Town Cape of University

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The copyright of this thesis vests in the author. No
quotation from it or information derived from it is to be
published without full acknowledgement of the source.
The thesis is to be used for private study or noncommercial research purposes only.
U
ni
ve
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ity
Published by the University of Cape Town (UCT) in terms
of the non-exclusive license granted to UCT by the author.
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To
w
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own umLidc::d
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eX~lDlination
at
U
ni
ve
rs
ity
of
C
ap
e
To
w
n
dell!r:ree or
I am SmCerelY ""U"~"""''''' to
to
to
SUI)lec::t was
To
w
n
I
C
ap
to
"......_..,. gJra1J.tucle to
en<linD4JUSJly to
on .........6 ......""'" Chc;:clcs!
U
ni
ve
rs
i
ty
numerous
of
am
I
e
suprpm1ed me thr4)ugb
measurements
on
maiKllltg sure
Oloooswere
w
n
To
e
ap
C
of
ty
rs
i
ni
ve
U
1
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1
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:SUUlDlary ............................................................................................. 1
........
"
..........
"
111>
..........
II . . . . . . . . . . . . '" "' .... " ' " .... "' .... ". . . . . . . "' ...... "
.. "
.. II . . . . . . . . . . . . . . "' .. "' .... "
.. '" "' . . . . . . . . . . . . "
.. " ' " . . . . . " .... .: . . . . . . III" " ' ' ' "" .... ..
II II .. "
. . . . . . II . . . . . . . . . . . . . . "
.. "
............ "
.. '" . . . . . . . . "
.. , , " "
It"
(I . . . . "
"' ..
"
. . . . . . . . , , " It ..
(I . . . . . . "
. . . " " " .. ,, ..
'" ..
"
..
of
C
ap
e
To
1\Ile:al;Ulnmu::t1·I:s .... "' .
w
n
I:'atllenl:s ...................................................................................
l:un<1ulgs ............................................................................... .
KalllilOm
ni
ve
rs
i
ty
"""uuu",....
gluc:ose ............................................................................ .
~
........ "
.. "
. . . . . . . . . . . . . . . . . . . . '" . . . . . . "
.. "
........ "
. . . . . . . . '" "
.... "
. . . . . . . . . . II> .. (I .. "
. . . . II> ..
<II .. '" "
...... II . . . . . . "
.. II . . . . . . . . . . . . . . . . "
............. "
U
.. .. to ..
.. ....,........................................
.., ...,
nA...............u ...
"'
...................................................... " ........................ .
svnc.tro:me ........................................................................... 31
nSC·ussllon .................................. .
lylS.gl yl,;;CR:,llllit1 ............................................................................... .
KanQI()m
JO;U""",,,.,'" on QUJUll;:J"-"U'U . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
i
lSllll'Uii:l.t:JUUi ............. '"
n ...... _uv.JU...
to .. 41 .. " . . . . . . . . . . . . . . . . . . . . . . . . . II
<I>
II . . . . . . . . . . . . . . . "
• <I> •
It . . . . (I . . . . . . . . . . . . . . . . '" •
41 .. to .............. " ., . . . . . . '" . . . . . '" '"
SV1lOl"ODle ......................................................................... .
Limitati,ons ......................................................................... .
rec()mnlen(laU()ns .............................................. .
To
w
n
Rec4:>mnlendatiOJlS ......................................................................... .
U
ni
ve
rs
i
ty
of
C
ap
e
AppelldlC:es ........................................................................................ .
ii
to
as a cause
cOllSi(lerc~ one
To
w
n
- is
e
more
ni
ve
rs
i
ty
of
C
ap
esi1ulUIlies are
U
an acute cOl~narv SV]I1<.1rOD:le
on
a CfC)SS··sec::tiolnaJ OOISef1V'aU.ODlU.
SUblSeQlUeIltly
UU~UI~
Dn~eJnce
were SmiUIle(l ac(~0~run:2
"'U'''"~''''''''
as ....,,,,,...,..... a
dia:gtlolsed as ......." .... ". an
co]~narv
or abs:en(:e
an
event
1
no
to
were refltar(le<.t as aorlonnaJ
men
-C:::;l
to
C>3
:::; 1.3
was a common pn~SenUlLtlC'n to
To
w
n
C
a
uncommon
rs
ity
of
C
ap
e
seems to
"'UJLLU.''''''
COlIlpar:!SOn to
I'Ip'-TPit'.n
ni
ve
to
U
<
ctOm.pllca110IlS
" '....uu. ..... nl~!1tv
was
more common
p=
more co:mr.nolDl}i
CII<l)!3"""JlaL~;U
an mcreased
a
most common
was
a
a
2
was more common
=
was more common
more common
1-
a
of
VVI'~L""""i:O
C
ap
e
I,
To
w
n
to
seen
ty
same extent.
a potlentiaJ
are
we
ettlOemlC
common
sutliectq nres,entine .to
U
ni
ve
rs
i
uncommon
COlllt:rm;t.
nten-cmtion, or even Dn~VentaD1e ....i·......" ......t.r....
3
1
;ardlioV8SC1Ul81 Qlsc,ase is sec~ona
-a
- is COt1SlClen~
To
w
n
common cause
acute
rs
i
ty
of
C
to
ap
e
outcome
worse
It
is a
cause
it
ni
ve
2
starts to
is set at
not
U
is now
as
It is not
not
even
more
4,5
. It is
is
even
4
contribl11tes to
IS
or more common
normoglYlcaeJm1C patlen1ts. 6
It is now
COltlUIlonJ~ 8(~Cet)ted
anlce~g,
is
nn'i!PT"ilAll
w
rC~l!;taJlce
To
A.u.<......,.U
Chl~nllir1'P.1M7.I'II1
n
a COlrnplex .....,,'........... nroc:ess
clusteJ'in~
of
C
a
is IormalllY
ap
e
U1GU"L'''''
ty
causes
rs
i
to
to
ni
ve
IS
to
U
as an
as
to
2
2
is
is
7
8
to
can
2
it
is
5
is
2
UlQ.I~L\;;"
is COIlSI(Jlerc:~ to
a col'On:arv
pre'lfent:ion. It theJ-etolre is not
se
IS
recogJllZc;:(J as an mdlepcmdent
are
2 ......".v...~.... mCludm2 a
l11lCrease. moeeo an epllClenllc, is pre:<11cted
n
W"'dlffiiilll,;
To
w
SvncIJrol1rle) 10
ruaD~jlty
ap
e
to as
U
ni
ve
r
si
ty
of
C
retj~rre:d
a
2 ruallete:s:
is seen
2
a
is a
6
we can
a
most
To
w
n
are common
inJ:an::tions. 17
is an
1mnnli'tl'llft{'P
Cmlll()V8SC1.11ar
ap
e
t(\IPr~nl'p
AU.............
women
to
of
C
IOOHo" ....." '...
A ...AU.U"",
a
U
aQCl1tlOn.
ni
ve
r
si
ty
is a recent or COlltu:1Ulllg tcmaen(:y
mass
a
".(\..'v""'.....,.,.... to Wi:liUCl'~. 20
a
Ot)esl1~ 21
a slgIufic:ant conrela1tlon
an
two
C1ec:aC1C~S
was
a
7
2 ...........,... ,....."'.23
to an
l!e1ttmll!
worse
It
n
gec'gnJlPhllCal areas
to
m(hC~ln(mS
U
ni
ve
rs
ity
of
C
ap
e
are some
To
w
to an
is no reason to ........,,"""",""
an mClreal!le
not
31
so
denllon.stralted to
"1'I1"Ul~"'"
an inc:rel'lSe over ..........."" ..,..
are
an
8
is
2 dial)eti(~s.
OC4:urred or is even
to a ........."..,...t "'AV'..u~
SVI1nntom seen
seen at
"'-A"........J'
a
rs
ity
of
C
commonest
acute cOI:unarv SVlllmnttles is
ap
e
prc::aClllU:n8ltOO
To
w
n
it is
It is
U
ni
to cau:smg
to h8]PPC;m
ve
W Q,lUlJLlil:
..........,....·......i
to
marna~~e
an en,risa2ed increase
a
at
to invlestiJ~ate
9
2
To
w
n
1.
presen1ting to
cross-~lectlonaJ
olDserval1olnaJ,
I1p~[I'"'ntnJP
on COIlse<:Un
U
ni
perton:ned a
ve
rs
ity
of
C
ap
e
I.
to 4
was no
CO]iD.pan!~on
are
measurement
COlllec;tlOn was
np1r1'nTTl"l
were
a stWtutardllsed
To
w
n
1.
ap
e
a.
of
no
no ,..,...,.,,.11",,,,," bic,ml:lrk.ers or
U
ni
ve
r
si
ty
-
C
1.
i.
intiomled consent
to
11
were not llllLjl<UAJ dla:gnolsed on auJ.jIU"~IAVU to
1.
gIulCmle tc)ler'anc:e test
To
w
n
were too unStaDlle.
ap
e
measures were Obt:am,ed:
C
1
of
1.1
ity
1.2
ve
U
ni
2
rs
1.3
acute mv'oc~lrd.ial
an
n
To
w
ap
e
3
C
3.1
ity
of
em
ve
rs
em
4
U
ni
em
.lm-um".lUJ'''' "'Jl.la.u~"'i)
were
1n'U'P1"C!tnn
> 3 mm
plpv9tlnn>
on
5
syrldr1om,e was
UUlgIlLOSOO,
<II"',.,...1I"i" ....,." to
Jns1tabJle aJlglIla was "'''I-n",'',,,
as a ...
UJ........,....
at
.............. A .......
as:
To
w
n
acute COtnn:BrV """'11 ..·,........ .,." were ...A...u....._AJ
is
ap
e
or
C
or an
or new,...,...............
of
. . . ",.,QT........
ity
6
U
ni
ve
rs
ona
6
case
was
or more
onset
MOlllUlt~2
on
to ~"""'''''''''15'''' to
sanlPU::S were obl:amle<1:
2
were
ity
of
~7
C
ap
e
To
w
n
~rit~.rin
g1uc:ose, IGT == imPlured
U
ni
ve
DM "" diabetes mellitus
lmp~ured
rs
tolemnc:e, IFG ==
NGT= normal
were ......."g..'i""'"' as aDIlonnru
men
cru)les~~ol
was
:5 1.3 ...... ,..., .... "
women
~~~WlG"~
not ex(;eea
=
8+
]
15
DI()()(JIS ...V U _ I........
were
were
UU,AU':KU>
was pertonnlOO
C
ap
e
.... ~..................'V.u
as
Dn~ente:<1
To
w
are
as
U
ni
ve
rs
ity
of
10SPltlal
n
sum
as
were
3
1
1,
were Iet1naie.
were res:po:nsible
To
w
n
SVI1OO)m4e8
1
were
are Dre:SeDltoo
U
DWleDI1.S e'vall1atc~
ni
ve
rs
ity
of
C
ap
e
1,
=
2
1.
Total patieni\
ACS pmirnts
1I-11J1
, .\ge (lll~di'lIl. "al1!,~)(ye"n;)
(I~
- 'JT)
62
e4 - 'J7)
.~.--------+-------
I£thnidty
~77
131
('o[oui'ed
62<)
73
Rh,ck
623
0
Oll!~,.
