Send O de s o Rep in s o [email p o ec ed]
20 The Open Diabe es Jou nal, 2014, 7, 20-26
1876-5246/14 2014 Ben ham Open
Open Access
Pos meal Glucose Compa ed o O al Glucose Tole ance in Non-Diabe ic
Pa ien s wi h Acu e Myoca dial In a c ion
O.T. A ola*,1, P.I. Ne alainen2, M. Ko ila3, H. Huh ala4 and J. Alanko5
1The Hea Hospi al, Tampe e Uni e si y Hospi al, Tampe e, Finland
2Depa men o In e nal Medicine, Tampe e Uni e si y Hospi al, Tampe e, Finland, and School o Medicine, Uni e si y
o Tampe e, Tampe e, Finland
3Seinäjoki Cen al Hospi al, Seinäjoki, Finland
4School o Heal h Sciences, Uni e si y o Tampe e, Tampe e, Finland
5Valkeakoski Regional Hospi al, Valkeakoski, Finland
Abs ac : Backg ound: Abno mal glucose ole ance (AGT) in non-diabe ic pa ien s wi h acu e myoca dial in a c ion is
associa ed wi h dec eased su i al compa ed o hose wi h no mal glucose ole ance (NGT). The aim o his s udy was o
es i wo-hou pos p andial glucose (PPG2h) a e a mixed meal co ela es wi h he wo-hou o al glucose ole ance es
(OGTT2h).
Me hods: We p ospec i ely en olled 189 non-diabe ic pa ien s wi h acu e myoca dial in a c ion.
Resul s: Acco ding o he o al glucose ole ance es (OGTT), 37.0% had NGT, 4.8% had impai ed as ing glucose, 37.6%
had impai ed glucose ole ance (IGT) and 20.6% had diabe es. PPG2h a e each meal co ela ed wi h OGTT2h (R2=
0.13-0.26, P<0.001). In diabe ic pa ien s, PPG2h le els a e each meal we e highe (p<0.01 o all) han in he IGT and
NGT g oup. In he NGT and IGT g oup, PPG2h was highe a e lunch and dinne han a e b eak as (p<0.01), bu his
was no he case in he diabe ic pa ien s. In de ec ing diabe es compa ed o OGTT2h, PPG2h equal o o abo e 5.6 mmol/l
a e b eak as , 6.5 mmol/l a e lunch and 7.0 mmol/l a e dinne had a sensi i i y o a leas 76% and speci ici y o a
leas 42%. Glucose alues below he cu -o alues sugges ha OGTT need no be e alua ed.
Conclusion: PPG2h is a quick, p ac ical, simple and easy measu emen in clinical p ac ice. PPG2h co ela es wi h OGTT
bu he alue is lowe , so PPG2h canno be used o e alua e pos p andial glycemia wi h he cu en OGTT glycemic
h esholds. We he e o e sugges he use o new cu -o alues o PPG2h a e a andom meal o selec pa ien s in whom
OGTT is no needed o e alua e diabe ic s a us.
Keywo ds: Abno mal glucose ole ance, acu e myoca dial in a c ion, impai ed glucose ole ance, newly diagnosed diabe es,
o al glucose ole ance es , pos p andial glucose, s ess-induced hype glycemia.
INTRODUCTION
Physiological a ia ion o plasma glucose is igh ly
con olled a e ei he p olonged as ing o a meal; i is gene ally
be ween 4 and 7 mmol/l in humans. Glycosyla ed hemoglobin
A1c (HbA1c) p o ides a me hod o app oxima ing plasma
glucose concen a ion du ing he p e ious 2 o 3 mon hs [1,2].
HbA1c measu emen s a e he mains ay o moni o ing long- e m
glycemic con ol in pa ien s wi h diabe es melli us. Fas ing
plasma glucose (FPG) and wo-hou o al glucose ole ance es
(OGTT2h) le els co ela e signi ican ly wi h HbA1c wi hin i s
e e ence ange. Howe e , OGTT2h is a mo e sensi i e
indica o o abno mal glucose ole ance (AGT) han ei he FPG
o HbA1c [2]. The de elopmen o ype 2 diabe es p og esses
om no mal glucose homeos asis o pos p andial hype -
glycemia and only hen o as ing hype glycemia [3].
Add ess co espondence o his au ho a he Hea Hospi al, Tampe e
Uni e si y Hospi al, P.O. Box 2000, FI-33521 Tampe e, Finland;
Tel: +358 3 3116 611; Fax: +358 3 3116 4157; E-mail: olli.a ola@sydansai aala. i
Insulin sec e ion was i s demons a ed o be biphasic
o e 40 yea s ago [4]. A e a hype glycemic s imulus,
insulin concen a ion in plasma ises apidly wi hin minu es,
co esponding o i s -phase insulin sec e ion, and dec eases
a e 10-15 minu es. The g adual ise in plasma insulin
concen a ions ha ep esen he second-phase sec e ion can
be measu ed in he 2-3-hou pe iod a e glucose in ake [4].
