-301
                Departments of Cardiology, Anesthesia, and Endocrinology, Diabetes and Clinical Nutrition, University Hospital, Basel, Switzerland
                99065 Cardiology 2007;107:296–301
                © 2007 S. Karger AG, Basel

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                Figures: 1, Tables: 3, References: 28, Pages: 6
                Original Research


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