2
951
h'JJI(lI~
j j
)m
1m
of
C
SO
To
w
. Hale
ap
e
I
------+--------,
n
White
G~nder
rs
ity
Figurt' I; I£thnk di,tdhutioll in p'llients st't'u ill 1£L1 and those with ACS
ROO
,,
-,
iOO
ni
'JIlIl
ve
I Ifllil
U
!
44
n=l14
6()()
• Total patients
• ACS jlatknj,
~
•0 500
0
..j()()
300
2(~
l()()
0
White
C"lourrd
lIJad,
3.2. Clinical Findings
AI leasl one n sk 1,><:lor lilr ~ardiov;~,~u lar disea,e (on l1lslor),) was presenl in 20J palienl,
(94,')'%) . HypenellSl(ln was Ihe mosl COmmOll risk I"clor, I"ll owed by known CAD and a
1;.Ll1llIy history 01' CAD,
lyp" 2
diabct~s.
~lgmeU~
smoking (current), Iypc 2 dinbdcs, a fam ily histoJ), of
high clx,kstCfOI, peripheral vns.culHr diseasc anc.l stroke (tnble 3), Two Of
morc cardiovw;cular ri,k factors wen: preselll ill
4 or more in 50 palienls (23.4%). 5 OLmorc
palienls ( I ,r·;.) had
I)
J!l
19 patients
mor~
Hl 10]
(g.9'~.;,)
and 4
n
(4S_1~__;,)_
pallellts OJ_x',,;;), 1 or
nsk lactors. In tntaL 73 patients (:14. I '~.;,) were diHgnosed wilh low
ri,k urlOlahle allgillH. 76
(.1';5~--o)
To
w
pal lenls
1) ~
wilh high nsk unstable allgHla, .1 1
(14)~--;')
wi th
of
C
ap
e
NSTEMJ and 34 (1)_9%) wilh STEML In·hn'pLlal cmnplications OCClLITOO in 85 paticnls
(3'),7"--0), Congcstive heal1 jllilure was the most common
~ompli~aljon_
A small subsd oj'
paliellls were rd"elTed 10 a Ieltiary rn'''pitall;)r im'asive intcJ'>'CTitinn and Hn eVC11 sma ller
ity
gnlUp c.lied (table 4),
ve
rs
Tablc 3: Risk faclol'S for CAD on hi,tor.,'
"".
l\'umhcl' paticnts
Pcrccntllgc
Hyp.,n~n,ion
143
66,~
Known CAD
113
52,g
1'-.l1ni Iy hi,toT) of CA I)
71
33,2
U
ni
Risk I:ar!<lr
I
Smoking hlSlory
64
Diabele, Mellitus
52
hunily hi,IO[',), ol D'vI
51
Hig h Crn,kstcrol
.'14
Periph cra l vascular di sease
.'12
Cerebwvascular disease
2';
I
i
I,
29,<)
24.1
2U
15.9
14.9
!
11.7
19
I abk 4:
In-ho~pit31 "omplic"tion~
-- ~- - --~
COIllpli\-,l1ion
~umbH 1'1Ijj~lIl~
PtH'cntage
129
6(),]
,
}S, I
6
H
j}
Ii. I
7
"
,'-,'
\,jone:
Congesliv~
hCaJt j,'ilurc
RcelLn-cm ungmu
,,,
,,
,,
R~krled
De,,111
,
,,
,,
,,
,
w
n
I
Oral glucosc tolerance
To
~.3.
~,
,
admill~d
e
The glycUUlllc prome wul delnmincd Ul1<1 c-ollll'arcd in 1'14 of the 214 polk nt,
\VQ'
''lOt d'l\le in 2(1 p"lien\< due lO unwillmgl1e_" (n- l(1), dealh (n-1) or
ap
wilh ."'(,S, [I
A 1l1Odilied oral glueme loleranc e les l wu:< puJoml ed at disc-harl!c
ty
(;llIcosn'altgoric~
of
C
lran,rer to a leni ~'" in;;l ll ulC [()r rurther imer\'cnllo n (n- 7),
rs
i
on a[1 pUliem s admilkd wilh un A(,S and nol nlrcndy known 10 have diabete,; (142)_
normal
ni
ve
Taking thc known diabelics mlO alTounL palienL< Wer" Ihen divldcd imo
gllLcos~ I()kmnc~ (6~.
lllOS~
wilh n
}S.I'%'\ and (ho,,, with dy,glycaemia (121i. 64_,)0/01 _
U
SubjI'C(s who had a p,;or his(o,)' or diaOCle, W<'l'C dassllied as havmg P'evlOlLsly
dia,,'lloscd diaheles_ Olher subje<:[s we,,,
d,~"died ,,,,~ording
10 lhe modiiied 1997 ADA
critcria. as having a n'Mmal glocose lo["rance, an lsolated impuired ensling glucose. nn
isolawd impa ired
g l u~o'e
lOkl,mce. hoth impaired rasling- gl lll"'"'' und impail1cd
gllLCOS~
l()kL'an.:~ (th~
lattcr thrc~ ca(cgo.-i es also ktlOWn ns prediabetes) or diaheles_ Palit'fll, w11h
w~re
;; ubdl\'idcd ,nw those nlrcady known to havc diahete,; Qnd lho;; e wilh newly
lilaOCleS
llia,,'llostil cli abel."" C]a"dicalion oj' glucose abnonrw ljtics ncnll-ding to the ]<!97
lDod ified AIlA
c,;(~ria
are lab u[akd in luhl " 5_ Th e
pL'e\ aknc~
or
glu(os~ nbnonnaliti~s
2(1
w~re
lh~
f~,lillg
deknl1ined wlih ll",
plasm,1
gluws~
prevalence of dysgJycocmia when adding
lh~
(FT'Ci) lesl alone and
lh~ll
compmed lo
2 hr post-load glucose (PG) value (table
6).
Table 5: Prevalence of glucose abnormalities according; to 19'n modified AHA
criteria
%
,VGT
~s
iso/weeliFG
IJ
lso!wed J(iT
:oJ
-' 5.1
w
l\"rmal
n
"
I1 08 .1%)
OM
of
New
22
11.3
52
26.~
ty
i Iliab~t<"
"I
16
C
fFG ",,,I leil
I
11.9
e
t2~.il%)
ap
! Prediabetes
To
(35.1%)
"0m101 ::Iuc"," ",1""",,,._ TH, - imp'in:d j;"tlllg glue"",,, lCiT - impairt'J glue',,"e
ni
ve
rs
i
,,'(iT
U
Table 6: Nllmher 01' patients recruited with FPG, 2 br I'G and the t"tal "I' glutost'
ahnonnali!ics
--
FPG
2 hr PG
Both
NGT
I(X)
sa
68
IG,
2'!
39
52
Inl
13
18
'\'CiT - nonmLl
~lllC''''':
lol' mnee, J(3 T -
._--
'''~.<\11' ...1"Iu",,,<,
--
22
(01.,-,"'000, 1)\1 -
,
~ i ,hett,
21
Re~lUitll1g
di aheLie ralle"Ls l>y ellh"r crite'rio" alo,,~ or lhl1r combi"aLio'L -'/0.1 % (9) ILlel
bOLh, 18,2% (-'/) mel the fa,ling ~rileria alone onci 40'>""'0 ('I) met tllC 2 Ill' Xlst iO<ld
eilh~r
c1iknol1 alolle, SlIllil3Jly, n'cruiLing patknts wilh IInpaired glucose tolerance fly
Cnlenol1 alollc {\]' Lheir cOlllb,nation,
30,8'~"i,
(16) nre( b(){h,
25~";,
(H) mct lhc fasling
CI'ilCliJ only and 44,2% 123) met tlK" 2 hr post· lml(l criwrion alone.
[)y~g iyca"mi"
wa<; more commOll ill Co ioLll"eds (72.3°··;' 01' all
dysgiycaellm buL lhese
w
h,~j
To
1[>-0.071. The lllajority of macks (88.'l'!·") and ail Indians
n
Coloureds) than \Vh,Le, (58.8%). howe"er, this did not reach Slal1Slicai signific~ nce
iJttcr two groups 'verc (ll" small to 1><: <;tati s1 iC'11i y sib'Tllllcall i (ligLire 2).
h~'
C
'"
I. ~G'T
ni
ve
00
ty
00
rs
i
,,
",~
of
00
•
'"
Nhnidty
e
2: Di,tribulion of rl~'sgly~:teUlia
ap
Figllr~
00
,.
U
'"
'"
"
\\1,;,"
DysglycQcmia was comrrX)1l in both mules
{·01011.. d
(~2.9'!..~
Rb,"",
01' all lllak,) and females
p-O.55 (!jgure 3), The mcdian age ofpaliellLs w1lh dysglycaerllla (65 ycars, rangc
(67~";':1,
J~-(17)
was Slgrllficmltly highcr than tix)se with r-.CH (56 years_ T"Tlge 24-90) (I' - 0,(3).
22
.
..
, .."I
"
i
1
•
. . . . 0.
..
" , ', ... 1<
n
"
w
'"
prenou~
,,~haeml~
e\enl wa, present in 46.2% 01'
nnci 59.1%. "fne" diahctks. Pmients with l\GT 'vere more likdy to h..lVe
C
~rcdiabelin
e
A hl,'tmy or a
ap
Clinit3i
To
"
of
low nsk LAP III wlllpans.on to both thelr prcdiaklic and
diabcti~
COlLlltcJ'pmts (p < 0.0 j I
I.hio
In
Will;
diabetics (3, 4. j ".'f,). compared to pnxliabetics (1, 1,9%) Bild l\ GT (j. I .5%) hut
nul
ni
ve
highest
rs
i
ty
(table 7, figure 4) and leoo likely \0 develop wmplicatiOllo (I' - 0.04). Mortality wa,
,Iatisli~ally
significant (p - O.5R)_
comnar~'
e,'en!, and complicatiom
In
the
U
ruh!\> 7: A cm"parism, "f low risk
diffl',-"nl glucme categoric'S
L
L",,· ~i~k
, J";GT
I
rH'n(
C<>mpiiealiom
Prediabetes
._---
I 34 (5()'% )
19 C 7.<fO(;,j
15
(2~,,)'_!-")
'3
(44.~%)
! Viab....tes
!
20
(27'!-a)
35 (47.3%)
1
23
Fi~ur{'
A rompal'is"" of 10'" .-is\.. "o,.""a,.y e'cnls and
4.
differ{'n{ :::Incosf
e()rnf'lic~lions
III Ihe
ca{p~ories
00%
;0)%
-10%
g
,,'.Il!
.. Low mk
.'"
.. c, ","""'"''''''''
w
n
'~ -'Q"I.
To
211""
ap
e
10%
0"1.
of
C
NGT
gltlu",~
,In
(~l dis~haj'ge
(){iTT
U
ni
ve
dCknnined w,th
",a, llcrcrmin.-:d ill paliel\t< ",hose
rs
i
A ral\d"",
ty
3.4. Ralldom glllcos(' nil admissioll
11,1 mmol . . l. diagnostil ofdiahete;,
alrc-lriy known with
d;ahet~,
/\ nmdom glucose level ::.
diabcl~s (59.6%,)
random
and
j()
~
a",1 :l
W'~
glyc~<ll11lc'
proJilc ,
w~rc
known «I'
or known hislOry of diabete,). Ilw ",,,,lia,,
]ouud inn patiClllS of which 16 ra1ie!1ls
T'~ti~'1HS
wcn.; laicr dj,lgnosed w,th
di~bet~s
w~r~
by OGTT.