Type 2 diabe es is a polygenic diso de in which
en i onmen al o acqui ed ac o s modula e he isk and
pheno ype o he disease. Bo h he edi a y and modula ing
ac o s can a ec be a-cell unc ion and insulin sensi i i y
[4]. Fi s -deg ee ela i es o ype 2 diabe es ha e educ ions
in i s - and second-phase insulin elease while ha ing no
change in insulin sensi i i y [4,5]. Thus, impai ed i s -phase
insulin sec e ion and he esul ing pos p andial
hype glycemia is a p ima y de ec o impai ed glucose
ole ance (IGT) and ype 2 diabe es. Se e al mechanisms
migh explain pe u ba ions o he biphasic insulin sec e ion
in a pa hological si ua ion [6]. Reduced i s -phase insulin
sec e ion is esponsible o he impai ed inhibi ion o hepa ic
Pos meal Glucose A e Myoca dial In a c ion The Open Diabe es Jou nal, 2014, Volume 7 21
glucose ou pu pos p andially in IGT and ype 2 diabe es.
Toge he wi h diminished pe iphe al glucose up ake, hese
pe u ba ions con ibu e o pos p andial hype glycemia [5].
The wo ldwide epidemic o ype 2 diabe es and i s
complica ions is a g owing p oblem. Acco ding o la ge
coho s udies, pa ien s wi h diabe es o p e-diabe ic
condi ions a e a highe isk o ca dio ascula e en s han
hose wi h no mal glucose ole ance (NGT) [1,7]. Diabe ic
pa ien s and also newly-de ec ed diabe es o IGT pa ien s a e
also a a high isk o dea h and ca dio ascula e en s a e
acu e myoca dial in a c ion [8-10]. Fu he mo e, he e is
e idence ha pos challenge glucose is associa ed wi h
ad e se ca dio ascula ou comes and dea h in bo h he
diabe ic and non-diabe ic popula ions [1,7,11-13]. Thus,
mos epidemiological da a implica e pos p andial
hype glycemia in he de elopmen o ca dio ascula
diseases, while he link be ween as ing glycemia and
diabe ic complica ions is inconclusi e [14]. Ca alo e al.
[11] ound ha pos p andial glucose (PPG) p edic ed
ca dio ascula e en s be e han as ing plasma glucose
(FPG) in pa ien s wi h ype 2 diabe es, especially in women.
The Eu opean Socie y o Ca diology and he Eu opean
Associa ion o he S udy o Diabe es ecommend ha an
o al glucose ole ance es (OGTT) is indica ed i HbA1c
and/o FPG a e inconclusi e in pa ien s wi h ca dio ascula
disease [15].
FPG is mo e p ac ical han OGTT o e alua ing
ca dio ascula isk. Howe e , AGT de ined by OGTT is
be e o de e mining ca dio ascula p ognosis a e
myoca dial in a c ion [8]. OGTT is a non-physiological es
o glucose abso p ion ha classi ies pa ien s by hei
me abolic cha ac e is ics. No mally, people ea wo o ou
majo mixed meals pe day wi h a a ying ca bohyd a e,
p o ein and a con en . Thus, glycemic excu sion a e a
meal is lowe han a e OGTT [16]. The e e yday pic u e is
hus be e e lec ed by PPG2h han OGTT2h. A s anda d
mixed meal may no always be applicable, and i is no
known whe he a andom PPG2h can be used o es ima e a
s anda dized OGTT2h esul .
In he Diabe es In e en ion S udy (DIS), PPG was an
independen isk ac o o dea h in pa ien s wi h ype 2
diabe es [13], while in he STOP-NIDDM S udy [12],
dec easing PPG wi h aca bose was associa ed wi h a lowe
incidence o ca dio ascula e en s in pa ien s wi h IGT. By
con as , he HEART2D S udy [17] ound no di e ence in
u u e ca dio ascula e en a es a e myoca dial in a c ion
be ween p andial s a egy g oups and basal s a egy g oups
in diabe ic pa ien s, while he di e ence o PPG be ween he
g oups was negligible.
The aim o his s udy was o e alua e PPG2h compa ed
o OGTT2h in pa ien s wi h acu e myoca dial in a c ion
wi hou known diabe es.
MATERIALS AND METHODS
Subjec s
Pa ien s wi h con i med myoca dial in a c ion [18,19]
and wi hou known diabe es o ecei ing an ihype glycemic
ea men we e en olled be ween Sep embe 2006 and July
2008 a Tampe e Uni e si y Hospi al and Seinäjoki Cen al
Hospi al. The inal coho consis ed o 189 ou o 229
en olled pa ien s (Fig. 1). Pa ien demog aphics a e gi en in
(Fig. 1). All co ona y in e en ions we e pe o med a
Tampe e Uni e si y Hospi al.
Inclusion c i e ia we e a e i ied acu e myoca dial
in a c ion, an age be ween 18 and 90 yea s, plasma glucose <
11.1 mmol/l (di ide by 0.05551 o ge mg/dl) a admission,
and an abili y and allowance o ea egula ood con aining
ca bohyd a es. Myoca dial in a c ion was diagnosed in cases
o wo measu emen s o an ele a ed se um oponin T
concen a ion (>0.03 µg/l) and ei he ypical symp oms o
myoca dial ischemia (ches pain las ing >15 minu es, o
pulmona y edema in he absence o ca diac al ula disease,
o ca diogenic shock, o en icula achyca dia o
ib illa ion) o elec oca diog am changes (ST changes, new
le bundle b anch block, o new pa hologic Q wa es)
[18,19]. Pa ien s wi h p e iously diagnosed diabe es o
ecei ing an ihype glycemic ea men , and/o enal
insu iciency ea ed wi h dialysis we e excluded.
