Glycated hemoglobin A1c-based adjusted glycemic variables in patients with diabetes presenting with acute exacerbation of chronic obstructive pulmonary disease

Figures & data

Table 1 Characteristics of the enrolled patients

Characteristic	N=251
Age (years)	76.0±12.6
Gender (male)	211 (84.1%)
Corticosteroid use	101 (40.2%)
Congestive heart failure	44 (17.5%)
Coronary artery disease	85 (33.9%)
High-risk group	179 (71.3%)
Malignancy	32 (12.7%)
Cerebrovascular accident	39 (15.5%)
Pulmonary infection	84 (33.5%)
Chronic kidney disease	60 (23.9%)
Smoking	214 (85.3%)
Blood glucose at admission, mg/dL	225.9±148.6
Hemoglobin A1c, %	7.9±2.1
Glycemic gap, mg/dL	45.9±123.3
Stress hyperglycemic ratio	1.3±1.4
Modified stress hyperglycemia ratio	277.2±14.1
Acute respiratory failure	35 (13.9%)
Hospital stay (days)	9.4±13.1

Note: Data presented as mean ± SD or n (%).

Table 2 Comparison of patients who were admitted to the ED with AECOPD in the low- or high-risk groups

Variable	High-risk (n=179)	Low-risk (n=72)	P-value
Age (years)	75.9±12.4	76.2±13.1	0.87
Gender (male)	155 (86.6%)	56 (77.8%)	0.08
Chronic steroid use	89 (49.7%)	12 (16.7%)	<0.01*
Congestive heart failure	31 (17.3%)	13 (11.1%)	0.89
Coronary artery disease	58 (32.4%)	27 (37.5%)	0.44
Cerebrovascular accident	27 (15.1%)	12 (16.7%)	0.75
Malignancy	21 (11.7%)	11 (15.3%)	0.45
Pulmonary infection	58 (32.6%)	26 (36.1%)	0.59
Chronic kidney disease	45 (25.1%)	15 (20.8%)	0.47
Smoking	160 (89.4%)	54 (75.0%)	<0.01*
Blood glucose at admission, mg/dL	244.0±160.3	181.0±102.2	<0.01*
Hemoglobin A1c, %	8.1±2.0	7.5±2.1	0.03*
Glycemic gap, mg/dL	58.8±133.0	13.7±87.6	<0.01*
Stress hyperglycemia ratio	1.4±1.6	1.1±0.5	0.11
Modified stress hyperglycemia ratio	29.2±14.8	24.1±11.5	<0.01*
Acute respiratory failure	31 (17.3%)	4 (5.6%)	0.02*
Hospital stay (days)	9.8±10.0	8.4±18.8	0.42

Notes: Data presented as mean ± SD or n (%).

* P<0.05.

Abbreviations: AECOPD, acute exacerbation of chronic obstructive pulmonary disease; ED, emergency department.

Table 3 Comparison of patients who were admitted to the ED with AECOPD with or without ARF

Variable	ARF (n=35)	No ARF (n=216)	P-value
Age (years)	77.5±11.6	75.8±12.8	0.46
Gender (male)	29 (82.9%)	182 (84.3%)	0.83
Corticosteroid use	19 (54.3%)	82 (38.0%)	0.07
Congestive heart failure	8 (22.9%)	36 (16.7%)	0.37
Coronary artery disease	15 (42.9%)	70 (32.4%)	0.23
Malignancy	3 (8.6%)	29 (13.4%)	0.42
Cerebrovascular accident	4 (11.4%)	35 (16.2%)	0.47
Pulmonary infection	18 (51.4%)	66 (30.7%)	0.02*
Chronic kidney disease	6 (17.1%)	54 (25.0%)	0.31
Smoking	32 (91.4%)	182 (84.3%)	0.27
Blood glucose at admission, mg/dL	246.9±179.6	222.6±143.2	0.37
Hemoglobin A1c, %	7.3±1.3	8.0±2.1	0.06
Glycemic gap, mg/dL	84.3±115.7	39.7±115.7	0.05*
Stress hyperglycemia ratio	1.5±0.8	1.3±1.4	0.22
Modified stress hyperglycemia ratio	32.8±17.7	26.9±13.3	0.02*
Hospital stay (days)	18.3±17.0	8.0±11.8	<0.01*

Notes: Data presented as mean ± SD or n (%).