(a ra!1(k,,,, cuI-of] vallLc for dysglycaelni,'1 W<lS found ill 5
rmiellt, w ith lle\vly diagnosed diabcks (47.6%), The ",,,,Iiall
gh",,,,~ m pali~n(s
with a low )i,k core'!U")' event
Ihose wllh a high risk c:Dron<lry
~\'~Ill (5.~
w,,,, signilicilltly lower lhJll
mmol ..'I am17.1 ",mol..'1 I\;SPCClivdy. p
<.
0.011
24
C,llnilmly, the lllooian ntJl(]Olll
gluGo,~
k"el,n paliellls who de\d0p"d
~Ompll~"liollS w:~,
slglllflcanlly h ighcr th:m those who did nOI (7, 65 mmol/1 vs 5, ~ mmol/, r <
I), I)] j,
J.S.llbIAc
An Hb I Ac was pert;mned 011 179 of lhe 194
delernllDed. A
~Olle(;lioll
or labmltlory
pall~nl'
~n-or ",~ts
whose
g-ly~"emi~
profile
wer~
",sponsib1e l')f misslllg- dala III :5
palicnts, The mcdian Ilb1Ac wa" k;;s in those with -"Gf than in the prcdiabetic. (I' <
to diabetics (p < 0_01)_ The median HbA 1" was
n
~ompared
w
0.(1) as well as ill prediabetics
To
also "ig-mlicmllly highelln kno"n diabct,cs lhan in new diabetics (p < 0.1)1). Tllerc
cvcnts and ill tbose who dc\'d0p"d
~ompllcalioll'
C
table~,
alld lhose "ho ,lid 110l (p-O_5'f and
U
ni
ve
r
si
ty
of
r 0,05 l'Csj>cdi,cly) , See
C"l"lIl:II')'
ap
e
no diffet'GncG in the median j-]bAlc between patients with low "nct high risk
\V~5
25
'r" hl~ 8; As'oci"tioll het" C,'" 'nedi,," H hA 1c a lid glyl,wlllic
pmlil~,
"lIrllllar." c, ('Ills
alld c"'nplicalill'"
\ledianllbAIC %,
Ran~e
,v(jf'
5,2
4.4 - oJ)
f',edi"hctics
5,4
4.5" 6.9
Diaberic,<
1i.1i
4.6 - 12.5
Old
7, I
4.9 - 12.)
Nlw
~, <)
4.6 - 9.9
w
n
-
(;Iy~a~mk I'rllftl~
~.)
l1igh risk
~,5
44
12.)
5.4
4.4 - 12.5
NSTE\1J
5,6
4.7 - 12.0
5,)
4 ,5-~,~
C
ECG ChaIll'l"
of
STI"I,11
si
ty
Clllllplical i"n.
y~-,
5,6
4.4-125
SA
4.4 - 12,)
U
ni
ve
r
.\-'()
--
4.) - 12.5
ap
e
L"w risk
To
Cllmnar," c"CIII
"'\ glyc<wmic tartd of Ilbl AC
w~,
7
f01l!ld in
W~rl' mol'~
4~%
alld
rn()j'~
statistical
,ugg~'ted
(\fpatienls known In have,
ilkdy to have a low n,1..
cl~\ -clop Ulmpli~~tiom
HblAC
7 (a,
by
th~
diahl·l~s.
/ULkTicJIl Diabetes i\,.';c>eiali"nl
Known rli<lbdlcS ",ith a Ilhl AC "
~nr",wry ~VL'fl1
(10. 41.7%)
~nd
kS8 likdy to
(R, :;3.3%) m comparison (0 their diabct'c u)Unte'l,mts wllh a
7. who "we Ie" likel:' to have a low risk coronary
l,v~n(
(6, 13.1%, p=O.lo)
likdy to dndop complication, (14, 5-'.9%_ 1'-0,14) bllt this did not meet
Slgmlicanc~, S~l' figur~
5.
26
I'iglll'~
5; . \,~odation bcn"rrn IlbA I C, low ri,].; ror'onary rwntl and rOlllplicalions
oO"!.
,
~
• L<I,," I;,k ~wnt
'j; In%.
L11:1 Con",lic.tio",
To
w
n
"
••
ap
e
lU%
of
C
IlbAlC<7
rs
ity
3.6. Anthropollletry
and
had an
hody m""
index (8\11)
"s a BM! :> 25). wilh a similar plnalGnc~ in th~ l1omwglyeaCtl1ic (47., 62.7%)
dy'glyca~mic (S'i,
73.3%) gWlIp' (1' - 0.13) . There wa , 110 relationship to ;;ex, "ith
(ddincd as a Dt>IJ :': 30) (p < 0.(1). See figure u.
ulxle)l11mal
dr~Ul11rcrelKe
')s.(,% (In)
()I'pali~nls
11l>nnog l ycaemi~
JCmotes
iocr~a;;ed
U
ni
t(kfin~'"(1
67 . 2'~--')
ve
Two [hLH/:; e)f the ,objcd, (135,
(~4,
c:
('~ntral
gg em in females and ::: 102
hUI rlwrc COmllLOn in
th~
oh-;,sity
~m
(des~l;hoo
in males) was
as all
p.-cs~nl
in
dysglycaemic (gO. 65.6%llh,,11 inlhe
group 1-'2, 47 I";{" P - i).OJ) and llwre eommlm ly
7Q.3%J tho" mules (39, 37 5%, p ' 0.1)1).
sc~
a;;s()cia[~d
wilh
iig.ure 7.
27
. ,.
741°,(.
...,
.~
500",•
• r~ , ......
~I! %
l.
•• )00,.
To
w
n
"'.k
~D~.
•••
R~11
of
C
t
ap
e
10":-,
ity
of 1 111\11 and ce ll lui o ...."'i~, hy ~CDlI"r
ve
rs
I'rf",.~n~,·
U
ni
l'ij:urf 7;
""
!
50%
t
~Q%
•
~O%
...
II:1M I
3.7. Lipid prolile
The most common lipid abn0l1naiity seen in patients with ACS was thm or a low IlDL-L
'('he I",,,-a lellce of di lien;llt lipid aiJnnnna Iil ies is detai Icd ill lable Q. The prevalence of a
Inw HDL-C was less
~OmJllO[]
mlhose with a nOntlal
gl lJ(; os~ lolerdjl;;~ compm-~d
lo
th~
predwbelles as well as diahl.-'ties, A similm lrend was seen wilh increased lriglycerides,
and the combinatioll or low lIDL-C and high triglycerides (the so-ca lle d ill5ulin re5istant
-c,
~nmm(lll
however. \Va.,
in all .l glucose
~a1~gnri~s,
S""
10 and ligure g.
There was no
,ignifi~anl dift"renc~
groups or between
rre,'"I~n~c
and
rcm~les
profil~,
I.h~ din~rem ~Ihni~
of
within the same ethllic grou ps, See tab le 1 1,
uf diff<Tenl lipid "bnurm"lities
C
Table <J,
m~lcs
1:.:;lw""n the hpid
ap
e
labl~
To
w
n
dyslipidaemia). A hi gh Llli
Prevalence
of
Lipid Ahn"rm"lit,"
rs
ity
--------1 HOI.
InO
~2,9
127
6~.3
70
36,3
tin
34,2
ve
r 1./)/
U
ni
r TG
lHm&r TG
Table I U:
Pre\--alenc~
otlipid
ahnormaliti~s
in
,h~ diff~"cnl
glucmc catcguric,
(aucos~ ('lIt~g"'~'
I
NCiT
i
i
0;',
"
p
-
lJiaheles
I',."diahere,'
44
(~(,.3%)
01
(91.0'%)
0.02
:, 1 n.
"
C,4"/)
' . " ,0
>R
(2R.l%)
1~
(.15.3%)
l2
(47.8%)
ll.()6
I j IlJn & r 1(.
15
(23A%)
17
(33,3%)
J2
(47,8%)
lI, III
45
(72.6%)
34
(68,(1';;')
4U
(63.5'~"')
lI.50
1 HJ)L
~_[J)L
T ~ble 11, Prenllellee 01' dill"erenl I i"id
I
, HJ
Fellmlr,
While
i
r {O{
(75.0"{')
1),67
8
(26,7%)
21)
(34.5%)
1).4(,
(3S"~~";')
0,35
,
(26,7%)
1'1
(32,8%)
0,18
(75,4%)
0.71
(7 1.4%)
3!
(56.4"..,,)
I 0,59
25
(41A'~")
115 (41.7%)
2J
4'
-
. -
3O
-
-
-
0.11
To
''-"
._-
p
44
16 (44,4 %)
---
j
I
(90,0%)
0.14
27 (75J)%)
i
While
27
(R-'.I%)
1 1lDL
1&r TG
CoIOIlf<'d
p
49
(Rii.I%)
-'I
~nd ethnicit~·
w
n
i
gender
l\1ule,
! C"lolired I
. HDf
~bn"rrn al itie, b~'
in the di lTerent glucose categories
e
~bll"rrn ~l itk,
C
ap
Hg;u rr 8; p'"r\'ulenl"e of Iipid
of
too'Yo, -
rs
i
ty
90'1.
70%
•
"~
60% -
0
:!
« \HDL
U
<
ni
ve
!lO"/o
. jTG
SO%
.,HDL
&
,TG
o lLDl
40%
30% 20%
10%
0%
'<GT
I'rediaoctt"s
Ili~beles
30
':\.H. Metabolic Syndrome
rwo thirds of patients
.'ldnlltt~d
wilh ACS (124, 63.6%) fullil l",1 Ifk diagno,;l.l, ,nteri<l
tor Ill<el"boilc syndrome as ,;tipulill.en by the AT!' 111 30 The mediiln age oi"palients "lIh
w", 60,5 jTM' (mnge 34"'J7),
and 66 yeal'S respcctively. p
<
0.01). The
.\1,,1¢, w<ere felung<er than felllak~ (52
h ' gh~sl prevalen<:~
rcpr~,entali\'c.
88.9'/,) hUI 11m sample sue was IlK' small to be
COIOUTCd patient> (45. 70,3"<.) met the /\TP jJj criteria for
coloured kmaks
wa< Illore
e
whil~
kmalcs (43,
more at risk of developi ng
I'r~v~lcIl<x
95~--(,
C1 0.81 - 5.2<)).
oj" thL'
dm,t~ring
rs
i
ddl'erencc in the
metabolic syndwmc. as did
~ommon
I~ble
U
ni
ve
eTh nic ,aTegone,; as outlined In
In
i"emul~s
p < 0.01, and appeared to be nlore common in
(n-26. R6.7°/,) than
cOllnlcl'p""S (risk raTio 2.1,
palients (g,
\lore than two thirds of
70.5~--;,).
ap
i"~lllales
5m--ol,
11lelaholi~ syn drom~
C
colour~'d
than males (4S,
syndrom~
of
7ti.S~--;.,)
ty
(76,
th~
lh~ blu~k
To
5S,7% (71) of\,·hites (p = 0.12). Th e metaholic
Wll.' in
w
n
mddboli~ ,ynJrolll~
12 .
5e~
jiglL'" 9, Th=
p~O.09,
than
pnlling
lh~ ir
white
sc~med
to be no
Ih~
differ<ent
of mctnbolic [isk f<letor, in
Figllre 9: A"oriatioll het" een mr(:l bolk synrl rome, gentJer and ethnieil)
lOU";..