Demog aphic and clinical in o ma ion was collec ed du ing
he hospi al s ays.
Hype ension was eco ded i ea ed p io o en ollmen .
Smoking his o y was eco ded i he pa ien smoked o had
smoked egula ly. P e ious myoca dial in a c ion was
eco ded i p e iously ea ed o diagnosed. A he oscle o ic
disease was eco ded i ea ed su gically o pe cu aneously,
o i a pa ien had ypical symp oms ( o example
claudica ion). Family his o y was eco ded i he e was
ca dio ascula disease in he amily a a young age (unde
50). S oke was eco ded i p e iously diagnosed.
The glucome abolic s a e was classi ied based on he
Wo ld Heal h O ganiza ion c i e ia [16] o plasma glucose.
NGT was ecognized as FPG <6.1 mmol/l and OGTT2h
glucose <7.8 mmol/l, impai ed as ing glucose as as ing
glucose 6.1-6.9 mmol/l and OGTT2h glucose < 7.8mmol/l,
IGT as FPG <7.0 mmol/l and OGTT2h glucose 7.8-11.0
mmol/l, and diabe es as FPG ≥7.0 mmol/l o OGTT2h
glucose ≥11.1 mmol/l. Pa ien s we e classi ied as ha ing
AGT when FPG was ≥6.1 mmol/l o OGTT2h ≥7.8 mmol/l.
Wais ci cum e ence was de ined as cen ime e s abo e
isk limi (women >88 cm (>35”) and men >102 cm (>40”)).
All pa ien s ecei ed s anda d ca diac ca e. Angiog aphy
was pe o med on all bu 18 pa ien s who had ei he
con aindica ion o an i h ombo ic he apy o whose
symp oms s abilized wi h conse a i e ca e. Fi een ou o
171 angiog aphed pa ien s we e no e ascula ized because
o clinically negligible co ona y s enoses.
Biochemical Analyses
Admission plasma glucose was measu ed wi h Li escan
One Touch® Ul a® 2. HbA1c was analyzed immuno-
chemically (no mal ange 4.0-6.5%, Tina Quan ®, Roche,
Basel, Swi ze land). Venous blood was d awn du ing OGTT
(a 0 and 120 min). PPG plasma glucose was measu ed 120
min a e b eak as , lunch and dinne wi h an ARKRAY
Glucoca d X-me e GT-1910®.
The pa ien s’ glucome abolic s a es we e e alua ed wi h
OGTT no ea lie han 24 hou s a e admission o hospi al,
and PPG2h was measu ed wo hou s a e b eak as , lunch
and dinne . OGTT (75g glucose in 330ml wa e ; Glukodyn®)
and PPG measu emen s we e pe o med on he wa d du ing
22 The Open Diabe es Jou nal, 2014, Volume 7 A ola e al.
s able condi ions be o e discha ge. Mean hospi al die
con en was calcula ed om he daily con en o meals o e
se en consecu i e days du ing he s udy (Table 3).
Plasma c ea inine, o al choles e ol and iglyce ides we e
analyzed by a pho ome ic enzyma ic me hod and plasma
high-densi y lipop o ein (HDL) choles e ol was analyzed by
a di ec enzyma ic me hod (In eg a®, Roche, Basel,
Swi ze land). Low-densi y lipop o ein choles e ol was
calcula ed by he F iedewald equa ion (F iedewald 1972).
T oponin T was analyzed immunologically (Elecsys®,
Roche, Basel, Swi ze land). The es ima ed glome ula
il a ion a e (GFR) was calcula ed by he Cock o -Gaul
o mula and he modi ica ion o die in enal disease
(MDRD) o mula [20,21].
All blood sampling and OGTTs we e pe o med by he
in e na ionally acc edi ed labo a o y o he adjacen
uni e si y hospi al (Labo a o y and Pha macy Public U ili y
o Pi kanmaa Hospi al Dis ic , Tampe e, Finland).
S a is ics
The no mali y o he a iables was assessed g aphically.
Con inuous a iables a e p esen ed as means (SD) o , when
dis ibu ion was non-pa ame ic, as means (Q1, Q3), and
ca ego ical a iables as coun s and p opo ions (%). Pa ien s
whose glucome abolic s a e was no p ope ly classi ied we e
excluded om he analysis. The no mali y o con inuous
alues was es ed wi h he D’Agos ino-Pea son es . The
co ela ion be ween a iables was es ed wi h Pea son’s
co ela ion coe icien , wi h he excep ion o oponin T and
iglyce ides, which we e es ed wi h Spea man’s ho.
Di e ences in baseline cha ac e is ics we e compa ed using
he Chi-squa ed es , a wo- ailed Fishe ’s exac es , he
independen samples - es and he Mann-Whi ney U- es
(SPSS 11.5, Chicago, IL, USA). The ecei e ope a ing
cha ac e is ics (ROC) cu e app oach was used o e alua e
sensi i i y and speci ici y o PPG2h in de ec ing diabe es a
each meal compa ed o OGTT2h. We emphasized sensi i i y
o e speci ici y because we conside PPG2h o sc een
pa ien s o u he e alua ion by OGTT.