* P<0.05.

Abbreviations: AECOPD, acute exacerbation of chronic obstructive pulmonary disease; ARF, acute respiratory failure; ED, emergency department.

Table 4 Univariable and multivariable regression analyses for developing ARF

Variable	Univariable		Multivariable
	HR (95% CI)	P-value	Model 1	HR (95% CI)	P-value
			Variable
Age	1.011 (0.981–1.042)	0.46	Age	1.013 (0.980–1.046)	0.45
Gender (male)	1.108 (0.427–2.870)	0.83	Gender (male)	1.032 (0.371–2.872)	0.95
Corticosteroid use	1.941 (0.945–3.985)	0.07	High-risk group	2.918 (0.935–9.106)	0.07
Congestive heart failure	1.481 (0.623–3.523)	0.37	Pulmonary infection	2.482 (1.164–5.295)	0.02*
Coronary artery disease	1.564 (0.756–3.238)	0.23	Glycemic gap	1.002 (0.999–1.005)	0.12
High-risk group	3.561 (1.209–10.487)	0.02*
Malignancy	0.605 (0.174–2.102)	0.42
Cerebrovascular accident	0.667 (0.222–2.009)	0.47
Pulmonary infection	2.390 (1.160–4.928)	0.02*
Chronic kidney disease	0.621 (0.245–1.575)	0.31	Model 2
Smoking	1.993 (0.577–6.878)	0.27	Variable	HR (95% CI)	P-value
Blood glucose at admission	1.001 (0.999–1.003)	0.37	Age	1.012 (0.980–1.046)	0.46
Hemoglobin A1c, %	0.811 (0.650–1.001)	0.06	Gender (male)	1.013 (0.363–2.824)	0.98
Glycemic gap	1.003 (1.000–1.005)	0.05*	High-risk group	2.910 (0.933–9.075)	0.07
Stress hyperglycemia ratio	1.078 (0.886–1.311)	0.45	Pulmonary infection	2.507 (1.175–5.348)	0.02*
Modified stress hyperglycemia ratio	1.026 (1.003–1.050)	0.03*	Modified stress hyperglycemia ratio	1.023 (0.999–1.048)	0.06

Notes:

* P<0.05. Multivariable analysis included all variables with P-values <0.05 from the univariable analysis, age and gender. Model 1: incorporating glycemic gap; model 2: incorporating modified stress hyperglycemia ratio into multivariable analysis.

Abbreviations: ARF, acute respiratory failure; CI, confidence interval; HR, hazard ratio.

Figure 1 Glycemic gaps, stress hyperglycemia ratios, modified stress hyperglycemia ratios, and COPD classifications.

Abbreviation: COPD, chronic obstructive pulmonary disease.

Figure 2 ROC of acute hyperglycemia, HbA1c level, glycemic gap, stress hyperglycemia ratio, modified stress hyperglycemia ratio, and acute respiratory failure development in patients presenting to the ED with AECOPD.

Abbreviations: AECOPD, acute exacerbation of chronic obstructive pulmonary disease; AUC, area under the curve; CI, confidence interval; ED, emergency department; HbA1c, hemoglobin A1c; ROC, receiver–operator characteristic.

Table 5 Comparison of the characteristics of patients with AECOPD during chronic corticosteroid use with or without the development of ARF

