Evaluation of hemoglobin A1c criteria to assess preoperative diabetes risk in cardiac surgery patients

Abstract

Objective: Hemoglobin A1c (A1C) has recently been recommended for diagnosing diabetes mellitus and diabetes risk (prediabetes). Its performance compared with fasting plasma glucose (FPG) and 2-h post-glucose load (2HPG) is not well delineated. We compared the performance of A1C with that of FPG and 2HPG in preoperative cardiac surgery patients.

Methods: Data from 92 patients without a history of diabetes were analyzed. Patients were classified with diabetes or prediabetes using established cutoffs for FPG, 2HPG, and A1C. Sensitivity and specificity of the new A1C criteria were evaluated.

Results: All patients diagnosed with diabetes by A1C also had impaired fasting glucose, impaired glucose tolerance, or diabetes by other criteria. Using FPG as the reference, sensitivity and specificity of A1C for diagnosing diabetes were 50% and 96%, and using 2HPG as the reference they were 25% and 95%. Sensitivity and specificity for identifying prediabetes with FPG as the reference were 51% and 51%, respectively, and with 2HPG were 53% and 51%, respectively. One-third each of patients with prediabetes was identified using FPG, A1C, or both. When testing A1C and FPG concurrently, the sensitivity of diagnosing dysglycemia increased to 93% stipulating one or both tests are abnormal; specificity increased to 100% if both tests were required to be abnormal.

Conclusions: In patients before cardiac surgery, A1C criteria identified the largest number of patients with diabetes and prediabetes. For diagnosing prediabetes, A1C and FPG were discordant and characterized different groups of patients, therefore altering the distribution of diabetes risk. Simultaneous measurement of FGP and A1C may be a more sensitive and specific tool for identifying high-risk individuals with diabetes and prediabetes.

Figures

FIG. 1.

(a) Venn diagrams for diabetes: individuals meeting criteria for diabetes as (A) hemoglobin A1c (A1C) ≥6.5%, 2-h post-glucose load (2HPG) ≥200 mg/dL and (B) as A1C ≥6.5%, fasting plasma glucose (FPG) ≥126 mg/dL. (b) Venn diagrams for prediabetes: individuals meeting criteria for prediabetes as (A) A1C 5.7–6.5%, 2HPG 140–200 mg/dL and (B) as A1C 5.7–6.5%, FPG 100–125 mg/dL. (c) Venn diagram indicating abnormality (diabetes or prediabetes) by A1C, FPG, or 2HPG.