E hics
The s udy p o ocol was app o ed by he E hics
Commi ee o Tampe e Uni e si y Hospi al and conduc ed
acco ding o he Decla a ion o Helsinki. All pa ien s ga e
hei w i en, in o med consen .
RESULTS
Acco ding o FPG, 134 (70.9%) pa ien s we e heal hy, 47
(24.9%) had IFG, and 8 (4.2%) we e diabe ic. Acco ding o
s anda dized OGTT, 70 (37.0%) pa ien s had NGT, 9 (4.8%)
had isola ed inc eased as ing glucose, 71 (37.6%) had IGT,
and 39 (20.6%) had diabe es. Thus, 79% (31/39) o newly
diagnosed cases o diabe es would ha e been missed using
as ing glucose only. The mean ime om admission o
hospi al o PPG2h assessmen was 5 (4) days ( ange 1-30
days) and he co esponding ime o OGTT assessmen was 6
(4) days ( ange 1-31 days). OGTT2h glucose did no
dec ease wi h inc easing ime om acu e myoca dial
in a c ion ( s=0.006, p=0.934).
The AGT g oup had lowe HDL choles e ol, highe body
mass indexes and iglyce ides, mo e equen hype ension
and la ge wais s han pa ien s wi h NGT (Tables 1 and 2).
The mean and ange o ca bohyd a e con en o b eak as ,
lunch and dinne was 48g (43-51), 58g (47-67) and 62g (49-
83g) espec i ely in ou ine weekday hospi al meals (Table
3). PPG2h le els a e each meal in he NGT, IGT and
diabe es g oups a e shown in (Fig. 2). In pa ien s wi h newly
diagnosed diabe es, PPG2h le els a e each meal we e
Fig. (1). Flowcha . PPG = pos p andial glucose.
Pos meal Glucose A e Myoca dial In a c ion The Open Diabe es Jou nal, 2014, Volume 7 23
highe han in he IGT (p<0.001 o b eak as , p=0.014 o
lunch and p=0.007 o dinne ) and NGT g oups (p<0.001 o
b eak as , p=0.001 o lunch and p<0.001 o dinne ). PPG2h
did no di e be ween he NGT and IGT g oups a e any
meal (p=0.075 o b eak as , p=0.586 o lunch and p=0.056
o dinne ).
Table 1. Demog aphics o pa ien s wi h no mal (NGT) o
abno mal glucose ole ance (AGT) in hospi al. Values
a e gi en ei he as numbe (%) o as mean (SD).
NGT
AGT
P
No. o pa ien s
70
119
Sex, F/M
26/44
35/84
0.272
Age, mean (SD), y
66 (12)
65 (12)
0.656
BMI, mean (SD), kg/m²
27 (4)
29 (5)
0.024
Wais >88/102 cm (%)a
39 (56)
82 (69)
0.089
Smoking (%)
33 (47)
68 (57)
0.213
Hype ension (%)
34 (49)
84 (71)
0.011
Family his o y (%)
41 (59)
71 (60)
1.000
P e ious AMI (%)
8 (11)
17 (14)
0.822
P e ious CABG (%)
4 (6)
8 (7)
0.546
P e ious S oke/TIA (%)
6 (9)
4 (3)
0.144
AMI = acu e myoca dial in a c ion, BMI = body mass index, CABG = co ona y a e y
bypass su ge y, TIA = ansien ischemic a ack. a Wais ci cum e ence acco ding o he
Na ional Choles e ol Educa ion P og am (NCEP).
The e was a signi ican co ela ion be ween OGTT2h and
PPG2h a e b eak as ( 2=0.26, p<0.001), lunch ( 2=0.13,
p<0.001), and dinne ( 2=0.16, p<0.001) (Fig. 3). S anda d-
izing o age o body mass index did no change he esul s.
The sensi i i y o PPG2h o de ec ing AGT (acco ding o
OGTT limi s) is 22%, 26%, and 38% o b eak as , lunch
and dinne espec i ely. The speci ici y o PPG2h o
de ec ing AGT is 100%, 83% and 83% o b eak as , lunch,
and dinne espec i ely. The sensi i i y o he single highes
glucose alue a e any meal o de ec ing AGT was 52%
and he speci ici y was 71%. Compa ed o mo ning
OGTT2h, he sensi i i y and speci ici y o PPG2h o
de ec ing diabe es a he cu -o poin o 5.6 mmol/l we e
78.4% and 42.1% espec i ely. Fo lunch, he sensi i i y and
speci ici y o PPG2h a he cu -o poin 6.5 mmol/l we e
77.8% and 47.4% espec i ely, and o dinne , he sensi i i y
and speci ici y o PPG2h a 7.0 mmol/l we e 76.5% and
55.1% espec i ely.
Table 2. Biochemis y o he pa ien s wi h no mal (NGT) o
abno mal glucose ole ance (AGT) in hospi al.
Values a e gi en as mean (SD o Q1,Q3).
