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Background: Microalbuminuria (MA) is a wellknown risk factor for coronary artery disease (CAD) in diabetics and non diabetics. It is associated with higher cardiovascular mortality. However, the impact of MA on the morbidity and mortality of the acute coronary syndrome (ACS) in diabetic patients is not definitively known and the relationship between the degree of albuminuria and outcome of ACS is unclear. Aim of the Work: To Study the morbidity and mortality of diabetic patients presenting with acute coronary symptoms in relation to presence of MA during ICU admission. Patient and Methods: This study was planned to evaluate the impact of MA on outcome of ACS in diabetics patients admitted to ICU in internal medicine department Zagazig University. The study included 80 patients with acute coronary syndrome 60 diabetics and 20 non diabetics. Patients were classified into four groups: Group (A): 20 ACS non diabetic patients with no albuminuria. Group (B): 20 ACS type 2 diabetic patients without albuminuria. Group (C): 20 ACS type 2 diabetic patients with MA. Group (D): 20 ACS type 2 diabetic patients with macroalbuminuria. Urinary albumin excretion rate was performed to all patients with ACS. They were followed up during their staying in the ICU for the occurrence of heart failure, pulmonary embolism, shock, arrithymia or death. Serum lipid profile and HbA1c were performed also for all patients. Results: Complications occurred more significantly in albuminuric patients with MA (70%) and with macroalbuminuria (65%) than non albuminuric patients (20%);(P<0.001). Complications also occurred more significantly in patients with HbA1c>7%(69.7%) than those with HbA1c<7%(30.3%);(P<0.001). Also complications occurred more significantly in patients with serum triglyceride>150 mg/dl(78.4%) than those with serum triglyceride<150 mg/dl(14%);(P<0.001) and LDL>100mg/dl(82.4) than those with LDL<100mg/dl(15.3%);(P<0.001). Conclusions: There is a significant prevalence of albuminuria in diabetic patients in comparison with non diabetic patients. Complications including life threatening disorder as arrhythmia, heart failure, shock and cardiac arrest occurred more significantly in diabetic albuminuric patients with ACS during admission to ICU. Complications occurred more significantly in patients with abnormal lipid profile especially patients with hypertriglyceridemia or LDL > 100mg/dl. Keyword: Microalbuminuria, Cardiovascular disease, Acute Coronary Syndrome, Diabetes, Hypertriglyceridemia. INTRODUCTION icroalbuminuria (MA) is a wellknown risk factor for coronary artery disease (CAD) in diabetics and non diabetics. It is associated with higher cardiovascular mortality, especially in diabetics. However, there are few data linking angiographic severity of CAD to MA (1). The presence of albuminuria is a powerful predictor of cardiovascular risk in patients with type 2 diabetes (T2D) and hypertension. In addition, multiple studies have shown that decreasing the level of albuminuria reduces the risk of adverse cardiovascular outcomes (2). In most survival studied in non-insulin dependant diabetes mellitus (NIDDM), microalbuminuria predicts early mortality; in cross-section studies, it is associated with CAD morbidity (3). MA was found to be an independent predictor for the presence and severity of CAD. A strong relationship between MA and the severity of CAD was reported by Deveci et al., (4). However, the impact of MA on the morbidity and mortality of the acute coronary syndrome (ACS) in diabetic patients is not definitively known and the relationship between the degree of albuminuria and outcome of ACS is unclear. The aim of this work is to Study the morbidity and mortality of diabetic patients presenting with acute coronary symptoms in relation to presence of MA during ICU admission. PATIENTS AND METHODS This study had been carried out in Internal Medicine Department, Cardiological Intensive Care Unite, and Biochemistry Department at Zagziag University Hospitals. It included 80 patients with ACS: 60 diabetics and 20 non diabetics. Their ages ranged from 50 to 86 yrs old with mean ± SD 59.7 ±8.7 years and 40 of them are males and other 40 are females. Inclusion criteria: Patients who were diagnosed to have ACS were included in this study either diabetics or not. Exclusion criteria: Patient with renal disease, liver dysfunction, those receiving medication affecting kidney albumin excretion were exclude from this study. Patients were classified into 4 groups: Group (A): 20 ACS non diabetic patients with no albuminuria. Their age ranged from (45 -75) years. M Z.U.M.J.Vol.19; N.6; November; 2013 -476study of the impact of microalbuminuria on  Group (B): 20 ACS type 2 diabetic patients without albuminuria Their age ranged from (4575) years. Group (C): 20 ACS type 2 diabetic patients with MA. Their age ranged from (4980) years. Group (D): 20 ACS type 2 diabetic patients with macro albuminuria. Their age ranged from (4870) years. All patients were subjected to the following: Full history taking and detailed clinical examination with particular consideration on:  Symptoms and sings of coronary heart disease.  