To review the management of blood glucose in acute coronary syndrome (ACS) a literature search was undertaken using Medline and Embase databases (January 1950—July 2008), bibliographies of retrieved articles, review articles and Department of Health reports. Trials were eligible for inclusion in the review if they (i) included patients with ACS and hyperglycaemia with or without diabetes or compared insulin infusion or glucose-potassium-insulin infusion with active controls, (ii) were randomised, and (iii) assessed mortality and morbidity. Eight trials met the above criteria (two of which have yet to report). Only two of the remaining six trials reported that insulin therapy significantly reduces mortality in ACS patients with hyperglycaemia. In conclusion ACS is of major public health importance in the UK and hyperglycaemia in the setting of ACS is associated with worse outcome. Current variability in management of blood glucose in ACS reflects a paucity of robust evidence to guide practice. Two ongoing trials may resolve the uncertainty about optimum blood glucose management in ACS.
Allender S., Peto V., Scarborough P. et al. Coronary Heart Disease Statistics. London: BHF, 2007.
2.
National Diabetes Support Team.Improving Emergency and Inpatient Care for People with Diabetes. March 2008. Leicester: NDST, 2008 .
3.
Norhammar A. , Tenerz A., Nilsson G. et al. Glucose metabolism in patients with acute myocardial infarction and no previous diagnosis of diabetes mellitus: a prospective study. Lancet2002;359:2140-4.
4.
Stranders I. , Diamant M., Van Gelder RE et al. Admission blood glucose level as risk indicator of death after myocardial infarction in patients with and without diabetes mellitus. Arch Intern Med2004;164: 982-8.
5.
Marfella R., Verrazzo G., Acampora R. et al. Glutathione reverses systemic hemodynamic changes by acute hyperglycemia in healthy subjects. Am J Physiol1995;268:E1167-73.
6.
Kawano H., Motoyama T., Hirashima O. et al. Hyperglycemia rapidly suppresses flow-mediated endothelium-dependent vasodilation of brachial artery. J Am Coll Cardiol1999;34:146-54.
7.
Ishihara M., Inoue I., Kawagoe T. et al. Impact of acute hyperglycemia on left ventricular function after reperfusion therapy in patients with a first anterior wall acute myocardial infarction. Am Heart J2003;146:674-8.
8.
Marfella R., Nappo F., De Angelis L. et al. The effect of acute hyperglycaemia on QTc duration in healthy man . Diabetologia2000;43:571-5.
9.
Libby P., Marroko PR, Braunwald E.The effects of hypoglycaemia on myocardial ischaemic injury during acute experimental coronary artery occlusion. Circulation1975 ;51:621-6.
10.
Kosiborod M. , Inzucchi SE, Goyal A. et al. Relationship between spontaneous and iatrogenic hypoglycemia and mortality in patients hospitalized with acute myocardial infarction. JAMA2009;301:1556-64.
11.
Weston C., Walker L., Birkhead J.Early impact of insulin treatment on mortality for hyperglycaemic patients without known diabetes who present with an acute coronary syndrome . Heart2007;93:1542-6.
12.
Kosiborod M. , Rathore SS, Inzucchi SE et al. Admission glucose and mortality in elderly patients hospitalised with acute myocardial infarction: implications for patients with and without recognised diabetes. Circulation2005;111:3078-86.
13.
Malmberg K. , Ryden L., Efendic S. et al. Randomised trial of insulin glucose infusion followed by subcutaneous insulin treatment in diabetic patients with acute myocardial infarction (DIGAMI Study): effects on mortality at 1 year . J Am Coll Cardiol1995;26:57-65.
14.
Van Den Berghe G., Wouters P., Weekers F. et al. Intensive insulin therapy in critically ill patients. N Engl J Med2001;345:1359-67.
15.
Van den Berghe G., Wilmer A., Hermans G. et al. Intensive insulin therapy in the medical ICU. N Engl J Med2006 ;354:449-61.
16.
Furnary AP, Gao G., Grunkemeier GL et al. Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg2003;125:1007-21.
17.
Gandhi GY, Nuttall GA, Abel MD et al. Intensive intraoperative insulin therapy versus conventional glucose management during cardiac surgery. Ann Intern Med2007;146:233-43.
18.
Golden SH, Camille PV, Kao WHL, Brancat F.Perioperative glycaemic control and the risk of infectious complications in a cohort of adults with diabetes. Diabetes Care1999;22:1408-14.
19.
Furnary AP, Zerr KJ, Grunkemeier GL, Starr A.Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures . Ann Thorac Surg1999;67:352-62.
20.
Malmberg K. , Ryden L., Wedel H. et al. Intense metabolic control by means of insulin in patients with diabetes mellitus and acute myocardial infarction (DIGAMI 2); effects on mortality and morbidity. Eur Heart J2005;26:650-61.
21.
Diaz R., Paolasso EC, Piegas LS et al. Metabolic modulation of acute myocardial infarction: the ECLA glucose-insulin-potassium pilot trial. Circulation1998;98:2227-34.
22.
The CREATE-ECLA Trial Group Investigators: Effect of glucose-insulin-potassium infusion on mortality in patients with acute ST-segment elevation myocardial infarction. JAMA2005;293:437-46.
23.
Ceremuzyński L., Budaj A., Czepiel A. et al. Low-dose glucose-insulin-potassium is ineffective in acute myocardial infarction: results of a randomized multicenter Pol-GIK trial. Cardiovasc Drugs Ther1999; 13:185-9.
24.
Cheung NW, Wong VW, McLean M.The Hyperglycaemia: Intensive Insulin infusion In Infarction (HI-5) Study: A randomised controlled trial of insulin infusion therapy for myocardial infarction. Diabetes Care2006;29:765-70.
25.
The Immediate Metabolic Myocardial Enhancement During Initial Assessment and Treatment in Emergency (IMMEDIATE) care study. www.clinicaltrials.gov/show/NCT00091507 (Accessed 14 July 2008).
26.
INTENSIVE Trial.www.sanofi-aventis.ca/live/ca/medias/CC1E2A67-6117-4B3E-8077-7CD98621BD50.pdf (Accessed 14 July 2008).
27.
Opie LHMetabolic management of acute myocardial infarction comes to the fore and extends beyond control of hyperglycaemia. Circulation2008;117:2172-7.
28.
Diaz R., Goyal A., Mehta SR et al. Glucose-insulin-potassium therapy in patients with ST-segment elevation myocardial infarction. JAMA2007;298:2399-405.
29.
Chaudhuri A. , Miller M., Nesto R. et al. Targeting glucose in acute myocardial infarction: has glucose, insulin, and potassium infusion missed the target?Diabetes Care2007;30:3026-28.