NGT
AGT
P
Hemoglobin (g/l)
132 (17)
132 (18)
0.899
C ea inine (µmol/l)
77 (18)
82 (20)
0.111
eGFR (CG, ml/min)
96 (31)
96 (35)
0.887
T oponin T (µg/l)
2.2 (0.2, 2.7)
2.7 (0.3, 3.1)
0.403
HbA1c (%)
5.4 (0.5)
5.5 (0.5)
0.623
Choles e ol (mmol/l)
5.0 (1.4)
4.8 (1.2)
0.341
LDL-choles e ol (mmol/l)
3.1 (1.1)
3.0 (1.1)
0.633
HDL-choles e ol (mmol/l)
1.3 (0.4)
1.1 (0.3)
0.014
T iglyce ides (mmol/l)
1.5 (0.8, 1.6)
1.9 (1.0, 2.1)
0.012
CG = Cock o -Gaul o mula, eGFR = es ima ed glome ula il a ion a e, HbA1c =
Glyca ed hemoglobin, HDL = high-densi y lipop o ein, LDL = low-densi y lipop o ein.
Table 3. Mean con en o s anda d hospi al die .
B eak as
Lunch
Dinne
Amoun (g)
564
674
607
Ene gy (kcal)
383
545
483
Ca bohyd a es
(g)
48
58
62
P o ein (g)
23
30
23
Fa (g)
11
20
15
SFA (g)
5
6
6
g = g ams, kcal = kilocalo ies, SFA = sa u a ed a y acids.
Fig. (2). Mean pos p andial (± 95% CI) glucose concen a ion (mmol/l) wo hou s a e each daily meal (PPG2h) in h ee di e en pa ien
g oups acco ding o an o al glucose ole ance es : no mal glucose ole ance (NGT), impai ed as ing glucose and glucose ole ance (IFG and
IGT), and diabe es.
24 The Open Diabe es Jou nal, 2014, Volume 7 A ola e al.
DISCUSSION
This s udy is he i s o demons a e a co ela ion
be ween PPG2h and OGTT2h in non-diabe ic pa ien s wi h
acu e myoca dial in a c ion. PPG2h is e y speci ic o
ca ego izing glycemia bu i lacks sensi i i y wi h he
glucose h esholds cu en ly se o OGTT. New PPG2h
h eshold alues a e he e o e sugges ed o he clinical
decision o p oceed o OGTT es ing.
Plasma glucose is highe a e OGTT compa ed o a
s anda dized mixed meal [16]. Gas ic emp ying a e liquid
inges ion is mo e apid han a e a solid mixed meal, hus
gene a ing a non-physiologic in low o glucose o he
duodenum and po al ein ci cula ion [22,23]. The p o ein
and a con en o a meal may delay and a enua e he
abso p ion o glucose and he eby p oduce a shallowe
pa e n o PPG excu sion [24,25]. In his s udy, he highes
co ela ion be ween PPG2h and OGTT2h was seen a e
b eak as despi e he lowes peak glucose (Fig. 2).
The co ela ion be ween PPG and OGTT ( 2=0.13-0.26,
p<0.001; Fig. 3) in he p esen s udy suppo s he indings o
ea lie s udies. This is he case e en hough ou pa ien s we e
acu ely ill and we measu ed PPG2h a e non-s anda dized
e e yday hospi al meals. Meie e al. [16] demons a ed a
co ela ion be ween a s anda dized mixed meal and OGTT
( 2=0.78) and sel -measu ed home p o iles and OGTT ( 2 =
0.34). Oka e al. [26] epo ed a loose co ela ion ( 2=0.11)
be ween a s anda dized ice-based meal and OGTT2h in a
popula ion sample. The s ic es ing p o ocol by Meie e al.
[16] gi es a high co ela ion be ween OGTT2h and PPG2h,
bu wi h a mo e p ac ical app oach a home o on he wa d,
as in he p esen s udy, he co ela ion is less subs an ial.
Mo e unce ain y mus be accep ed i pa ien s a e es ed by
he mo e p ac ical me hod compa ed o a s ic labo a o y
me hodology when assessing pos p andial glycemia.
In he s udy by Meie e al. [16], non-diabe ic pa ien s
ca ego ized by OGTT also had no moglycemia wo hou s
a e b eak as , lunch and dinne . In ou NGT g oup, despi e
no mal PPG2h a e b eak as , he PPG2h a e lunch and
dinne was inc eased. Simila ly, PPG2h was highe a e
lunch and dinne compa ed o b eak as in he IGT g oup.
This aises he ques ion o whe he pa ien s in he NGT
g oup ha e a ansien s ess-induced dis u bance in
glycemic ole ance due o acu e myoca dial in a c ion. A
simila pa e n o s ess-induced pos -meal glycemic changes
has been epo ed a e p os he ic su ge y [27]. Acu e s ess-
induced hype glycemia is also suppo ed by a s udy whe e
61% o non-diabe ic pa ien s wi h acu e s oke had AGT a
discha ge, bu a e e-in es iga ion a h ee mon hs mo e
han hal o hem we e ca ego ized as ha ing NGT [28]. By
con as , in he s udy by Wallande e al. [29], 93% o newly
de ec ed diabe ic pa ien s e alua ed by OGTT du ing acu e
myoca dial in a c ion a discha ge s ill had AGT a e 3 and
12 mon hs. This is suppo ed by ou inding ha OGTT2h
did no change wi hin he one-mon h spec um o sampling.
Thus, he e is con adic o y e idence abou he ansi o y
na u e o hype glycemia ela ed o acu e se e e illness.
The epidemiological da a suppo he hypo hesis ha
pos p andial hype glycemia, no FPG, is he isk ac o o
ca dio ascula diseases [14]. In he Diabe es In e en ion
S udy (DIS), he blood glucose a e b eak as , no as ing
blood glucose, p edic ed myoca dial in a c ion and mo ali y
in newly diagnosed ype 2 diabe ic pa ien s [13].
Pos p andial blood glucose has been ound o be a s onge
p edic o o ca dio ascula e en s han as ing blood glucose
in all ype 2 diabe ic pa ien s, especially in women [11].
AGT de ined by OGTT is sugges ed o be a good isk
ma ke o de e mining ca dio ascula p ognosis a e
myoca dial in a c ion [8]. In ou s udy, he e was a i m
co ela ion be ween OGTT2h and PPG2h. Measu ing PPG2h
ins ead o OGTT2h could be an easie and mo e p ac ical
way o e alua e he pos p andial glycemic s a e a e
myoca dial in a c ion in clinical p ac ice. All measu emen s
in ou s udy we e made du ing ou ine ca e on he wa d. The
only excep ion o no mal ca e was he PPG measu emen
h ee imes a day. The e a e no s udies on he ole o PPG as
a su oga e a e acu e myoca dial in a c ion in he non-
diabe ic popula ion. A s udy compa ing he PPG2h o
OGTT2h as a ca dio ascula isk ma ke is he e o e called
o .
The pa hogenesis o ype 2 diabe es melli us suppo s he
sc eening o pos p andial hype glycemia ins ead o as ing
glucose o HbA1c in he non-diabe ic popula ion [2]. Only
a e he pos p andial glycemic con ol is los will he
de e io a ion o as ing hype glycemia ensue [3]. Ini ial
dec ease o pos p andial insulin elease and also insulin
esis ance ha e been p oposed o be gene ically ansmi ed
isk ac o s p edisposing indi iduals o ype 2 diabe es [4]. In
pa ien s wi h IGT, dec easing PPG wi h aca bose was
Fig. (3). Co ela ion be ween wo-hou o al glucose ole ance es (OGTT2h) and wo-hou pos p andial glucose (PPG2h) a each daily meal
in non-diabe ic pa ien s wi h acu e myoca dial in a c ion. Dashed lines ep esen glucose cu -o alues o 7.8 and 11.1 mmol/l.

Pos meal Glucose A e Myoca dial In a c ion The Open Diabe es Jou nal, 2014, Volume 7 25
associa ed wi h a lowe incidence o ca dio ascula e en s in
he STOP-NIDDM S udy [12].
No hamma e al. showed ha OGTT can p edic
ca dio ascula e en s in pa ien s wi h myoca dial in a c ion.
We adop ed a simila s udy design o compa e PPG2h o
OGTT2h. Despi e simila inclusion c i e ia and he e y
simila popula ion and way o li ing in Sweden and Finland,
hese wo s udies ha e some di e ences. Fi s , as ing
glucose c i e ia o diagnosing diabe es di e be ween he
Wo ld Heal h O ganiza ion and Ame ican Diabe ic
Associa ion. Second, whole blood glucose le els a e 12%
lowe han plasma glucose. Plasma sampling in ou s udy
should inc ease de ec ion o IGT and diabe es. Thi d,
compa ed o he pa ien s o No hamma e al. [30] ou
pa ien s we e olde , mo e obese, and had mo e a equen
his o y o hype ension, which would be expec ed o inc ease
he numbe o AGT pa ien s. Ins ead, compa ed o he s udy
popula ion o No hamma e al. [30], he e we e ewe new
diabe ic pa ien s (21% s. 33%) bu ha dly any di e ence in
he numbe o AGT pa ien s (63% s. 68%). The bes
explana ion o hese di e ences is he p og am o he
p e en ion o ype 2 diabe es in Finland, which was
conduc ed du ing 2003-2008 [31].
The e a e a numbe o limi a ions in ou s udy. Fi s ,
du ing ou s udy a g ea majo i y o pa ien s le hospi al
be o e being able o pa icipa e in he s udy. They we e
ei he no gi en pe mission o ea egula meals be o e
ans e o ano he uni o hey did no ha e ime o OGTT.
We canno exclude he possibili y ha he s udy popula ion
is biased o include mo e sick and olde people and
complica ed cases. Second, we did no eco d wha
p opo ion o ood was ea en, which may inc ease he
numbe o alse nega i e esul s. Thi d, we did no
s anda dize meal size o he con en o ca bohyd a es, p o ein
o a . Fou h, medica ion was eco ded only a discha ge.
Howe e , he e ec o medica ions on he OGTT and PPG2h
measu emen s a e simila .
On he o he hand, he s eng h o his s udy, is a p ac ical
e e yday app oach in e alua ing pos p andial glycemia.
CONCLUSION
PPG2h is a quick, p ac ical, simple and easy es ima e o
e alua ing pos p andial glycemia a e myoca dial in a c ion
in clinical p ac ice. Because he PPG2h alue is lowe han
OGTT2h, he sensi i i y o PPG2h in de ec ing IGT and
diabe es is low wi h he cu en cu -o alues designed o
OGTT. New cu -o alues o PPG2h a e he e o e
sugges ed. The new alues could be used o ind pa ien s in
whom u he es ing by OGTT is no needed.