Variable	Corticosteroid users			Non-corticosteroid users
	ARF (n=19)	No ARF (n=82)	P-value	ARF (n=16)	No ARF (n=134)	P-value
Age (years)	76.7±12.5	75.2±12.4	0.62	78.3±10.7	76.1±13.0	0.52
Gender (male)	14 (73.7%)	71 (86.6%)	0.17	15 (93.8%)	111 (88.1%)	0.26
Congestive heart failure	4 (21.1%)	18 (22.0%)	0.93	4 (25.0%)	18 (13.4%)	0.22
Coronary artery disease	6 (31.6%)	21 (25.6%)	0.60	9 (56.3%)	49 (36.6%)	0.13
High-risk group	19 (100%)	70 (78.7%)	0.08	12 (75.0%)	78 (58.2%)	0.20
Malignancy	2 (10.5%)	12 (14.6%)	0.64	1 (6.3%)	17 (12.7%)	0.45
Cerebrovascular accident	2 (10.5%)	9 (11.0%)	0.96	2 (12.5%)	26 (19.4%)	0.50
Pulmonary infection	8 (42.1%)	21 (25.6%)	0.15	10 (62.5%)	45 (33.8%)	0.03*
Chronic kidney disease	2 (20.5%)	24 (29.3%)	0.09	4 (25.0%)	20 (22.4%)	0.81
Smoking	18 (94.7%)	74 (90.2%)	0.56	14 (87.5%)	108 (80.6%)	0.50
Blood glucose at admission, mg/dL	203.9±87.5	242.6±142.1	0.49	298.0±242.4	219.4±144.3	0.22
Hemoglobin A1c, %	7.1±1.1	8.1±1.8	0.02*	7.6±1.6	8.0±2.4	0.49
Glycemic gap, mg/dL	47.4±97.4	42.1±121.9	0.86	128.0±205.7	38.2±121.1	0.01*
Stress hyperglycemia ratio	1.4±0.7	1.2±0.6	0.30	1.6±0.85	1.3±0.8	0.52
Modified stress hyperglycemia ratio	29.6±14.1	27.4±13.8	0.53	36.5±21.0	26.6±13.1	0.01*
Hospital stay (days)	19.7±11.9	8.7±17.5	0.02*	17.9±22.0	7.5±6.3	<0.01*

Notes: Data presented as mean ± SD or n (%).

* P<0.05.

Abbreviations: AECOPD, acute exacerbation of chronic obstructive pulmonary disease; ARF, acute respiratory failure.

Figure 3 Effects of corticosteroid use on acute hyperglycemia, HbA1c levels, glycemic gaps, stress hyperglycemia ratios, and modified stress hyperglycemia ratios in patients who were admitted to the ED with AECOPD.

Note: *P<0.05.
Abbreviations: AECOPD, acute exacerbation of chronic obstructive pulmonary disease; ED, emergency department; HbA1c, hemoglobin A1c.

Table 6 Comparison of the characteristics of corticosteroid users versus non-corticosteroid users among AECOPD patients

Variable	Corticosteroid users, (n=101)	Non-corticosteroid users, (n=150)	P-value
Age (years)	75.5±12.3	76.3±12.8	0.95
Gender (male)	85 (84.2%)	126 (84.0%)	0.97
Congestive heart failure	22 (21.8%)	22 (14.7%)	0.15
Coronary artery disease	27 (26.7%)	58 (38.7%)	0.05*
High-risk group	89 (88.1%)	90 (60.0%)	<0.01*
Malignancy	14 (13.9%)	17 (12.7%)	0.67
Cerebrovascular accident	11 (10.9%)	28 (18.7%)	0.10
Pulmonary infection	29 (28.7%)	76.3±12.8	0.19
Chronic kidney disease	26 (25.7%)	34 (22.7%)	0.58
Smoking	92 (91.1%)	122 (81.3%)	0.03*
Blood glucose at admission, mg/dL	223.2±113.5	227.8±158.4	0.81
Hemoglobin A1c, %	7.9±1.7	7.9±2.3	0.84
Glycemic gap, mg/dL	43.1±117.3	47.8±127.5	0.77
Stress hyperglycemia ratio	1.2±0.6	1.3±1.7	0.49
Modified stress hyperglycemia ratio	27.6±13.8	27.6±14.4	0.91
Acute respiratory failure	19 (18.8%)	16 (10.7%)	0.19
Hospital stay (days)	10.5±17.0	8.6±9.7	0.26
Mortality	2 (2.0%)	4 (2.7%)	0.73

Notes: Data presented as mean ± SD or n (%).

* P<0.05.

Abbreviations: AECOPD, acute exacerbation of chronic obstructive pulmonary disease.

Table 7 The association between HbA1c-based adjusted glycemic variables and chronic blood glucose control

Variable	HbA1c <7%, (n=100)	7%≤ HbA1c <9%, (n=92)	HbA1c ≥9%, (n=59)	P-value
Glycemic gap	23.8±76.7	35.6±101.0	99.3±188.5	<0.01*
Stress hyperglycemia ratio	1.2±0.6	1.2±0.6	1.4±0.7	0.10
Modified stress hyperglycemia ratio	24.6±12.2	27.5±12.8	33.4±17.2	<0.01*

Notes: Data presented as mean ± SD.

* P<0.05.

Abbreviation: HbA1c, hemoglobin A1c.