VALUE OF ADMISSION GLYCOSYLATED HEMOGLOBIN LEVEL IN PATIENTS WITH ACUTE ST- SEGMENT ELEVATION MYOCARDIAL INFARCTION

Riham Elfawal 1 , Zizi Saad 2 and Amal Kandil 3 . 1. Clinical Pathology Department, Faculty of Medicine, Alexandria University/Basic Medical Science Department, Al Farabi Medical College. 2. Cardiology Department, Faculty of Medicine, Zagazig University, Egypt. 3. Medical Surgical Department, Faculty of Nursing, Alexandria University, Egypt Nursing Department, Al Farabi Faculty of Dentistry and Nursing. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 17 August 2018 Final Accepted: 19 September 2018 Published: October 2018


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3. For primary PCI wiring culprit artery based upon ECG, revascularization of culprit artery only was done unless patient in cardiogenic skoch (Wigins et al., 2010). 4. We use the visual method for evaluation and assessment of number of significant diseased coronary arteries, with special focus on infracted related artery (guided by ECG) on type of the lesion either type A, B, C (Ryan et al;1988) 5. Also, we used TIMI flow grading system in primary PCI cases Follow up period: Was done six months after the onset of MI mainly for: 1. Heart failure according to Killip class classification. 2. Reinfarction. 3. Mortality. 4. Stroke. 5. Ventricular tachyarrhythmias.
Through phone calls followed by hospital visit in outpatient clinic

Statistical analysis
Statistical presentation and analysis of the present study was conducted, using the mean, standard deviation, analysis of variance [ANOVA] test and chi-square test by SPSS V 21, students "t" test was used to test the significance of the difference between two independent sample means, value of < 0.05 indicates a significant result.

Results: -Demographic data:
there was no significant difference between the three groups regarding age, sex. hypertension, smoking, family history and obesity, previous MI, previous PCI (p value > 0.05). .  Regarding three vessel diseasethere was high statistically significant difference between the three group (p value <0.001). There was high statistically significant difference between the three groups regarding lesion type A, B and C p value (0.000)  TIMI flow in patients who had undergone primary PCI: There was statistically significant difference between the three groups regarding TIMI flow value<0.05 1430  1431 Figure 4:-shows adverse cardiac events in the study groups (1,2&3) The present study shows significant difference among different groups of HbA1c as regard the degree of successful reperfusion. This was supported by the significant difference among different groups of HbA1c as regard TIMI flow grades in patients who have undergone mechanical reperfusion with higherpercentage of TIMI 3 in group (1)and the significant positive correlation between HbA1c and absent STR.
The present study shows that there was significant difference among different groups of HbA1c as regard adverse cardiac events on short term follow up period, a multi regression analysis in the present study confirmed that HbA1c over 6.5% is an independent predictor outcome of adverse cardiac events.

Discussion: -
The present study shows that in patients with acute STEMI, admissionhigher HbA1c level is associated with more severe CAD, lower ST-segment resolution,higher percentage of TMI 1 flow and lower rate of complete revascularization with TIMI 3flowafter primary angioplastyand higher incidence of mortality.
Stress hyperglycemia in STEMI patients was associated with significantly increased rates of mortality and congestive heart failure and shock, most of these studies, were in trials of fibrinolysis therapy, the evidence linking hyperglycemia with an adverse prognosis in patients treated with primary percutaneous coronary intervention (PCI) derived mainly from observational registries (Planner et al., 2013) In the present study the peak CK-MB shows statistically significant difference among different HbA1c groups with higher mean peak CK-MB in group (3) withstatistically significant positive correlation between peak CK-MB and HbA1c (r=0.771, p 0.00). This goes with the fact that hyperglycemia with STEMI is associated with significantly larger enzymatic infarct size beyond the fact that the stress response with higher catecholamines, cortisol, cytokines and TNF-α lead to more extensive myocardial damage. This was concordant with (Naitoet al., 2013) who found significant difference between HbA1c level and peak CK-MB In the present study there was significant difference among different HbA1c groups as regard ST-segment resolution (STR), with higher percentage of absent STR in group (3) Group (1) Group (2) Group (3) that hyperglycemia reflect insulin deficiency which increase expression of adhesion molecules, enhance leukocyte adhesion to capillary walls and aggravate free-radical-related reperfusion injury augmenting the formation of microthrombi by increasing platelet aggregation, hyperglycemia also alter endothelium-dependent vasodilatation and impair endogenous fibrinolysis (Marfella etal., 2000) (Chen et al., 2004).
In the present study there was significant difference among different HbA1c groups as regard, number of diseased coronary vessels with higher number of three vessel disease in group (3) with statistically significant positive correlation between HbA1c and number of diseased vessel (r=3.693, p=0.000). This was concordant with previous studies (Cakmaket al., 2008) (Kassaian et al., 2012). This goes with the fact that HbA1c increase of one percent is associated with 2.8 fold increase in CAD and in severity of coronary artery lesions, this was explained by the fact that insulin resistance in hyperglycemia promote molecular mechanism by Advanced Glycation End products (AGEs) which are intimately involved in the pathophysiology of cardiovascular disease by stimulating inflammation, contributing to atheroma formation modulating vascular stiffness and the disturbed endothelial function by reduction nitric oxide release, increased vascular smooth muscle proliferation (Prasad et al ., 2012), beyond high risk profile of those patients , it is worth mentioning that even HbA1c value in normal range is associated with presence and severity of CAD (Ashraf et al., 2013) .
On the contrary, thiswasdisconcordant with (Ertem et al., 2013) who found no significant difference between HbA1c level and severity of CAD. This discrepancy was due to that he used Gensini score for assessment of the severity CAD in his study and non-diabetic were only included in his study.
In the present study there was significant difference among different HbA1c groups as regard lesion type (A, B, C). This was concordant with (kassian et al., 2012) who found highly significant difference among HbA1c groups as regard lesion type C. This goes with the fact that diabetes is associated with more extensive coronary artery lesion, more complex lesion more diffuse excessive toutuousity in the proximal segment, extreme angulations and total occlusion (Ryan et al., 1988).
In the present study there was significant difference among different HbA1c groups as regard TIMI flow grades in patients who had undergone 1ry PCI, with higher percentage of TIMI 3 in group (1) and significant higher percentage of TIMI 1 in favor of group (3), this finding goes with the fact that hyperglycemia is associated with higher rate of TIMI 0\1 and lower rate of complete revascularization TIMI 3 This was concordant with (Planner et al., 2013), this was explained by the fact that hyperglycemia adversely affect platelets function ,endothelial function , promote inflammation and result in procoagulable condition, it is worth mentioning that hyperglycemia per se in STEMI lead to impaired coronary flow on presentation and after primary PCI (Bobbertet al., 2011) . This goes with our finding that TIMI 3 complete revascularization is higher in group (1) the least level of HbA1c, and TIMI 1 flow has statistically significant difference between group (1) and (3)  In the present study we assess HbA1c level on the short-term outcome (six months) to detect major adverse cardiac event as mortality, heart failure and reinfarction, In the present study there was significant difference among different HbA1c groups as regard adverse cardiac events, this was concordant with previous studies (Cakmak et al.,  2008) (Kassaian et al., 2012).This goes with the fact that hyperglycemia is associated with large infarct size, more hemodynamic compromise, congestive heart failure, cardiogenic shock and mortality, beyond the fact that diabeticpatients with poor glycemic control are at two-fold more risk of developing MACE, while good controlled diabetics showed lower rates comparable to non-diabetics.
In the present study there was higherpercentage of mortality in favorof group (3). This was concordant with (Cakmak et al., 2008) this goes with the fact that higher HbA1c level at admission was associated with higher baseline characteristics, largerinfarct, more extensive coronary artery lesion, lower STR, higher percentage of TMI 1 flow, lower rate of complete revascularization TIMI 3 flow Regarding diabetes mellitus and HbA1c, both predict adverse outcome in the present study. This was concordant with (Cakmak et al., 2008), this goes with the fact that hyperglycemia is associated with larger infarct size, lower successful response to reperfusion and high-risk profile. On the contrary, thiswasdisconcordant with (Lazzerietal., 2012), this discrepancy was due to that non-diabetic patients were only included in his study.

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The present study shows that there was significant difference between both types of reperfusion as regard complete and partial STR in favor of primary PCI ,this was concordant with (Sejersten et al., 2009) , this goes with the fact thatsuperiority of primary percutaneous coronary intervention over fibrinolysis, if the doortoballoon is completed in a timely fashion because TIMI 3 flow is achieved more in primary PCI patients , but we found no significant difference between both types of reperfusion regarding biochemical data , severity of CAD , outcome of adverse cardiac events .  al., 1993),this was explained in our study by small sample size, which make our study not powered to detect difference between two types of reperfusion beyond short term follow up period and random selection cases according to capability of our primary PCI center.

Conclusion: -
The present study shows that admission higher HbA1c level in patients presented by acute STEMI is associated with more severe CAD, lower ST-segment resolution, lower rate of complete revascularization TIMI 3 and higher incidence of mortality.
Higher HbA1c level should be considered for risk stratification of patients presented by acute STEMI who are amenable to primary PCI