ABBREVIATIONS
AGT = Abno mal glucose ole ance
FPG = Fas ing plasma glucose
GFR = Glome ula il a ion a e
HbA1c = Hemoglobin A1c
IGT = Impai ed glucose ole ance
NGT = No mal glucose ole ance
OGTT = O al glucose ole ance es
OGTT2h = Two-hou o al glucose ole ance es
PPG = Pos p andial glucose
PPG2h = Two-hou pos p andial glucose
ROC = Recei e ope a ing cha ac e is ic
SD = S anda d de ia ion
CONFLICT OF INTEREST
No compe ing inancial in e es exis s o any au ho .
ACKNOWLEDGEMENTS
The expe assis ance o M s. Ka i Pel omäki, RN, is
g a e ully acknowledged. This s udy was suppo ed by The
Hea Cen e , Tampe e Uni e si y Hospi al, Tampe e,
Finland and he Depa men o In e nal Medicine, Tampe e
Uni e si y Hospi al, Tampe e, Finland. Funding sou ces had
no in ol emen in he s udy.
REFERENCES
[1] Cou inho M, Ge s ein HC, Wang Y, Yusu S. The ela ionship
be ween glucose and inciden ca dio ascula e en s. A
me a eg ession analysis o published da a om 20 s udies o
95,783 indi iduals ollowed o 12.4 yea s. Diabe es Ca e 1999;
22: 233-40.
[2] Woe le HJ, Pimen a WP, Meye C, e al. Diagnos ic and
he apeu ic implica ions o ela ionships be ween as ing, 2-hou
pos challenge plasma glucose and hemoglobin a1c alues. A ch
In e n Med 2004; 164: 1627-32.
[3] Monnie L, Cole e C, Dunsea h GJ, Owens DR. The loss o
pos p andial glycemic con ol p ecedes s epwise de e io a ion o
as ing wi h wo sening diabe es. Diabe es Ca e 2007; 30: 263-9.
[4] Ge ich JE. Is educed i s -phase insulin elease he ea lies
de ec able abno mali y in indi iduals des ined o de elop ype 2
diabe es? Diabe es 2002; 51 (Suppl 1): 117-21.
[5] Van Hae en TW. Ea ly dis u bances in insulin sec e ion in he
de elopmen o ype 2 diabe es melli us. Mol Cell Endoc inol
2002; 197: 197-204.
[6] Henquin J-C, Ishiyama N, Nenquin M, Ra ie MA, Jonas J-C.
Signals and pools unde lying biphasic insulin sec e ion. Diabe es
2002; 51 (Suppl 1): 60-7.
[7] DECODE S udy G oup, he Eu opean Diabe es Epidemiology
G oup. Glucose ole ance and ca dio ascula mo ali y: compa ison
o as ing and 2-hou diagnos ic c i e ia. A ch In e n Med 2001;
161: 397-405.
[8] Ba nik M, Malmbe g K, No hamma A, Tene z A, Oh ik J,
Rydén L. Newly de ec ed abno mal glucose ole ance: an impo an
p edic o o long- e m ou come a e myoca dial in a c ion. Eu
Hea J 2004; 25: 1990-7.
[9] Capes SE, Hun D, Malmbe g K, Ge s ein HC. S ess
hype glycemia and inc eased isk o dea h a e myoca dial
in a c ion in pa ien s wi h and wi hou diabe es: a sys ema ic
o e iew. Lance 2000; 355: 773-8.
[10] Tami a K, Ka ayama M, Takagi T, e al. Impac o newly
diagnosed abno mal glucose ole ance on long- e m p ognosis in
pa ien s wi h acu e myoca dial in a c ion. Ci c J 2007; 71: 834-41.
[11] Ca alo F, Pe elli A, T a e sa M, e al. Pos p andial blood glucose
is a s onge p edic o o ca dio ascula e en s han as ing blood
glucose in ype 2 diabe es melli us, pa icula ly in women: lessons
om he San Luigi Gonzaga Diabe es S udy. J Clin Endoc inol
Me ab 2006; 91: 813-9.
[12] Chiasson J-L, Josse RG, Gomis R, e al. Aca bose ea men and
he isk o ca dio ascula disease and hype ension in pa ien s wi h
impai ed glucose ole ance: he STOP-NIDDM ial. JAMA 2003;
290: 486-94.
[13] Hane eld M, Fische S, Julius U, e al. Risk ac o s o myoca dial
in a c ion and dea h in newly de ec ed NIDDM: he Diabe es
In e en ion S udy, 11-yea ollow-up. Diabe ologia 1996; 39:
1577-83.
[14] Ce iello A, Hane eld M, Lei e L, e al. Pos p andial glucose
egula ion and diabe ic complica ions. A ch In e n Med 2004; 164:
2090-5.
26 The Open Diabe es Jou nal, 2014, Volume 7 A ola e al.
[15] Au ho s/Task Fo ce Membe s, Rydén L, G an PJ, e al. ESC
Guidelines on diabe es, p e-diabe es, and ca dio ascula diseases
de eloped in collabo a ion wi h he EASD: he Task Fo ce on
diabe es, p e-diabe es, and ca dio ascula diseases o he Eu opean
Socie y o Ca diology (ESC) and de eloped in collabo a ion wi h
he Eu opean Associa ion o he S udy o Diabe es (EASD). Eu
Hea J 2013; 34: 3035-87.
