Saturday, February 08, 2014

Glycemic control and outcome in patients with ACS

This is not practice changing but interesting:

Objective  To study the effectiveness and safety of intensive glucose management in patients with ACS who have hyperglycemia, aiming at strict blood glucose normalization...
Patients with ACS with an admission plasma glucose level of 140 to 288 mg/dL were eligible for inclusion and enrolled from July 23, 2008, to February 8, 2012. Patients with insulin-dependent diabetes mellitus were excluded.

By insulin-dependent I'm not sure if they meant DM type 1 or patients with DM 2 who were on insulin for glycemic control.  Anyway, here's more from the paper:

Interventions  Intensive glucose management strategy, aiming at a plasma glucose level of 85 to 110 mg/dL by using intravenous insulin, or to conventional expectative glucose management...
Main Outcomes and Measures  End points were assessed according to the intention-to-treat principle. The primary end point was high-sensitivity troponin T value 72 hours after admission (hsTropT72); secondary end points, area under the curve of creatine kinase, myocardial band (AUC–CK-MB), release and myocardial perfusion scintigraphy findings at 6 weeks’ follow-up.
Results  In the intensive management arm, median hsTropT72 was 1197 ng/L (25th and 75th percentiles of distribution, 541-2296 ng/L) vs 1354 ng/L (530-3057 ng/L) in the conventional arm (P = .41). Median AUC–CK-MB was 2372 U/L (1242-5004 U/L) vs 3171 U/L (1620-5337 U/L) (P = .18). The difference in median extent of myocardial injury measured by myocardial perfusion scintigraphy was not significant (2% vs 4%) (P = .07). Severe hypoglycemia (less than 50 mg/dL) was rare and occurred in 13 patients. Before discharge, death or a spontaneous second myocardial infarction occurred in 8 patients (5.7%) vs 1 (0.7%) (P = .04).
Conclusions and Relevance Intensive glucose regulation did not reduce infarct size in hyperglycemic patients with ACS treated with PCI, and was associated with harm.

The glycemic target of the treatment group, 85-110 mg/dl, is one we would never use today in hospitalized patients. It has been shown over and over again that in hospitalized patients with a variety of conditions such intensity of control is not beneficial and probably harmful. Neither should we ignore hyperglycemia. The problem is we do not know the optimal level. We have a lot of research looking at these very strict targets.
 We need more evidence about more relaxed control targets.

No comments: