Postmeal glucose compared to oral glucose tolerance in non-diabetic patients with acute myocardial infarction

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.