[16] Meie JJ, Balle B, Menge BA, Gallwi z B, Schmid WE, Nauck
MA. Excess glycaemic excu sions a e an o al glucose ole ance
es compa ed wi h a mixed meal challenge and sel -measu ed
home glucose p o iles: is he OGTT a alid p edic o o
pos p andial hype glycemia and ice e sa? Diabe es Obes Me ab
2009; 11: 213-22.
[17] Raz I, Wilson PWF, S ojek K, e al. E ec s o p andial e sus
as ing glycemia on ca dio ascula ou comes in ype 2 diabe es: he
HEART2D ial. Diabe es Ca e 2009; 32: 381-6.
[18] Myoca dial in a c ion ede ined - a consensus documen o The
Join Eu opean Socie y o Ca diology/Ame ican College o
Ca diology Commi ee o he ede ini ion o myoca dial
in a c ion. Eu Hea J 2000; 21: 1502-13.
[19] Thygesen K, Alpe JS, Whi e HD, Join ESC/ACCF/AHA/WHF
Task Fo ce o he Rede ini ion o Myoca dial In a c ion. Uni e sal
de ini ion o myoca dial in a c ion. Eu Hea J 2007; 28: 2525-38.
[20] Cockc o DW, Gaul MH. P edic ion o c ea inine clea ance om
se um c ea inine. Neph on 1976; 16: 31-41.
[21] Le ey AS, Bosch JP, Lewis JB, G eene T, Roge s N, Ro h D. A
mo e accu a e me hod o es ima e glome ula il a ion a e om
se um c ea inine: a new p edic ion equa ion. Modi ica ion o Die
in Renal Disease S udy G oup. Ann In e n Med 1999; 130: 461-70.
[22] Albe i KG, Zimme PZ. De ini ion, diagnosis and classi ica ion o
diabe es melli us and i s complica ions. Pa 1: diagnosis and
classi ica ion o diabe es melli us p o isional epo o a WHO
consul a ion. Diabe Med 1998; 15: 539-53.
[23] Collins PJ, Ho owi z M, Cook DJ, Ha ding PE, Shea man DJ.
Gas ic emp ying in no mal subjec s--a ep oducible echnique
using a single scin illa ion came a and compu e sys em. Gu 1983;
24: 1117-25.
[24] Ca el G, Egli L, T an C, e al. Con ibu ions o a and p o ein o
he inc e in e ec o a mixed meal. Am J Clin Nu 2011; 94: 997-
1003.
[25] Mande s RJF, Wagenmake s AJM, Koopman R, e al. Co-inges ion
o a p o ein hyd olysa e and amino acid mix u e wi h ca bohyd a e
imp o es plasma glucose disposal in pa ien s wi h ype 2 diabe es.
Am J Clin Nu 2005; 82: 76-83.
[26] Oka R, Hi umi S, Kobayashi J, e al. The ela ionship be ween
pos -p andial plasma glucose and pos -challenge plasma glucose in
Japanese popula ion. Diabe es Res Clin P ac 2007; 78: 282-8.
[27] Pili-Flou y S, Mi i io F, Pen o nis A, e al. Glycaemic
dys egula ion in nondiabe ic pa ien s a e majo lowe limb
p os he ic su ge y. Diabe es Me ab 2009; 35: 43-8.
[28] Da e JA, Engel ME, F ee cks R, e al. Abno mal glucose
me abolism in non-diabe ic pa ien s p esen ing wi h an acu e
s oke: p ospec i e s udy and sys ema ic e iew. QJM 2010; 103:
495-503.
[29] Wallande M, Malmbe g K, No hamma A, Rydén L, Tene z A.
O al glucose ole ance es : a eliable ool o ea ly de ec ion o
glucose abno mali ies in pa ien s wi h acu e myoca dial in a c ion
in clinical p ac ice: a epo on epea ed o al glucose ole ance es s
om he GAMI s udy. Diabe es Ca e 2008; 31: 36-8.
[30] No hamma A, Tene z A, Nilsson G, e al. Glucose me abolism in
pa ien s wi h acu e myoca dial in a c ion and no p e ious diagnosis
o diabe es melli us: a p ospec i e s udy. Lance 2002; 359: 2140-
4.
[31] Saa is o T, Pel onen M, Keinänen-Kiukaanniemi S, e al. Na ional
ype 2 diabe es p e en ion p og amme in Finland: FIN-D2D. In J
Ci cumpola Heal h 2007; 66: 101-12.
Recei ed: Ap il 12, 2014 Re ised: Sep embe 30, 2014 Accep ed: Oc obe 2, 2014
© A ola e al.; Licensee Ben ham Open.
This is an open access a icle licensed unde he e ms o he C ea i e Commons A ibu ion Non-Comme cial License (h p://c ea i ecommons.o g/licenses/
by-nc/3.0/) which pe mi s un es ic ed, non-comme cial use, dis ibu ion and ep oduc ion in any medium, p o ided he wo k is p ope ly ci ed.