9U";'.
HII%
~
•,,>.
700;.
60 %
,
0
~
11! Male
~
.::,
.."
Female
~O%
To
E
w
n
SU";..
0
JO·/~
~
ap
e
211 ·/~
C
100;.
Uo;.
of
Coloun.,tJ
ty
'Vhile
rs
i
Tahle 12: Pre\alenre of the rlustrring of mrtal.H>lic risk factnrs ill 111<'
ni
ve
ratcgorifs
..
U
1\0 risk factm,
1--- 0
_-
m~in
-
e1fmk
1
Elhnjdl)
Whites
Colourrrl
0
(OJ)
,,
(2.3)
c'
( 12.) J
22
( 17. j )
,C
J
(2 6(1)
J4
(2(,.4)
,,
25
(34.31
3:1
(25.('1
4
11
(15.!)
2J
(17 .8)
5
9
(IV)
14
(10.9)
32
CHAPTER 4
DISCUSSION
Chesl
p~ln
due lo ACS was a common
pr~sel1tatjon
to the LV, with a simliar
pr~vaknc~
in thc' CniOllrL'tl (11,60".) U11d \Vhite (14,q.o/,,) populations. However, despite 1he I"rge
proportion ofhlock p"tie nls asse,,,,d in the ED (623), ACS still '''ems to be lincommon
in thi s pOP111mion (L4'!"o), It is commonly accepted Ihal /\CS afiCet;; male's mOre than
(1',3'~--a
vs
~,I%).
This may indicate thm
Iher~ w~s
no bias in the study
To
similar extent
w
n
fem"les: however, in our study population hO lh males "'k' females were affected to a
or [I may bc an indicalor thai CAD has Jimlly caught up in Ii:'rllales,
ap
rcm~lcs),
e
sckclion (\vhich commonly occur, duc, to thc alypical prcsc'T1lmion of chest pam m
lmp(lrtan~e
of ioc'11li fyinl( not only people with asymplornatic diabcks but abo those
of
The
C
4.1. Dysgl)'cacmia
diseas~
IS a major ea llsc of deoth ill "II catego li es of g lucose
ni
ve
llMI macl'Ovascular
rs
i
ty
with Ire; and I(iT (prediC1l:.etes) can not be emphasized enough. as it is well documcnled
ablk'mnalitics, incllKl ing those hdow diabdic lcvd;; , t<ot only do patients willi
incre~sed
U
c'slablished diabe,ks llavc' all
mn\"lS~d ris~
fPG ,HId 2 Ill' blood glucose
lor cardiovasC1llur disease. but also those witll
th~se
Me
~ J s o i n dep~ndent
risk
f"cl'~-,; fc~'
nil·
c~use and cardiovasc lliar mOlbidlly and mortality" , Incrc~ sj ng evidenc~ sllggests Ihat. for
diagnnSlS, the
lIS~
01 lasling pl"smCl gl uco;;c' lcvds alone will miss pati,'nls "';lh
~
higll
risk or diabcles relatcd morbidity and mOI1ality, " Furthemll~'e, the prevalcn£~ of
undiagIJ{ls~d
dwbdCS and IGT will be, lImkr eslimalcd 10 a largc' exknt.
espcci~lly
III
lemale and elderly populutions, if li.o.'li ng l(hK:ose alon..:' IS usc,.],' Also, lasting glucose
33
l1l~aSUr~l1lellts
alnne do
t"~
"Ienti Cy 1mli "idual,
~T
i ncre~'ed risl< of deJth J'soci med with
hype'! glycaemia.'
C~n'cntlytbel"<:
i, nl'
~niqw biologi~Jl
mJl'ker tbat ,an clistingui,h
p":(~)k
o r di alxtc;; from peop le with normJI glu\CO;;c metnbol i"n. thu;; th e ofJI
with IrG_ IUT
gl~~o,,'
tokran-.;"
k';! j, ]\yommerxkd JS tb~ gold standard in ide'1lti lymg tbe di lJC]'e'nt categorie, 01' gllLcose
aLltlonnaliti~s_
imp~ired gl~co;;e
with
tolerance. who ba\ie tbe greate;;t
~nables
deledi"n of"
Jttrib~mbk
risk of
n
indi\iid~al,
It also provl(l"s additional prognoslic mlillmation ami
To
w
d~alh'
Sil fa"_ maS;; ,creening for asymptommic diab.:te;; Jnd IGT has not b.:en recommended in
poplliation; howe'n".-. targeting of groups at high risk of diabetes
e
g~'n"ral
cn~ld
be
ap
th"
C
t>"ndici~1 as thes~ pali~nt;; collid bendit Ii-o", early int"rv~mi()n_)" Pati"nts wlth C\D by
of
ddinition Can be considered m high [i,1;: and ,hould tbll' he included in the subgroup of
llndiagno;;~cl
with
undia;:nos~>J diabet~s
(as up
lO
sm';, or
patienls with
ii' thq remain ""'tnptl1lnntic for many yeJr,) "" well "",
ni
ve
diabcte's are
pati~nts
rs
i
identilying tho;;e
ty
poplLlation m whilm glycaemic tc,ting mlL>! be pe'rJiml1ed, [3mdits i\f ;;cre,'ning inclu,k
th{lS~
>i! risk Ii" Jiabelcs (IfG and IGT). Early ide,ntiticiiticm of the IJtter group Ie",,, TO early
U
inte'!venTion -rrategic' TO f<'(luce or nelJY jll'()gr"" to di"beles·" as "ell as an lT1.;,;r~a",,1
s~rvei ll~txe
~nd
Jysl!picla,mi~,
TreJl l1l¢nt
for
olh~r
obesITy JJ1d smoking
ass<'ciakd nsk
facl""
like, hypnle-Ilsion.
Screening 111 CAD improw",,; pos>lhilllie" I'm
l'r¢ventwn ,,1- ~,u,lj Ov,~,C~ 1"" compl ication'L
We iilUnd ii high pre'valence of dy,glyc~emia
(6~'!'Q)
in pm;"n!;; admitlffi with an
cnronmy ,yndrom,' tID.l it Can he a,sumcd Ihat Thi, condition is Jlso
h(qllials ;;erving the swne pilpulmii)]l grolLpS,
Thes~ re,~l!s
are in
rrev~lent
~gj'eement
a~lLt~
al "ther
with ;;everal
34
recml repli..t~·0 .42.43
or Ihe
12(, palients diagnos"d WI th dy,gly~aemia. 74 (5R. 7';'0) wcre
ncwl y diagnosed wilh a gl ucose "b'lOmwlil y and 52
(41.3'~';'J
werC prcviol1s1 y dl agno>cd
wnh di .. heles. IT 'H.IY well bc Ihm Ihc tJue prevalence of dysglyc:'~lnia is higher in our
P(}PUliltion he,mllg 111 nlll1d that all O(j'l I could not he pcrlimlled in a small suhset of
palielllS due to serious
canli(}Vils~ular
relatcd complic,lIions {eg de,lIh Of" refelTaI
j(}
leniary ho'pi lals Ii)r reva", uiari/.:tti()nl.
the prcvalcoce of dysglycaemia whcn adding
md b()th,
IS.2'~,;,
palients hy
1 hr post-I(>ild gluC(}se valuc. By
~ither ~nl"rion alon~
lir their combinalion.
e
diilhdi~
th~
C
of
ai, >IlC or their
~ombinatil'n.
30. S% (n- I Ii) met hoth. 25%
tolcran~e
(n~ 13)
by
met Ih e
ty
~riteri()n
(n"'9)
(n-4) met the lasting criteria alone al)(140.<;';'(, (n=9) mellhe 1 hr P(»t
load criteri(>Il alone, SImilarly, r"cruiting patients willi imp,urnl glucose
eitll"r
40.1~,'"
ap
rccmiting
To
w
n
In palicnts IlOt pre"io'.lsly diagnosed with diahetes. the prc\'aicllCe (}f gluC(}se
rs
i
fasting crilel;a (}nly and 44.2% (n-23) met th" 2 hr p"st-Imwl crilerion alone. Thcse
h~en
llllSS",1 il a I-')'(i al()ne wa, lISed as thc sok
U
woul d have
ni
ve
lindi ngs 'UggL'ht that a sigmfkant prop0l1ion of pallcnts wilh prediabetC8 or diahetes
lI"ng the sugi!L'hkd 10" cr
~,,\-ojT "ahl~
s~rcemng
pro",;dur,' (cven
01 5.6 rmm}I./1 li.>r diagnosis of Il-'G and 7 mmol"'-I
for jhe diagno,is of dia bel,--s). Thcse findings also agree with previOll' findings lhal
allhollgh a FPG and 2 hr PG k"c1 sometimes identify thc same llldividuals,
lin~n
lh"y
may not ~oioci(k."' Tlli, ha, impod anl implications for llsual mediCal pnlctice. An 00'1'1
sh(}tlld
he~om~
Paticms with
a mor" wIdely
dysglyca~mia
t,,~d
lo"lm 'YCrccning high-risk poPlllations.
"ere (,Ider (mcdi,m
ag~
li5
y~ilrs)
lhan tho,,, with a nlinnal
gluco,e lOlcraoce (median agc 56 years) in (}\Jr st 'Kly coh(}!t. This IS ll(l l slll}1rising '" Ihe
~ge:
'I'ccitlc
I'r~vak'IKe
o('l'alie:ms ",ilh d",l:>eles and Impaired gIUt:o.,., I()l erallec IIInease.'
llllearly with agc ui' to HI<: sev~nth to cigln d0lO00CS in both me:n and worn~n," A iligk'
prcv~lGncc Clf dysglyc"e:m',a
;)1 kmaics th.m male:s was sugg~sled.4< h"wewr. "e foul1d
dy>glye""m", to I:>e "" wmlllon ill males (hY,";,) ,e, I';;male s (67%) ill our study grollP,
High diabetes rate., havc preYEolisly bcenl\;porkd in Colourcds
comp~red
to Whites .md
!3lxks:14 Then: was a trend 10 all inneased rreyaleoc~ oj'd:>'sglyeaemia m C()loureds
(72,3~,'(.)
n
mmparcd to Willtes (5S.S%). I:>ut litis did not n:.lCh ,tmistic,,1 ,ignitleal1ce
st~tllS. ~lu~h
e
'11\; lInawarc ot th"'r high 11,k
and those at hEgh risk of
be~n
allel1tion ha.'
ap
diabel~s
To
di"l:>el~s
TYP ically. pcrsons with rUT .md asymplOI11alic
devel()ping
w
(p=(L(l7).
slll:>s~'quellt
C
dircckxi "t delc:cting undiagnosed diabetes as its ",creased risk for
of
~omphcations ~nd nWJ1ality i, well acknowledged". Only r""eml:>'. alt~ntion Iws tumcd
new
(habeti~s
those: with type 2 diab"'~s. We l(lUnd
rs
i
fadon;~,
in our study I'Cll'ul"tiol1 "irc:aQy
ni
ve
risk
ty
to those ",ilh IeS.,er degree., oj' gluLOmelab"hc abnormalitics. who tend to sharl: the same:
One would hke t() pre sullIe that tim, was "
at
hl~l
U
pali~ms
risk I(\r dcvd oping
lhal46~,';,
e:xpe[l~n~ed
v~ lu"bk
c~rdiova.,.,ular
ofpredi"bctic, .lIld
a previous
5\1'~,',
i.,~hocmi~
of
cvcnt.