Estimation of BMI and waist /hip ratio.  Routine laboratory investigations.  Complete blood picture using sysmex S.F3000 automated analyzer.  Liver and kidney function tests using Dimnsion E.S. chemical auto analyzer.  Admission blood glucose level  Urine analysis for detection of albuminuria.  Serum uric acid.  Cardiac enzyme CPKMB  All patients have also  ECG  Plain X-ray chest  Pelvi-abdominal ultrasonography.  Specific laboratory investigations:  Serum lipid profile (cholesterol triglycerides LDLHDL).  HbA1c.  Microalbumin in urine  Creatinine in urine. Principle of methods: 1. HbA1c measured by HbA1c kits (code, 11044, 11045 Bio systems). After preparing the hemolysate, where the labile fraction is eliminated hemoglobins are retained by a cationic exchange resin. HbA1c is specifically eluted after washing away the hemoglobin A1+b fraction1 (HbA1c), and is quantified by direct photometric reading at 415nm. The estimation of the relative concentration of HbA1c is made by the measure of total hemoglobin concentration by direct photometric reading at 415nm. 2. Albuminuria: measured by microalbumin (code, 31324, 31924 Biosystem). Albumin in the urine sample causes agglutination of the latex particles coated with anti-human albumin. The agglutination of the particles is proportional to the albumin concentration and can be measured by turbidimetry. After interpretation of the results of microalbumin in urine and creatinine in urine calculation of albumin creatinine ratio was done. According to National Kidney Disease Program (NKDEP) urine albumin-to-creatinine ratio (UACR) in evaluating patients with T2D for kidney disease: UACR is a ratio between two measured substances. Unlike a dipstick test for albumin, UACR is unaffected by variation in urine concentration. According to NKDEP Albuminuria is a term that describes all levels of urine albumin. Microalbuminuria is a term used to describe urine albumin levels not detected by a dipstick test, i.e., 30mg/g – 300mg/g. Macroalbuminuria is sometimes used to describe albumin levels more than 300mg/g. RESULTS A total of 80 ACS patients (60 T2D and 20 non diabetics) were recruited for the study. 1Study of the demographic data and clinical characteristics among studied groups: Table (1) shows the demographic data among diabetics and non diabetics. The diabetic group comprised 30 women and 30 men while the non diabetic group comprised 8 women and 12 men, the sex distribution didn’t differ significantly between the two groups. The age rang in the diabetic group was (45-75) years while it was in non diabetic group (45-70), the mean age in diabetics was 59.7±8.7 while it was in non diabetics 57.8±8. The mean age didn’t differ significantly between the two groups. There was non-significance between the two groups of the study as regards body weight (BW), height and body mass index (BMI). 2Study of the biochemical parameters between the 2 groups: Table (2) shows the comparison between the 2 groups of the study as regards their serum lipid profile (total cholesterol, triglycerides, low density of lipoprotein [LDL], high density of lipoprotein [HDL]) (mg/dl). Serum total cholesterol was significantly higher in diabetics then non diabetic (p< 0.05) while LDL, HDL didn’t differ significantly between the two groups. Serum triglycerides were none significantly higher in the diabetics than in the non diabetes. On the other hand, admission blood glucose was significantly higher in the diabetics than in the non diabetics (p< 0.001). The same as HbA1c which was significantly higher in diabetics than the non diabetics (p<0.001). Also, the cardiac enzymes (CPK-MB) was non significantly different between the two groups (p > 0.05). Albuminuria expressed by (Alb /cr) ratio was significantly higher in the diabetic group in mg/day in excretion Albumin ̃ mg/g in UACR (g/dL) Creatinine Urine (mg/dL) Albumin Urine  Z.U.M.J.Vol.19; N.6; November; 2013 -477study of the impact of microalbuminuria on  comparison with the non diabetic group (p< 0.001). 3Study of the relation between albuminuria and outcome of ACS patients admitted to ICU: Table (3) shows the outcome was assessed as the occurrence of any complications requiring assistance or death. These complications included life threatening conditions as arrhythmia, heart failure, shock and cardiac arrest. Complications occurred more significantly in the albuminuric patients with microalbuminuria (70%) and with macroalbuminuria (65%) then non albuminuric patients (20%) (p <0.001). Complications occurred more significantly in MA patients (70%) than nonmicroabluminuric patients (20%) (p <0.001). Also, in the relation between MA and outcome there were more significantly in macroalbuminuric patients (65%) than non macroalbuminuric patients (20%)

STUDY OF THE IMPACT OF MICROALBUMINURIA ON THE MORBIDITY AND MORTALITY OF THE ACUTE CORONARY SYNDROME IN DIABETIC PATIENTS DURING ICU ADDMISSION