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In 2002, Norhammar et al. published the results of the oral glucose tolerance testing (OGTT) of 181 consecutive patients admitted to the coronary care unit because of acute myocardial infarction (AMI) and without previously known diabetes. Among these patients, previously unknown diabetes and impaired glucose tolerance (IGT) were much more common than expected, 31 and 35%, respectively. Equally high prevalences were detected when the OGTT was repeated 3 months after the event. This finding was soon repeated in the large material of the Euro Heart Survey and also extended to the patients with stable coronary heart disease (CHD). Of the 923 patients with an acute CHD event, 22% had newly detected diabetes and 36% IGT. Among the 997 patients with stable CHD, 14% had newly detected diabetes and 37% IGT. It should be noted that 31% of the Euro Heart Survey patients had previously known diabetes. When added to the figures revealed by the OGTT, this means that about half of the CHD patients had diabetes and, additionally, about a quarter had IGT. Similar findings have been reported from a smaller Austrian study among patients undergoing elective coronary angiography. An important feature of the Euro Heart Survey was that two-thirds of the patients with abnormal glucose regulation would have remained undiagnosed without the use of OGTT. The same group has recently provided additional evidence that using different cutpoints for the fasting blood glucose, or a combination of fasting blood glucose, glycosylated haemoglobin A1c and statistical modelling, is insufficient to overcome the problem and cannot reach the same diagnostic accuracy as OGTT. The aforementioned studies have been limited to European populations and their generalizability to other ethnic groups has been uncertain. Another limitation is that almost a third of the eligible patients did not undergo OGTT in the Euro Heart Survey, which creates some uncertainty around the prevalence estimates of diabetes and IGT. Given these limitations, the new results from the China Heart Survey are an important confirmation and extension of the earlier European findings. Hu et al. report results that are remarkably similar to those of the Euro Heart Survey and demonstrate that in China as well, the usually sour CHD contains a sweet tinge. Among the 3513 patients hospitalized for CHD, 33% had previously known diabetes. After OGTT, the proportion of diabetic patients increased to 53%, and a further 24% had IGT. No difference was observed between patients hospitalized for acute CHD and stable CHD. Furthermore, 81% of patients with new diabetes and 87% of those with IGT would have remained undiagnosed if OGTTs had not been performed. The acute CHD patients in the China Heart Survey as well as in the Euro Heart Survey are a selected subset of survivors of an acute event. A considerable proportion of CHD events are out-of-hospital sudden deaths or deaths in the emergency room. Since these patients do not survive long enough to have an OGTT, it should be considered whether this could bias the prevalence estimates obtained from these surveys. Data on glucose tolerance and sudden cardiac deaths are understandably scant, but available evidence suggests that diabetes and higher blood glucose levels predispose to sudden cardiac deaths. Furthermore, the fact that in both studies the prevalence of diabetes and IGT was similar in stable and acute manifestations of CHD makes a substantial survival bias unlikely. An interesting feature of the Chinese study is that the patients were not obese by Western standards. The average body mass index was 24.2 kg/m and the waist circumference 90 cm among men and 88 cm among women. In the Euro Heart Survey, these were 27.4 kg/m, 99 and 95 cm, respectively. It has been suggested earlier that the cutpoints for obesity, in particular for waist circumference, should be different for different ethnic groups, with Asians having lower thresholds than individuals of European origin. These Chinese data clearly support the need for ethnicity-specific cutpoints for obesity, but further research is warranted to find out whether there could be a common underlying pathology for CHD and impaired glucose regulation, independent of obesity. The prevalence of diabetes is increasing all over the world. There are, however, no data on the prevalence trends of diabetes and IGT among patients with CHD. It can be hypothesized that with better control of other risk factors, such as high cholesterol, high blood pressure, and smoking, and with simultaneously increasing obesity, the

Sweet and sour coronary heart disease: results from the China Heart Survey