Glycemic control for acute myocardial infarction in patients with and without diabetes mellitus
- Richard W Nesto, MD
Richard W Nesto, MD
- Professor of Medicine
- Tufts University School of Medicine
- Silvio E Inzucchi, MD
Silvio E Inzucchi, MD
- Professor of Medicine
- Yale University School of Medicine
- Section Editors
- Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Coronary Heart Disease; Myopericardial Disease
- Professor of Medicine
- Mayo Clinic College of Medicine
- David M Nathan, MD
David M Nathan, MD
- Editor-in-Chief — Endocrinology
- Section Editor — Diabetes Mellitus
- Professor of Medicine
- Harvard Medical School
Patients with diabetes mellitus are at increased risk for myocardial infarction (MI) and diabetes is considered a coronary risk equivalent by the National Cholesterol Education Program , since type 2 diabetic patients without a prior MI have the same risk of developing an MI as nondiabetic patients who have already had an MI (figure 1) . (See "Prevalence of and risk factors for coronary heart disease in diabetes mellitus".)
Maintenance of strict glycemic control improves long-term microvascular outcomes in patients with both type 1 and type 2 diabetes. Intensive glycemic control aiming for near-normal levels has been shown to have a substantial beneficial effect (58 percent reduction in major CVD events) on macrovascular outcomes in type 1 diabetes, when applied early in the disease course and after one to two decades of therapy. In the setting of type 2 diabetes, with several co-prevalent risk factors for CVD, any beneficial effects of intensive glycemic control on macrovascular disease are likely to be less than those from similarly stringent control of blood pressure and lipid levels. In the acute setting, the evidence of benefit from strict glycemic control with insulin therapy in patients with acute MI is limited. The evidence in other groups of patient is inconsistent. (See "Glycemic control and intensive insulin therapy in critical illness" and "Glycemic control and vascular complications in type 1 diabetes mellitus" and "Glycemic control and vascular complications in type 2 diabetes mellitus".)
Poor glycemic control in diabetic patients and stress hyperglycemia in nondiabetic patients is associated with worse outcomes after acute MI but it is not fully understood as to whether strict glycemic control during AMI hospitalizations improves outcomes. These issues will be reviewed here.
The possible value of glycemic control in diabetic patients undergoing coronary artery bypass graft surgery is discussed separately. (See "Coronary artery revascularization in patients with diabetes mellitus and multivessel coronary artery disease", section on 'Perioperative glycemic control'.)
SERUM VERSUS BLOOD GLUCOSE
Practitioners should be aware that glucose measured in whole blood is generally 12 percent lower than values obtained from serum (or plasma). In the studies cited below, an attempt has been made to specify which was reported.
- National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation 2002; 106:3143.
- Haffner SM, Lehto S, Rönnemaa T, et al. Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. N Engl J Med 1998; 339:229.
- Capes SE, Hunt D, Malmberg K, Gerstein HC. Stress hyperglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview. Lancet 2000; 355:773.
- Malmberg K, Norhammar A, Wedel H, Rydén L. Glycometabolic state at admission: important risk marker of mortality in conventionally treated patients with diabetes mellitus and acute myocardial infarction: long-term results from the Diabetes and Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) study. Circulation 1999; 99:2626.
- Wahab NN, Cowden EA, Pearce NJ, et al. Is blood glucose an independent predictor of mortality in acute myocardial infarction in the thrombolytic era? J Am Coll Cardiol 2002; 40:1748.
- Kosiborod M, Rathore SS, Inzucchi SE, et al. Admission glucose and mortality in elderly patients hospitalized with acute myocardial infarction: implications for patients with and without recognized diabetes. Circulation 2005; 111:3078.
- Mehta SR, Yusuf S, Díaz R, et al. Effect of glucose-insulin-potassium infusion on mortality in patients with acute ST-segment elevation myocardial infarction: the CREATE-ECLA randomized controlled trial. JAMA 2005; 293:437.
