LAUSR

With great interest we read the article by Açar et al about the association of prediabetes with higher coronary atherosclerotic burden among patients with first diagnosed acute coronary syndrome (ACS). The authors reported that at first presentation of ACS, the severity and extent of coronary artery disease in prediabetic patients was comparable to diabetic patients and more advanced than nondiabetic patients. We have some concerns about the study. First of all, the categorization of the study population using only glycated hemoglobin level may be misleading and especially overdiagnosing prediabetic population. In this study, patients were assigned to the prediabetic group based on HbA1c levels (5.7% < HbA1c < 6.5%). Whereas it is recommended the use of HbA1c to define the prediabetic population, recent studies have reported that HbA1c had not adequate sensitivity and specificity to identify prediabetes in patients with coronary artery disease and overdiagnosed prediabetes comparing with the oral glucose tolerance test (OGTT). We proposed that interpretation of HbA1c levels accompanying with insulin levels and/or OGTT could empower the study. The prediabetic population is a not very well-defined, gray zone patient group. Besides the controversies in the diagnosis of prediabetes, the main problem arises from our inability to distinguish prediabetes from confounding factors including abdominal obesity, hypertension, and dyslipidemia. All of these confounding parameters are the components of metabolic syndrome. We think metabolic syndrome could be a significant confounding factor in analyzing the atherosclerotic burden in prediabetic population and should not be overlooked. Evaluation of metabolic syndrome and its components such as waist circumstance, triglyceride level, and also body mass index could strengthen and elucidate the findings of the study. We thank the researchers for addressing the severity of atherosclerotic burden in prediabetic patients with ACS. In patients with ACS, the screening of glucometabolic state and early recognition of prediabetes may utilize more individual therapy and more aggressive risk factor interventions leading to improvement in survival.