()ppoitlll1ily mis",d lo idemilY
disease and ils
~()TlIplicaliom"
Earlicr
ddeelioll of lm p"ircd gluco&.' toicrance and ,e,:>'mplomallc d,abelcs cou ld Ll(l to
mili alion of secondary pr\;ycl1live me"-surc:' al an earher .'lag~.
1l has been
report~d
that p'llicnts with
imp~irl"d
of inerc:ased cardIOvascular modlidity .lIld
norIllal
~llIcose toler~l1~e;
lhis
~x~ess
gluco.,e loienmee run an
""~1"lity
addition~1
risk
nlll1jlared with palienls wilh a
eardi()vascular nsk is prGscnt evcl1 '11 lower bl(l(,d
glucosc concentr~tion-s th~11 those Ihal cau"e: ll1ienlvasc,,]ar cOlllplications.";'In our study_
36
dysglycacmi~
p"t'GnlS "·'tb
,,"crG mor" likely ;0 pl'csGnt with a high risk
(7 3%,'1 and more likdy 10 (kveiop cal'diov<J>clJar
~omplica!ioI1S
!hen-wunkrparts ". ilh a nonn"l gluc()se (27'};, and
25'}'~
coron~['y
"VCllt
(75%) in comparison to
],CS1X-'(;ti,'dy),
4.2. HhAlc
fily~akd
hac-'lll()gIOOiTl (HbAlc) has ne,'"r occn
],Gcommcnd~d
as a
diahel~s
kst fo],
ha., b""n
n
dmocks, altho"gh its usefulllt'Ss in the screening and diagrK"'s ())'
di~gnos1ic
To
w
w](I~I\' ddmtcd.-" It is msensitiv~ in the low mnge, thus a normal HbAIe can not excl\lde
the pre",,,,,e () I" diab,,!es or KiT-",' ATl()lhcr dmHl !all is Ihat j I dlX'S not reveal lllfonn~tioJl
ap
e
about p(\st-prandial glucose levels: Ihis ini')I1natiol1 i, tLsel"u1 in order!() f1I'"dlct incrcas crl
~Jl(1
impaired
glu~os e
tokraoce_
C
cardinva'ndar ri,k in paticnts with both normal
of
A lllwllgh there \Va, a statistically significant differen.;e in Ih~ llltdJim HilA Ie m O\lf Sllldy
thos~
b~
imerpret<xl '" wilhin nOfl11allimils. Th" suggests that
OIl II, OWn is insCTlSitivc to
di"gl1o,,,d
diahel~s
I\'oold still
dy ,g1y~ueI111~.
I\'a" a., cX!"-'(;tcd,
per~eived
dGtermin~
those subset of palienl, ",ilh ntlWly
ThG mcdian HbAlc in patients wi1h prevjou,ly diugn,,,ed
U
HbAI~
e~ch val~~
ni
ve
r
dinoctcs,
wnh IGT and those with Tlewjy diagnos(.'(l
si
ty
group hetween tho,e with \lfi'!',
,ignijjc~ntlv high~r
'mlnnal' hmit. In viGI\' 01" this, we
than all
wo~ld
oth~r
groups and above IhG
like to
s~ggesl
Ihal
HbAI~
d"lennination is n()t esscnlial in the ilCutC managel11en1 of ACS in palients TlOl known
wilh
dial"'t~,
HbA I~ i,
tho\~
wid i, thus ol"mmimal
howev~r
a lLset",,1
v~lue
m~a"Ll-~
in the ED_
())' the dlicacy or gi1lcosc jowering trealmen! in
known with diabetes_ as it gives an integrated suulJnary or blood glucose kvds
<il.!ling thG prcrcciitlg
6-8wceks.
There is
~ol1\·indng
eviden~"
Ihm diabetic
:\7
micmangiopal.hy can be
reuuc~ll
hy lighl
glyca~ll1lC ~()JJlnJL
/\
r~~ent
ranUOll1l/l'U
I"" llcrnonmnktl thnt mncrovn"cuiar morbidity mid mOl1nlity in typ;; I
dinhct~s
~tlLlly
enn
al~o
be dfectivdy reduced with light glyc:I~ll1i~ ~onlmL'" Whether lhis can be ~xlrap<llal~d tn
type 2 uiabele,; is yet
to
th~
imponant factor behind
in lIbA Ie
be
det~nllin;.;d,
Thc redllction ofHbAlc was by rar thc most
reduction pf CAD with :1 21 '>'0 reducripn in each 1';'0
ue~rea,e
Similarly. the Hnlled Kingllom Pmsj",clive Diabeles Stully (lfKPDS)
ha~
n
deady ,hown Ihal exh p"rcent dcdme m Hb/\Ic cau8ed a 14':..;, lowcr rate of myoc:lrdi,11
have advocmed
tlhAl~
largels <7%,
I,~%
To
w
miarclion and l"cwer dcaLhs ti'om diabetes PI' any c:lUse,-" V,lr;olLS diabetf!.-' ,lsso~latiOlls
ll,an 5(f";' of known
diabctic~
m our ,tlLdy
high risk group, All.lHlugh
th~re
was a tenocncy ror known diaoctics with a IIbAlc
C
thi~
ap
e
gmlLr rcachcd this proposed glYC:lemic largeL indiC:lling the ,;uhnpllmal management in
~nmplicall()n_
of
7 tn have a low risk coronal}' event :lIld they were less likely lo .revelop
<'
Oil admis~iol1
rs
i
4.3. Random glutusc
ty
thIS dill nOl reach 'latistical >lgmlicance.
as a 'fLith' vital sign on admission or patients with .ACS, Ollainly ,IS :1 ,creening
U
gillcos~
ni
ve
ClInTnt practice in most smaller hospiials in the \Vestem Cape is to deknnine a ranuom
te>.t to LdentilY thosc with dJaoctes, disreg:ll'ding those ,lIhsel
~"l~gory
nfp'llj~nls
or Lmpair;.;ll gillcose loicrance, I\·pt pnly is ,,1\1<10111
ialling mto (he
glll~o,e inS"'1';l(lV~
llia1o'J1(),ing lliabet", and thtls umtlitabic In thi8 high risk pr>pUlmion, but it is
,,,erul in lli:lgnn,tllg
tillse neg:l(i\'e
lhos~
r~Sl.Ilh_
In
eY~n I~S';
wilh predLaoctes, It abo has a high risk of false Ix"ilive anll
11 ha,
rn,~n sllg~cslcd
howevel' to have a significant increasf!(l
sensiti\"ty in diagnpsing diabele, if the ~lLl-n If poin l is marhllly r~dllced to 7.2nllnolil'f.
but this still need 10 be v,ilid:lted_ Hy loweling
(h~
cllt-ol1' point or randpm glucose to
~mm(\L,'1
in ('11 r stndy. wc idcntifkd only 4 1
patl~nts (~9.
1%) of p" ticllts latcr
di~gn(\s~d
with di"hele., onll 12 palienls (2.'.5%) wilh ](iT
gllLLOS~
Alth"ugh delemnnmg random
abll(mmllilie< is
!Wl
nsduL lhere "strung.
th~
indqX'ndclll c)n
on admis.,i(lIl lO diagn"se lhos<' wilh gluc"se
subs~quenlmorbidity
state of
evid~nce
pr~morbid
glueos~
and m(,rlality "fter an acute
gln~c).'~ at
that high hloo..i
pr~dieh
wkranec.
admission,
in-hospital arK!
myo~anliall!llurdionl!l
bOlh
diaheli~.,
be
~xtrapc)lated
to the whole sp'-'eulI m c)1 ACS is unsurc. It was clcar from (,ur
w
~an
pali~nls pr~senling
findings though lhal lho.,e
To
llllS
n
and non-diabelic~, th~ mechanism or whid, "Il<.'l fulh' underst,,,xl a., yd,H." Whelher
with a high risk
~vent
had a
~ignili~alllh'
high~L'
odtnissic)n
p"ti~IllS
that dcvdc')Jcd in-hospItal
gl ucos~
k\ds
(7.7mmol/l)
ty
~igllLficantly
thosc
of
Simil~rly,
lhe twc) groups ,
,,1' similar prn lOuS gluwmctabolic SWtus in
C
i!l(li~alive
desp Ile a .,i11111 ar HbA k (5.5 % J,
ap
e
highcr admissic)n gluCl'se (7,lmmol./l) than tho.'e with a low risk evenl (5.8 mnll'I./I),
dit1;;'rene~
two groups . Recenl
sllLdl~s
"I", suggest thal rner.,al
ni
ve
thes~
rs
i
"c1mplicalions (5.Snm.ol/l), but again lhere "as link
in
or~tres~
compli~Ulion~
had
than
l!,,,.,e
"" thc)ul
th~
IlllA Ie
hctwc~n
hVp'-'rg.lycaemia at the
that thc
us~
U
timl' oj' lJ.yocardi~1 infareti,)n ~an imp.\)v~ thc clini~al oUlcome in th~se pat,ent.'~' and
of a glucose. msulin amI pota.'Slum
l!lrU~HJn I1W,'
reduce sholt an d long
t~l'1n
cardiovascular morbidily and monality in both diahetic and non-diabetic pmients with
acute myocardial
in(~rcti(,ns
olll1l'ugh
de~nll;ve
proor ,,(' the latter i., lac king and the
practice hils not g"imxi univcrsol npprovol."'-" Agai n, we do not knuw ,('llns data
extrupolatN to all categorks c)l ACS, Jr S c), eli nici"n.,
these
patienl~
r~.'pon si ble
Clin
b~
h'r lhe n"\Ila!lL>JHenl () ('
may nut c)nly have a res]X,nsihiEty to perfonn an OUI'!' (In patienls with
ACS lX'n,re <lisdmrge, but al", need
to d(;t~nnill~
the
admis~ion gluCl's~
and managc it
39
"Pllrl'l"i"ldy '" thi, will
hav~
dCJr bend,t, in dL,:rea,ing morbidity aJl(1 m",1ality_ lL i,
imlxmanlto 'lre", that a 'ingle glu..-l"C mca,urcmCllt OJ] "drllission Jilme
'"
~,cn lh",~ p,-~)pk
do~,
not
s"ffk~
wilh()Ul diahde, mighl rn.nefit I'rom light glocow COlltrl' ] ,mel ')ll'uld
lil"", be prcfo1111Lxl routinely thn ,ughoul their iK"pital ,lay_
lL !-la, n".,n ,ugge,led lhal palienl, wh() deve k,p sIre" hypcrglycaemi" arc likdv 10 be
dysgIYl'aemi~ when not str~%ed.'" OlLr I'mdmg s slLggat a similw- j'~sult a, 53 oj' the 5S
di,~harge,
and 22 diagno,ed with
(lj' which 3 I palienl, wer" pr"vi()u, 10' d iagW',ed wilh di abetes
dy,gly~acmia
To
dy,gIYC-:'emia on
w
n
p"ticnts (91.4%) with" randl'l1l gluco'c of8 e,r morc werc ,ubscqocnt ly diagnoscd ,,·ith
on the OGTT.
~llJSlered
wHh mher c(lmp()n"nls
syndromc (incilKling visccl,,1 obe'ity.
hypcrtrigly~cridemia.