- Goyal A, Mehta SR, Díaz R, et al. Differential clinical outcomes associated with hypoglycemia and hyperglycemia in acute myocardial infarction. Circulation 2009; 120:2429.
- Suleiman M, Hammerman H, Boulos M, et al. Fasting glucose is an important independent risk factor for 30-day mortality in patients with acute myocardial infarction: a prospective study. Circulation 2005; 111:754.
- Cao JJ, Hudson M, Jankowski M, et al. Relation of chronic and acute glycemic control on mortality in acute myocardial infarction with diabetes mellitus. Am J Cardiol 2005; 96:183.
- Timmer JR, Ottervanger JP, de Boer MJ, et al. Hyperglycemia is an important predictor of impaired coronary flow before reperfusion therapy in ST-segment elevation myocardial infarction. J Am Coll Cardiol 2005; 45:999.
- Pinto DS, Skolnick AH, Kirtane AJ, et al. U-shaped relationship of blood glucose with adverse outcomes among patients with ST-segment elevation myocardial infarction. J Am Coll Cardiol 2005; 46:178.
- Svensson AM, McGuire DK, Abrahamsson P, Dellborg M. Association between hyper- and hypoglycaemia and 2 year all-cause mortality risk in diabetic patients with acute coronary events. Eur Heart J 2005; 26:1255.
- Kosiborod M, Inzucchi SE, Krumholz HM, et al. Glucometrics in patients hospitalized with acute myocardial infarction: defining the optimal outcomes-based measure of risk. Circulation 2008; 117:1018.
- Kosiborod M, Inzucchi SE, Goyal A, et al. Relationship between spontaneous and iatrogenic hypoglycemia and mortality in patients hospitalized with acute myocardial infarction. JAMA 2009; 301:1556.
- Franklin K, Goldberg RJ, Spencer F, et al. Implications of diabetes in patients with acute coronary syndromes. The Global Registry of Acute Coronary Events. Arch Intern Med 2004; 164:1457.
- 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. Lancet 2002; 359:2140.
- Malmberg K. Prospective randomised study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus. DIGAMI (Diabetes Mellitus, Insulin Glucose Infusion in Acute Myocardial Infarction) Study Group. BMJ 1997; 314:1512.
- Malmberg K, Rydén 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 J 2005; 26:650.
- Cheung NW, Wong VW, McLean M. The Hyperglycemia: Intensive Insulin Infusion in Infarction (HI-5) study: a randomized controlled trial of insulin infusion therapy for myocardial infarction. Diabetes Care 2006; 29:765.
- Kosiborod M, Inzucchi SE, Krumholz HM, et al. Glucose normalization and outcomes in patients with acute myocardial infarction. Arch Intern Med 2009; 169:438.
- Finney SJ, Zekveld C, Elia A, Evans TW. Glucose control and mortality in critically ill patients. JAMA 2003; 290:2041.
- Anderson J, Adams C, Antman E, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 2002 Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, American College or Physicians, Society for Academic Emergency Medicine, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2007; 50:e1 www.acc.org/qualityandscience/clinical/statements.htm (Accessed on September 18, 2007).
- Van den Berghe G, Wilmer A, Hermans G, et al. Intensive insulin therapy in the medical ICU. N Engl J Med 2006; 354:449.
- Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:2354.
- SERUM VERSUS BLOOD GLUCOSE
- HYPERGLYCEMIA AND OUTCOME AFTER ACUTE MI
- Predictive value of admission glucose
- J- or U-shaped curve
- Worse outcomes in diabetic patients
- UNDIAGNOSED DIABETES
- VALUE OF GLYCEMIC CONTROL
- Critically ill patients
- Studies of patients with acute MI
- - DIGAMI trial
- - DIGAMI-2 trial
- - HI-5 trial
- - Observational evidence
- General medical patients
- METHOD OF TREATMENT
- RECOMMENDATIONS OF OTHERS
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS