Korolyuk O. Peculiarities of the course and treatment of coronary artery disease in patients with impaired glucose homeostasis and dyslipidemia

The object of study - stable angina and acute coronary syndrome (ACS), combined with impaired glucose homeostasis (IGH) and dyslipidemia. The aim - to improve diagnosis and efficacy of treatment of coronary artery disease (CAD), combined with IGH and dyslipidemia, based on the study of pathogenetic mechanisms and peculiarities of the clinical course. An examination of 116 patients with CAD and 20 individuals of the control group revealed that patients with IGH commonly had a combination of 4-5 metabolic syndrome (MS) criteria, systemic inflammation and activation of the sympathetic nervous system. Patients with impaired glucose tolerance (IGT) and combined prediabetic disorder (CPD) had more severe disease, along with earlier onset of CAD in women. Hepatic steatosis (HS) was revealed in 75.0 % of patients with CAD and IGH. In 31.2% of cases HS was accompanied by decreased hepatic insulin clearance that was associated with increased incidence of ACS and severe heart failure. We found direct correlation (p <0.0001) between HS and lipid profile parameters typical for diabetic dyslipidemia, indicating selective postreceptor hepatic insulin resistance (IR). Patients with impaired fasting glucose (IFG) had increased late phase insulin secretion and prominent hepatic insulin resistance. Persons with IGT had significantly decreased early phase insulin secretion and predominantly peripheral (muscular) insulin resistance. Patients with combination of IFG and IGT had severely reduced both hepatic and peripheral insulin sensitivity and comparable to diabetes early phase insulin deficiency. Early phase insulin deficiency in combination with IR potentiates diabetic atherogenic changes and is associated with high diabetes risk within 40 months. Abnormality of cardiac structure and function were decribed in patients with IGH. Significant inverse correlation was found between the size of the left cardiac chambers and indices of peripheral insulin sensitivity, along with indices of early phase insulin secretion in males. Women with IGH were more likely to have valve calcification, which inversely correlated with indices of insulin sensitivity. It was shown that metformin therapy improved insulin sensitivity and more effectively restored normal glucose regulation than weight loss (53.3% vs. 21.4%). Metformin may be indicated for patients with CAD and IGH, MS or proved IR; ACE inhibitors and metabolically neutral beta-blockers are advisable, however co-administration of several diuretics should be avoided due to diabetogenic effect. We proposed clinical and laboratory predictors of IR, cardiovascular complications and diabetes. Priority of oral glucose tolerance test was shown for evaluation of the metabolic state of patients with CAD and newly detected hyperglycemia. The results of the study were introduced into clinical practice and educational process. Industry - medicine.