()j'
lh" mctahl,lic
low HDL hypcrin,ulincmia
C
ap
e
AI1(l()nmLI gluco,,, 1()lenLJK'e i, onen
Farly
in
idenliti~mi('n
rs
i
nOf1ll('glyca"mic' palienl"
~mllmon
ty
foct(lrs th"t tend tp Ix' higher OJ' Illore'
of
and hyp"rlen,ion), each (,I- ",hK'h mdeT",ndelllly promOle mheJl)lhmmllo."i, /\11 arc
ni
ve
cnab lc initiaTion 01' potenti"lly bCJldki,,1
hypcrgly~a~mic
oj'
lh~,e
tr~atmcnt
pmicnts compared wllh
l1lelar.,lLc' allll()mlaliti", w()lLld
contribut in g to an impro\'cd
U
I'rogno,is_" We can tIlU' J%UmC th.11 intc"..-cntion, lh,1\ 1'C{luce the r;,k ofprogrc»ion 10
dial>eks arc abo
p01cmi,,1
li~e ly
t() r",luce CIlI) mOltalily in thi, group 'll1d
~otlld
he 01'
)ir~at
~ncf,l..<r,
4.4. Anthnlpumetry
It i, gcnerally "cceptC'd that obc,il}" whelhcr it b mC"'UI'cd '"
CCll1rrn obesity.
~aJTks
an incr"a,C{l
f-l~'11
or
a health ri,k lx.---cause of it, a,'>OCimion Wilh numcrou' mctalx,lic
~omplication, ,ud as ~ardi()vasl'l,lar cli,ease. lyp~ 2 diabetes and dy,lipidacmia," Bcing
(w"rv-;"iglll and
(,rn.,~
i, a""clated ,vilh insulin
re,i'lafl(;~
and the
'yJl(lrol11~'s
duster ()f
40
metabolic
di,ord~rs
compon~nts
"nei sub,cqllCntly all
th~ melaholi~
oj'
syndromc
ar~
positively ancct~d by ,,,eight loss." In,ulin rcsistance is consiJcr~d to rn, the link
prcsGn~c
between obeSlty "ml dysglycilcmia. It is paJ1icuiarly the
,,"hi~h
orn,sity
th~
is one oj'
hallmarks of the
disca,~.
oj"
vlSc~ral
or
It has long ocen noted that
,,"hcr~ th~
complications commonly IOllnJ in oocse palients are more dosely relatcd to
~xccss fal is ralh~rthan to cxc~ss fat pel
pr~v"l~nce
measured as all increascd
higher
t~mkncy
OJ"0\'C1Vicight and obe,ity in our study population. whcthcr
BMI167~";'J
w
n
I"und a high
'c.'"
or cenlral obesily (59"'-0). Females had a significant
obcs~.
than llde, to be
To
w~
~entral
regardless of whether incrcased B\H Or
ap
e
abdominal circumferencc \vas dctermiIled .. Our slud" agrces with the lindings or lhe
C
lnlerhean -\Iil~a ,wdy'" that ov~"'v~ight and ob~sity ar~ ,I, common in ColoulX'd, ,I, in
rrcvaknc~
of abdomin,11 oiX'sity has
b~~n
showll to be morc highly cOlTdatcd with
ty
I'hc
of
Whites.
Slgl1iti~anl
~ould
hie demonslraled ill
tlOrtl1oglycacmi ~
ill the prevakncc of ccntrill obesity
(47%) und dy'gIYC<lemic (61\%) gI'OUP, (p-().()I), but no
U
l1()rtl1oglyca~mic
diff~r~ncc
ni
ve
]'IIl<liIlgS 01' ,I
rs
i
metaboilc ri,k factors than is an elevaled B'vIL<'l Thes~ data ~aIl rn, extrapolaled 10 our
(('~'/,)
and
lhe
prevalenc~
dysgly~acmic
of an
i73'h,)
inaeased "Hr.,11
~'fOlLpS
difTcrcn~e
I.,.,tw~~n
(p=(), I 3). Further.
oocsity was as,<xiatoo with more metabolic ri,k f;'lCtor, than an
incr~a,~d
b~tween
lhe
c~ntral
13.\11 (3 and 2
ri,k 1;1ctor, re'pectivdy).
4.5. I>plipidat'lllia
DysiLp](iaemia is a maioT risk faclor I,)r
diabct~s
and
melaboli~
~ardiova.'~lLlar diseas~,
syndrome typic,llly dcmolls1r,lle a
'vIany patients wuh Iyp~
characlcrisli~
~
dyslipidacmia
41
(als{\ kll""" as dd,dic dyshpida"mia or mherogcnic d J sllpidacmiaL which consists of
jfl(xlcrale
c1evalH~]
~ hol ~,krol
in l11 ,:lycende kvch, 1m,· HDL
LDL panicll". Thi.' lipoprolein paUL""
1.,
v"luc>. and "nail
d~nse
a"ociall'<] wilh inollim re,islmlec' and.
IInponantl y, i.s pr~.sCllt long bL'lore 1hc nnsl1 "fdiahetes. ,.1
l! was predicl"d tong: '!gO lh"l 11", hp]d ahnorma[itlC' of trw insulin rc, i,tnrx:" .<yndl'Omc
arc lil.d}, 10 be the COmm01]e,li'onH of dy.,hl'idocmia ,eenlll Soulh A[iiea., Il! i, lhus n0l
i n~reas",1
LDL (()S%,J. Dc'pile the
pr",!i~led
hlgh
w
", llum an
pre\'a[en~e
01'
To
(,~3'y,), mor~
n
,"rpri.sing th<lt we f"und thm " [ow I [Dt ·C was thc most common lipid ahnmlll J [ity
in,ullll reSlsla"t tly.,lipidaemia (I"" HDL -C and/ or elevalcd higlyccritle,) in prcdiabdics
\w
al,{\ found a hl g:h pr~""l enee ,'f lh], l"nn pI' dJ sli pidaemla
e
and d ",h<.:li~s ('-J I ~.,(,)
th~
insulm
v.'"
arc templed to assume that th".se
r~SlSlaocc
palh and lhal many
m{\r~ p"li~m,
are
of
pmicnts are alrc,.-jy on
(7W~'-i,),
C
in patiC1l1S wilh a nNmol gjuco.<c t.,icrance
ap
(~~%,)
~Olllrasl
I.,
lh ~ lIln~a'lIlg pre\'alenc~
rs
i
In
ty
destincd to dcvelop dy,gl ycacmia in thc ncar fum rc.
or lilL' in,"lm rc,islant dyslipi dacmia in the
j,
in agr~~m~nt wilh pr<;ViOllS r~ports.03 Ho'Wcvcr. in lhc UKPD study.
U
cakgoric.S, Thi,
ni
ve
di fidCll! gluco.sc catcgorics, thc prcvalencc of a low I .1 )1 , r"mainoo .I imi la, in "I I g 1lJ(;{\se
LDL "la' thc 'trongcst inocpcndent predicl{\[' pI' CA l)
loll"w~d
by HDI. dwl eslemL
suppolting current guiddi]ws in which 1.-1)1 , lowe]ing remain, lh~ p,-im af)-' ilpid largd ."
Thc C"louroo population ofthc Vic,tcm Cape has hcen sh '."'"lo have a high
p r~""l"nc~
or card,o,a>Clllar lisk factors. particularly dy,l lpidacm ia,"'" Our smdy contlrmed lhis
lindin g and also IH"",llhal dy'llpidacmia di,rcgartl, oolh gClldcl' and racc with similar
high
pI~val~oces
in ",-hiles and C.,loured., a, wdl a, lm,k, and J'cmaic,.
42
4.6. Metabolic syndrome
The dinital impOltante of the mdab..,lic syndrome i, rdatcd to its
puta1i\'~
impact on
c,u'diovascuiar morbidity arid mortality. People with the mCI.'lbolic syndnJme have been
sl)own lo be at
ijl<;r,,,,,~d
nsk j()r canliovasculw'
dise,,,~
and diabde,. as we II as ror u~ath
ji"l.'lll cardiovascular dis~as~ and Ji\'m all taUsL"S."H', Once idclltified. carly preventative
meaSlLres are needed m ll..."e high lisk people wi lh the mam j()CUS on hk ,tyle
chang.~
n
anu tr~atmCllt of thc individu,li componellts if thc f01mcr fails.'"
To
w
"I'h" prevaknte oj" the mdabolic synd",m~ " dql~ndent Oll th~ ddlnitioll u;;ed to
diagJlosc it, Sc\'eral definitions of th" melaix,llc syndrome ex"i,
on~
consensu, group redcfincd thc metabolic syrldrome in
pntdicai dclinilion lha( w,uld 1:x; used in ally country to ioclltitY
C
order 1.0 provl{k
lh~
ap
e
Inl~rn:Llional Diab~\(;, r~dnation
R~cently,
of
people at high ri,k 01' cardio",,,clLlar dise,,,~ and dJabdes, " Thq u;..;u lh~ ATP III
C.irc.wllkrCIlc~.
syndrome, and ethnic-spetllic waiS[
ddinili(~l. ~)
clrc,umfcrcnc~ cut-on~ hav~
FPO only, and not an
U
thc
l) cenlral oocsily. a,
a,,~ss~d
by
is now a compul,ory compOllCllt to m,lk" the d"lgnosis of metabolic
ni
ve
r
waisl
chan~e"
si
ty
comp,"lCnts ,IS background with lwo main
abnOlmalilies but it I, llOw
rcrogIliL~d
hr I'Ci" also accep(abk in clinical
FPG "' 5.6. (ClmicillilS and
oon.
becn incorporated into
's ,till rrquil\;U to diag.nose glucose
that impaircd glucose to\craocc delClll1ined by a 2
practit~
res~arth~l-';
and lbey strongly rccommend an OUI'"!' if
al\; CIlcouraged though to 1',ltller add the 2 hr PO
as supplementary finding m order 10 rdam th.;; ,impliel1) ol-lhc ddlnitioll),
Atti1c ti me of pmccssing daw lor our sludy. we slill ,,,,,d
diagno,i, of mctaholic syndromc,
lh~
ATP 1!1 aitnia ror
th~
Th~ ~t~npon~nb
() (' lh~ mdaholil' syrlllroml'
w~rc I'n;(I"~nlly pr~sel1l
Wilh ACS at Karl13remer Ilospit'l!. We found a large p]'(}p(lltion of
'yndmm~
delin~ gluco,~
ha\'~ h~en
to hav e
mdaboli~ _'yndrom~ (64~,';'),
liiagnoscd had we adde.J
m~labok synlirom~.
