CARDIOVASCULAR COMPLICATIONS AND CARBOHYDRATE METABOLISM IN CORONARY SHUNTING “OFF-PUMP” ACCORDING TO THE REGIMEN OF GLUCOSE LOWERING TREATMENT IN ISCHEMIC HEART DISEASE AND DIABETES

Aim. To study the shortest term results of coronary bypass (CBG) under “off-pump” circumstances and the condition of carbohydrate metabolism in ischemic disease patients (IHD) with comorbid diabetes 2 type (DM2) under various regimens of perioperation glucose lowering therapy.

Material and methods. In the study, the IHD and DM2 patients included, receiving oral glucose lowering drugs (OGLD), with the mean age 57,5 (53-62) y.o., men 99 (78,6%). Before operation the patients were selected to the groups of OGLD (n=61) and insulin (IN) (n=65). In OGLD group the intake of the drugs was continued during perioperation period. In the IN group there was switch to short insulin. The dynamics of carbohydrate metabolism markers in different timeline intervals of postoperation period was studied, and its relation with the glucose lowering regimen. The early postoperation cardiovascular complications (CVC) rate was measured: myocardial infarction, stroke, atrial fibrillation. The carbohydrate metabolism parameters in subgroups of patients was measured, with CVC and without.

Results. At baseline there were no differences in carbohydrate metabolism parameters in groups. Loading IN, mean daily glucose levels, its variability and glycemia below the recommended perioperation range (6,1-10,0 mM/L) were lower than in OGLD group. Total number of CVC also predominated in IN group (20,0% vs. 8,2%, p=0,049). Complication subgroups and non-complicated, significantly differed by the baseline glycosilated hemoglobin, mean level of glucose and its daily variability in all timeline intervals studied, as by the prevalence of glucose <6,1 mM/L 0ne day before operation, just before and just after.

Conclusion. Patients underwent CBG as off-pump, after switch on short IN, comparing to OGLD patients, have higher mean glycemia level, its variability and number of shifts from recommended range, as higher rate of post-operation CVC.

1. The BARI 2D Study Group: A randomized trial of therapies for type 2 diabetes and coronary artery disease. N. Engl J Med. 2009; 360: 2503-15.

2. Bansilal S, Farkouh ME, Hueb W. The Future REvascularization Evaluation in patients with Diabetes mellitus: optimal management of Multivessel disease (FREEDOM) trial: clinical and an-giographic profile at study entry. Am Heart J. 2012; 164 (4): 591-9.

3. Dedov II, Shestakova MV. Algorithms of specialized medical care by sick diabetes", 7th re-lease. Diabetes mellitus. 2015; 18 (1S): 1-112. (Дедов И. И., Шестакова М. В. Алгоритмы спе-циализированной медицинской помощи больным сахарным диабетом», 7 выпуск. Сахарный диабет. 2015; 18 (1S): 1-112.)

4. Duckworth W, Abraira C, Moritz T, et al. Glucose control and vascular complications in veter-ans with type 2 diabetes. N Engl J Med. 2009; 360 (2): 129-39.

5. Skyler JS, Bergenstal R, Bonow BO, et al. Intensive glycemic control and the prevention of cardiovascular events: implications of the ACCORD, ADVANCE, and VA diabetes trials: a position statement of the American Diabetes Association and a scientific statement of the American College of Cardiology Foundation and the American Heart Association. Diabetes Care. 2009; 32: 187-92.

6. Marik PE, Preiser JC. Toward understanding tight glycemic control in the ICU: a systematic review and metaanalysis. Chest. 2010; 137: 544-51.

7. Jacobi J, Bircher N, Krinsley J, et al. Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. Crit Care Med. 2012; 40: 3251-76.

8. 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. J Am Coll Cardiol. 2014; 64 (22): 77-137.

9. Guidelines on myocardial revascularization. Eur Heart J. 2010; 31: 2501-55.

10. Dedov II, Shestakova MV, Maksimova MA. Federal target program "Diabetes". Methodical recommendations. 2002. (Дедов И. И., Шестакова М. В., Максимова М. А. Федеральная целевая программа «Сахарный диабет». Методические рекомендации. 2002).

11. Roques F, Michel P, Goldstone A, et al. Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 19030 patients. Eur Heart J. 2003; 24: 882-3.

12. ESC Third Universal Definition of Myocardial Infarction. Eur Heart J. 2012; 33: 2551-67.

13. U.K. Hypoglycaemia Study Group: Risk of hypoglycaemia in types 1 and 2 diabetes: effects of treatment modalities and their duration. Diabetologia. 2007; 50: 1140-7.

14. Komissarovа ES. Selection of the optimal level of glycemia in surgical patients with type 2 diabetes who are in the ICU and intensive therapy. Abstract. 2014; 1-26. (Комиссарова Е.С. Выбор оптимального уровня гликемии у больных хирургического профиля с сахарным диабетом 2 типа, находящихся в отделении реанимации и интенсивной терапии. Автореф. дисс. канд. мед. наук. 2014; 1-26.)

15. 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 (2): 277-87.