](
L'
thos~
tolerallc~
only
uSlXllh~
FPG
thererore not
with K;T di,lgno_'ed with the OGTT_ A,;
is often
d u_,t~red
surprisin~
(61_5~--o)
wilh olher
~ompnn~l1ls
or the
that we f01ll1d a high er prev,l!ence of
and diaheles (S2.4o,i,) lhan
Ihos~
wilh
To
mClabolic ,YlKlrome in patie11l'; wilh (;T
(.173~--':'J_
w~
wllh
aooormalilics, wc can >afcly a_"lLmc. thal cvcn more patients would
mentioned. abnol1nal glucose
'\IGT
A,;
n
LO
corollary
p,lti~llts ,Idmitt~d
w
acut~
III pali en!> admilled
An locn;ascd d lLsterin g 0(' mctabolic risk
Llct(}J'~
\\',1'; al,o noted as the
pre""l~nl'e
0('
m~1ab()lil"
synlirolllc in males and female, ha,; been
not~d
C
A SIIllLlar
ap
e
glycaemic profIle deteriorated fl\)m NCiT to IGT lO diab"le,;_
of
before.'" Howcver. we fOl1l1d a _'ign ificanlly higher pr~valen~~ in I~lllale_, (77',,;,) Ihan
w~
could not den")flslrate a _'ignilic anl differencc in the prevalence of
rs
i
for age. Although
ty
males (50",,',,)_ 1'<0.0 I. ]( is po>sibk lhat the gender (Jl'ev,l!enc e may change when adj ust~d
syndmn~
col()lIr~d r~male_, W~T~
U
app"ar; lhat
ni
ve
metaholic syndrolllc belween the hvo main
(risk ratio 2. L
95~--;,
vanahl~s_
ar~
groups (Coloured and White). it
al hlghn risk than white l;;"na!c, tt' have melaholic
('] O,SI - 5,29).
The lllctalx,hc syndrome 1S variously
dellnllions
ethni~
d etln~d
by
ditf~rent
10 some exknl aroitrarv Qiven the mllural
Clinicians
rcco~nising
orgaTll,;atiuns and all
~ol1linllllln
u(' biological
this will pay attention lo w[r""l.ing abnonnalilic, or
each of lh~ comjx,,,,,nts of lk _,yndronl<;_
44
CHAPTERS
LlJ\'1ITATlO\"S
Our sllLdy has
hospilal slay
th~ l\:~lllt~.
s~\ ~ral
Imlilations. Fir,ll y.
wh~rc lh~
clkCI or so-c~llc,i
lh~
diaglhlsis or dysgl yca~m ia was mll<le during
Slrc~s- induc~d
'I his iong"sl,l1lding concern ,1110 objection
,
"orh:'llnmer eI ai . who
demon~Lraled
a
~Lrong
bypcrgiyc;;;:mi:l
h~s
lx:en
answercd by
blood
glu~o>c
lcvds :lrc
n
rai~ed
To
w
indu~ed
con~lusively
wlTeiallon 1.,.,1 We~n Lhe 2 ilr blood gi uco",
,<,Iucs al discharge and al 3 mootic, 1<lllow-lOP, indicaling
nol only relaled 10 sLress
~ouid influ~nce
by lhe ischaemic evenl and Lhis was "onlinned in a
Ihe early pha.,e ,,(' illl aCUle
~oronm)'
during thdr bospil:ll
preveillive
m~a."Ll"S
syndrome and
~1<IY.
lil~reror~
high risk indivi<llLab can be
Ihereby pel'lnitling e,llly iniri,ihon of "Ppropri,l1e
fOl ceti,lin sl1ldy
ity
S~condly, l~bor!'loJ)' d,lt~
of
C
i<lcnti1i~tl
ap
e
latcr study" supf>OI1ing ~vidence thm :lbnorm,11 glu~os.e met~bol i sm ~'Ul be identified Ul
me~sures
were nol obLained III a small sub"'l
s~mples,
ve
rs
or paliellls tllle to inaoc..lualc colkClion <11' inabilily of the lalxl1;110ry 10 process
sm all.
U
ni
I'his could possibly klve inl1uenced the ,-esulls; alLbough lhe numbcn; inVl11ved were
Ih~ m~gnitude
of this effecI is unknown,
Thin!l)', the ovedl mmialily recorded was low al 3.3%" 'I'his may rdke!
including"
in~omplele
follow-up, as Lhe
oul~{)[n~
oJ'
lhos~
s~wnll
fac\Or:<;
patienls IransiC:rrc<l for hll'lhcr
in(er..-enlion is unknown
rin:llly, lbere W:IS no
subS~'luenl
rollow-up of patiellls adnnlle<l with ACS
WC C,ll lWI comment on the ,hOlt or iOllg term
gl oco,~
cat~gories, Thi~
OU1~Oll1e
an<llh~rdore
or p,lliellls in 1.1", dill"erenl
is an alea of C<lJlC~l1ls wb ,c h ro.luirc~ limber study.
45
CHAPTER 6
COl\CLUSIO:"l" ANI)
RECOI\nlE~I)ATIO~S
6.1. CO:,\/CLUSION
Che,l pmn due 10 an ocu(e CO'lmaf), symlwlllc
~ollstil"lcs"
large proportion oJ'p"licnls
sccn in Ule ED and afkclS bOll> Coloureds ,md \Vhiks \() the
Ih"t CAD i., not only" discasc of tile highcl'
in~omc
'~Il1C
cAkn!. This ,"gg",ts
\\,'hitcs, In
~ontrast
un~omlllon
in
w
n
rrcvab,cc uJ' AC S In both \Vlnte, ami Colowuh, we (,Juncl ACS lo be 'lill
10 the high
of
p,~ients
ho,pi l~l,
with ,'>Cutc
In
Ule Wc,km C'l't, 1Khmssion
~nd m~nag:emcnt lo
ap
e
In many snwlk,.
To
Bk..;k" dc"pilc prcdi clion' of " potcnti" I cpidcmic in this lX'pul at Lon gWlI p,
~oronary
"yndromc is the
rC'IXlJ~,ibility
of
th~
uischargc
Emcrgcncy
C
Dep,,,tmenl '" the chest pain 1LIlll I,mn, an ,ntegrul 1',,,1 ol'the ,,,,,,te "Jmi"",,'1..' w;·lru. Il
"c~ur'
of
h"s been ,hown repe"tedly th"l dy'g lyc,,,,mi,,
~swciatcd
e.~dlLdcd
us mJic.ated
In
OUr ,11LJy, ll,e high prevalence ill' JysglyC.";:LlH~ m
ni
ve
r
Cupc" nilt
with sevcral Nhc]' mctabolic risk factNS: the poPlllation of thc \Vcstcrn
si
ty
is
commonly in paticnlS with ACS anu
patient' with ACS and thc poor managcmcnt of thosc palicnts alre,,,ly diagno'''d wilh
U
diabetcs implicatc Ihal urgcnt 'tmtcgies ,hould be dcviscd 10 m"n"l!c dysglycaemi" 'lIId
to pi'cvcnt the con..'C'lucnccs of thc syndromc.
Surely, few dink,,1 'cUings cxi,t whcre the
p"tien[, can he
aculc
coron~ry
cx~""ueu,
iuentifi~"lion
of lhi, munher
,mJ nol lo perfonl1 "n (KilT dming Ihe
Jysglyc"emi~
conv~lescen~"
oj' un
syndromc is" val""t>lc OPIXlrtunity nlisscd
6.2. RECO\'I\'IEl\DATIONS
1, All p.'llic'* admittcd with an ACS ,hould hmfC "recning f,~' di"hc[es.
46
}, This scre~ning is be,! done with an OOT'I prior to discharge .
.1_ Asso<,iuku
mC!uh"li~
ri,k bdors should xlivdy
uccordingly: mo,t of these can
h~
h~
searched ti,,-
~nd
managed
meosufcd wilh simp le clinical parameters l-.btained
U
ni
ve
r
si
ty
of
C
ap
e
To
w
n
ill the ED,
47
REFERE:\"CES
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i(~' So~lh
La~t.;chcr
R.
cl
al. Initll11 burden 01 diseas.c e,timllIC"
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Cardi0"asclII~r
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V,.-iliiams G, ediwrs. i'cxtbook oi" diaoctcs, OxionL
l. Kannel
Kbdwdl~
I L)~7 p. l-:i 7
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'l~dy gm~p.
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w
I 'he I ) b.(01)1':
To
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n
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e
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C
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h~an
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ni
ve
r
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ty
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a ri,k factor lor lschocrnic hcart diseuse , ("{ill /I"v
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w
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D Jr
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To
)3,
S5
tTlcllitu,. In: L lcnberg Jnd Rilkin's Diabetes
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e
14(sul'pI5):SI
'lllrl projections to llw yCJr 2010, Diabclic Mooicinc 1997:
n
~.,tiL11at~s
~I
aL locreaslllg prevalence .,f lype 2 0\-1 111
C
14. C"llins YR. [XlWSC GK. Todlq"" PM.
ap
colllplicilti.M1S:
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('(11"1'
ns
ty
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~
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rs
i
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I~. ~1(llala
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ve
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49
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abnOllllaliti~
.Ii~bl
L Vylhilillgum S. Aht)ormal
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n
A ii',~'m 111di al1S wilh
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'Iype 2
To
w
21, \1otala .11..'1.. Pirie FJ. GOlLW, E, Am<.xl A, Om,I' '1-1.'1.. Higll incidellce
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8e~ker
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C
~~
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e
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ty
3SI,
be~rr dise~se
ni
ve
r
23, Scedat YK. Mayel FG, Khan S. Somers SIC J(\ul>erl G. Risk
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R~l1iilh
M(~)diey
U
m~les
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pO]llLlmioll: patient
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~
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67:
619-~25
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~el1lr~.
Cape Town comJllunLty. hcallh
30 Stc".n K, Levitt N, Fouric J.
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cI
~ell1er
~ar~
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al "
To
w
n
St~yJl
S Afi'
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e
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ity
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U
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of
l~
S(\uth A r,;c". 1;"<1 Aji' Met! j 1<)96: 73: 75S-763
ni
ve
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hla~1< ~on1ll1l1nity
id~ntill~atinn
1M, Bradsfl:Lw D, HolTman 1...1\1.
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ofplLbli~
prc\'"ICl1c~
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n
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e
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~
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ve
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U
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\lallllhcr~
K. Hamslen A
,,1
al. Abnclmlal gllLcose tolerance
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~
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~olllpaj'is(ln
with
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4~.
\1cic,..1 .I. Ilc if]uss S. (iallwi17 fl. rI ai, Influencc flf impaircd
Ion£! krm survival alie::.-
OCUl~ myocBrdi~1
~Iucos~ toleran~e
iniftl'difln. Thc LAngcndrcer
Oil
MYOCilrdi~1
,--,
Infarction andlllOO<! gluw,c in Diaoctlc palLent,
A"e,sm~nl
(L'>\1BDA1. TJrs,:h
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43, The DECODE ,twly group.
AS~
and
,~x "p"~ili~ prevaienc~,
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44. Stcjn K. Siiw" K. llilwkcn S.
e/
"I. Risk Factors As>cxiatGd With Myocanlial
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Afn~"
Study, CirCiliari(m 2()O'): 112: 3')')4-
4'). Laabo VI
H)-1>Crsiy~a~m'"
~ardiovascular dis~,~,~ ltl
ami
1',99:48 :937-942
Fll1~berg
'-.i.
M~niil
Th~
Level, of Fa,l.ing Plasma
Diabde" Control
lnten!~ntions
and
and
C"mpli~ali()ns
di,e ~be
HbAl~ 'vI~a,"rem~"l
Hogh-Risk IndividuaL; \\'ith
IJiahc/cs ('arc 200 1;: 465-471
(rX:(TiEDlC) Study
diaoctc, trcatn,cnt and cardiovascular
ni
ve
gll1COS~.
HI
C(lmpiications Trial'
rs
ity
47.
of
C
Improve s the lktectie)n of Type 2 Diabetes
No"diagn,-,sti~
type 2 diabetes. IJiaheles
I. f-j,lwn AD.
ap
e
46. Perry Re . Shankar RI< .
To
w
n
:;561
Epidcmiology
R~sear~h
e)1
Dial:>ctcs
(jroup. Inkn",,'e
ill patient, wllh tjpc I diabetes.}-i Elig/
U
.I '"led 2005,353: 2643-2653
4S. Qlau Q. Tuncn LH. ""cn-KiLLl.:aanniemL SK. el ,,/, Rm'Jde)m capillary whelie hh.)(xl
gilocose test as a sc,Iwning teSI fe).- diabetes mellit,,> in an elderly I}()pubtio".
Europmn Journal o{Public jjea/lh 1995: 5(4): 277 -1~(J
4'). o.,wald ri. Smith C'. BCllel;dge.1. Yudk,,' J. Dctcmnmml" and impe)ftance of stress
hypergiy~a~mia
m
tlo,,-diabeli~ pati~ms
with myoc,mlialml',rdwn. RUT 1936: 29J'
9 I 7·922
53
50, O'SlIUivJn J, Conroy R. Rol"'''()/l K,
pali~llts
Hid~y
N, l\,{lllcahy k.. In-hospiwl progllo,i, of'
with f;willg hypcrgiycJCllllJJfler lirst myocardial lllf;"dioll TJ;al>eles ewe
14:75S-760
11)')1;
51, 13dlodi G. Manicmch V, Malvao' V. et ai, II YPL'Tglycactnia
Inyu(;Jr~iJI
Jn~
progrw,i, of Jeutc
inti,rClion in pallGllls wnholLt diahetes melhllld_ ,1111 J C"rdiol.
I')~<);
64:
S85-SSS
11,.
S E. Hum D, ;vlalmlX-'Tg K, GeT';lein H C. Slrcss h::.--pergIJ'Catmia and incrcased
n
C~pcs
of death nfier lllJLXardial infarctioll in pJtlcnts wilh and ",ilholll diabelL"" a
s},slemHtic o"<'rview_ n", raileet 2(jf)(); 3:5:5:773- 77~
I'ath .() r(~'llbndi
I', lkJ11 K, GllIco,c-Imlllin-Potassiulll Therapy j"r Trealmenl oj'
ap
e
5},
To
w
52,
C
Al'lLte Myocardial In (;lrdioll tiJ'('ulmiol/ I 997, '!fi: I I 52 -I I 5b
of
54. Diaz R, Paola",o L A, Picgas L S, c/ ,,/. McWhohc ro..loduiatioll "j-Acute ro..lyocardial
ty
Infarction, '1 he LelA Gllicose-lnsuIHl-POWSSjurn PilOI Tnnl. Circuiul;on 19%: 98
ni
ve
rs
i
2227-22.14
55, Malmberg K, Norhatnmar A, Wedel H. Ryden L (Jly<:omcwholic State at Admi'SloTl:
U
important Ri>k MaThcr in ConVCntiollal! y 'i"realed Pali ents with l)iabeleo M ell itus and
Anl1e Myocardia I Inbrction. O,-"uiul;o" 1999: 99: 2626-2632
56, Davi"", M.I, Gray IP, Impaircd
glu~m,e
tolcJ'Jllc e, BMJ 1996: 312:264-265
57, De,pres, JP, LClllkux 1. Prlld'homrnc D, Trcatmcnt orobcsi1y: necd to
fOCIIS
on hi.,h
risk alxlomirlJUy OOC>c paticnts, BMJ 2()()1: .122: 7 I 6-720
5S, Goldstcin OJ, BcncJicwl health elTecl, of'a modest weightlos,_ fill.! 01"", 1')<)2: 16:
-'97
415
54
59 Vaguc J. La dilTercnliation se\udk fadcur determlllant des formcs dc l'ob6,itc.
l'r('sS<' Med 1947; 30: 339-411
60.
Ll~,e
All, \1eycr-Da\ls EJ, Tymicr HA. ,,/ ul. Dcve](:>pment c)f the Multiple
\1ctaboltc Sync1rome in lhc' AR1C cohorl: Joint Co ntrihutiClII Clf In sulin. HMl, al1d
W HR .. -11111 Lpirleillio 1<)<)7: 1: 41)7-4 I (,)
iii . rum.,,- I<C, II.fili us 11, Nd HAW. etall"r the Unilnl Kingdom
PrO\r~cti\'eDiahetes
To
w
n
Sllldy (,roup. Risk faclc))'s fc)f comnary artery d i,easc in non-in'lliin depetxlant
diabeks mellitus: UnlleJ Km/Cdom pwsI",c.tive dtabetc, ,tuc1y (UKPDS 23), BAfJ
~1arj\Z
f-J Ilyslipidaemia in Sooll th Africa. Chnm;G D;"nll'« .I' oj'lifestyle iii Suu,h
~hapter
'l. 97 - 1n~.
of
C
Afrim ,i'l<:c 1995- ~O\l5.
ap
e
62.
63. Wilson I' W F, Iliaheles MelhllLs and Cnronaf)' Heart DiseaSe. L'"docrinu/ MClab
~~7-~1
rs
ity
CiiIl2(11)1: 30:
64. lsomaa B, Almgren P. Tuomi T.
e/
al.
C"rdiovas~ular
lI.\orhldilY and Mc)rtalily
ni
ve
Associated Wilh the Me1ai:>.lh~ Syndromc. Diul><:/e.l' Cure ~OOI ; 24: 6~3-6~~
U
65. Lakka HYI ct 01. Th~ mcta!>"lic. <yndmme and ~ltal anu cardiovas.c,uiar disease
mortality in nlid<lle-age<1 m~n, JA .VA 211m: 2R8: 2709-2716
6("
Juutilainc[l A. Le·hlo S. ROl1Il~maa T, Pyiir;;i;; K. Laaho YI, Pwtcillu ria "nd
metabolic <yndm nw as p redidors oj' cardiovascular dcath in no n_d i"hetic omllype 2
diabetic men at,,1 ",'linen, TJiahetologiu
2(~)6:
49: 56--65
67. Gc'\xge K. Aicrti M, /.in1n1"\ 1'. Soh"w J, I'he n1dahok syndrc)me
a nc\v\vorld wide
deti 1l11ic)n. The L"neel J005: 366: I 05~-ll)ii I
5',
6R Ok",o C, Zhong Y. Ford E, e/ al_ Ass"",ialion be("ecn the
ill'
c()mrO I1~l1t<
'md gilit
<pe~d
melal>oh~
syndron-..e and
among U,S. adults aged 50 years _,"d o](kr: a c['()ss -
U
ni
ve
rs
ity
of
C
ap
e
To
w
n
sedional analy,i,_ HAle f'uhlic Healrh 20(l6; 6: 2R2-2R9
56
l"'I'ORl\IEJ) COl\SENT
\V e inviw you to partici[laW in a SllrV~y to ~stabli sh whm r",rC~lltage or p~liel1t' adm i!led
sun~r.s
with the InslLlin ReSlslmlce SYlldwme. Thi,
JcnlTlgem~nt
01 tlw sugar lUld cholesterol metabolism,
to Karl Bremer Hospital with angma.
wndition IS chamcklized by
al'llol'mal blO<X1
lJ1~reased
to the actiol1 of il1sulin in your f><xly, leadin g lo
risk oj heart disease. II it appears dlLring this survey lhat a high percentage
w
n
an
pressur~ ~nct resi,tanc~
stmt~gies
can he devi>cd to nctctn:;ss this probkm and
reduc~
the ri,k or
C
you aped dlLnng this survey? Yo", doctor wii I perIorm a
and lUl ECG wi lllx
dOll~
routil1~ ex~minati 011
ns u,unl. YOll will be weighed alld we wlll meaSlL]'e yoU!' kllgth
of
\V hal ~~n
ap
e
in our populat ion,
To
of pati~nts actillitled with all gil1a sulfers flnm this wlldil iOll. which seem, to he mcreasLTlg
cil'cumfel'~I1Le.
rs
i
ty
as well as .VOlL]' hip and aNominal
ni
ve
;, kllliry if any undcrlyillg myocardial damagc is
a<kJitionai blood will nl so he
~ollcded
Blc,od wi ll rom;l1ely. be lakell lo
pr~sent.
During thi> vcnepullclure.
to check your blo",icOllJl\. hpid pmtilc. YO!lI
U
glucose control ovel th e Inst I:;'w mOl1ths, illsul il1 leve l, and inil ammmory markers. 1\0
extra vellepulKtures wi l oc pcr l(lrm ect Oil admission. A urine sample will abo ""
co llede d to
W~
if there ar~ nll y [>fOldns pl'e,el1t ill YOllr urillc. ROlLtlJlC care will be takell
of you during your hospiwl st"y. OIl your day or discharge
additional blc'l'>d smnpk to Lheck your fnsting
glu~ose
w~
wJ!1 ask you for nn
alld d",l e,temi. This mean, that
you will be a.,ked 1l0t 10 Cal or drink anything fl'l!m 22hllll
th~
previou, night, alld hhxxi
will n., tnkell early m the morning so thm YOlL can , till havc your breakfa,L We wi ll abl
provide you wilh "' wsm drink (iI you are nol already diagllO,ed with ctiaocte>:1 nllct
57
repeat the b\,xl<1 sample ill 2 hl'S. Th is
~nable,
already dlagnosed, or atl;sk li)T devdoping
us 10 s"c if you hove di abetes, if not
tliabcte~. !r~o ,
we w lll
alh i s~
you regarding
your flLtlLrt management.
If at any point during this surve::.. YO)I w()\l ld like to discontinue your panicil'alion. you
are free to do so and
}our
car" lh"rean"rw,\lnol rn,
al re~led_
I hove read ami understand th" ab()v~ miimll ation and woul d ljk~ to participak.-i would
ap
e
To
w
n
not like 10 pJ1ticipatc in thc survcy.
ty
of
C
Paticnt:
Signaturt
Daw
U
\Vitncss:
ni
ve
rs
i
Prinl",lname
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59
PPL:NDIX C
'\1'1'E:\IHX C
A BBR EVIATIONS
ACS
AI1I\C COrolJalY ~rndroJT1c
AUH::ric3n Dl3bClC'- A"''''c1al,on
AM I
Acute myocardiJ I inf~rction
An'
..' doh I rcm mcnTPand
bypa ;;~ ~raft
CA l)
To
w
Conmary a]'l~"Ty
C "-I:H';
(' ol1lid<-"I1~e In l~r"al
D.\.
Lliabclc> mci l j1!1>
ED
Emergcncy Department
C
ap
e
CI
ity
of
llm ._C
rs
11' 1;
ni
U
FP(;
ve
! GT
IIID
n
RI\ II
f:ll.llll£ plasma gluC{'l!'c
K8H
KaT! Brcmci H,,;;pita!
I.RRR
Leti bundle bmnch bl"d,
1,1>1 .-(;
low -demlTY lip"pm tcin ch"ICo<lerol
N(m-~'r
clnation myoeanhal in jurel;on
O(; lT
Oral gltlCosc \Q lcflIllCC
f'CI
PCI'ClLlanCo ,, ' l!llen'en li on
tc;;\
1'(;
',0
ST-elevation myocardial infarction
TG
Triglyceride;;
l!AP
Unstable angina pectoris
UKPDS
United Kingdom Prospective Diabetes Study
U
ni
ve
rs
ity
of
C
ap
e
To
w
n
STEMI
61