The effects of intravenous insulin infusions on early mortality for patients with acute coronary syndromes who present with hyperglycaemia: A matched propensity analysis using data from the MINAP database 2008-2012

Real-world evaluation of glucose-lowering therapies and the use of weight-adjusted variable rate intravenous insulin infusion in the management of hyperglycaemia in patients with acute coronary syndrome (REGULATE-ACS)

INTRODUCTION

Admission hyperglycaemia in acute coronary syndromes (ACS) is a strong independent predictor of adverse clinical outcomes post-ACS. We examined the safety, efficacy, and feasibility of a modified, weight-adjusted variable rate intravenous insulin infusion (VRIII) and evaluated current practice of prescribing novel cardio-protective glucose-lowering therapies in patients presenting with acute hyperglycaemia across the ACS spectrum.

METHODS

REGULATE-ACS was an observational single-centre study of consecutive patients admitted with acute hyperglycaemia post-ACS between 2020 and 2021. Following updated local guidance on a modified VRIII, we evaluated its safety and efficacy in glycaemic control, cardio-metabolic complications including hypoglycaemia (blood glucose <3 mmol/L) and 30-day mortality. We also determined the prescription of glucose-lowering therapies pre-discharge.

RESULTS

Out of 107 patients, mean age was 64.9 ± 12.2 years, 82% had known diabetes, and 15% newly diagnosed diabetes. 86.9% (n = 93) had an admission glucose ≥11 mmol/L. In patients treated with VRIII (n = 63/93, 67.7%), glucose improved from 17.5 to 9.0 mmol/L (IQR 7.1-12.1), which was 3 mmol/L lower (p = 0.03) than in patients not treated with VRIII (n = 30/93, 32.3%) where median glucose reduced from 12.6 to 12 mmol/L (IQR 8.6-13.9). No significant hypoglycaemia, arrhythmia or worsening pulmonary oedema associated with VRIII was found. Novel glucose-lowering therapies were initiated in 20/71 (28.2%) and 3/15 (20.0%) of patients with prior and newly diagnosed diabetes, respectively.

CONCLUSION

This real-world analysis provides further support of efficacy, safety, and feasibility of a modified, weight-adjusted VRIII in managing acute hyperglycaemia in ACS. Despite established cardio-protective benefits of novel glucose-lowering therapies, <1/3 of eligible patients received such agents pre-discharge, demanding further research and awareness.

Glucose-lowering therapy and cardiovascular outcomes in patients with type 2 diabetes mellitus and acute coronary syndrome

Diabetes is a common comorbidity in patients hospitalized for an acute coronary syndrome event, and prevalence is increasing. Among patients hospitalized with acute myocardial infarction, diabetes can be an independent predictor of mortality and new cardiovascular events; both short- and long-term outcomes are worse for patients with diabetes relative to those without, and undiagnosed diabetes is associated with greater mortality. The impact of glycemic control on cardiovascular outcomes and the best approach to treat hyperglycemia upon hospital admission for acute coronary syndrome in patients with or without known diabetes remain open questions. This review assesses available evidence for hyperglycemia management at the time of admission for acute coronary syndrome and, thereafter, finds that (1) admission plasma glucose plays a role in predicting adverse events, especially in patients with unknown diabetes; (2) glycated haemoglobin is a likely predictor of events in patients with unknown diabetes; and (3) hypoglycemia at the time of acute myocardial infarction hospital admission is an important predictor for mortality in patients with and without diabetes. Whether glucose-targeted insulin and glucose infusion have advantages over glucose-insulin-potassium infusion remains controversial. Evidence for the effect of novel glucose-lowering agents used at the time of an acute cardiovascular event is limited and requires more dedicated studies.

Thrombus aspiration in hyperglycemic ST-elevation myocardial infarction (STEMI) patients: clinical outcomes at 1-year follow-up

Objectives

We evaluate whether the thrombus aspiration (TA) before primary percutaneous coronary intervention (PPCI) may improve STEMI outcomes in hyperglycemic patients.

Background

The management of hyperglycemic patients during STEMI is unclear.

Methods

We undertook an observational cohort study of 3166 first STEMI. Patients were grouped on the basis of whether they received TA or not. Moreover, among these patients we selected a subgroup of STEMI patients with hyperglycemia during the event (glycaemia > 140 mg/dl). The endpoint at 1 year included all-cause mortality, cardiac mortality and re-hospitalization for coronary disease, heart failure and stroke.

Results

One-thousand STEMI patients undergoing PPCI to plus TA (TA-group) and 1504 STEMI patients treated with PPCI alone (no-TA group) completed the study. In overall study-population, Kaplan–Meier-analysis demonstrated no significant difference in mortality rates between patients with and without TA (P = 0.065). After multivariate Cox-analysis (HR: 0.94, 95% CI 0.641–1.383) and the addition of propensity matching (HR: 0.86 95% CI 0.412–1.798) TA was still not associated with decreased mortality. By contrast, in hyperglycemic subgroup STEMI patients (TA-group, n = 331; no-TA group, n = 566), Kaplan–Meier-analysis demonstrated a significantly lower mortality (P = 0.019) in TA-group than the no-TA group. After multivariate Cox-analysis (HR: 0.64, 95% CI 0.379–0.963) and the addition of propensity matching (HR: 0.54, 95% CI 0.294–0.984) TA was still associated with decreased mortality.

Conclusions

TA was not associated with lower mortality in PPCI for STEMI when used in our large all-comer cohort. Conversely, TA during PPCI for STEMI reduces clinical outcomes in hyperglycemic patients.

Trial registration NCT02817542. 25th, June 2016

Electronic supplementary material

The online version of this article (10.1186/s12933-018-0795-8) contains supplementary material, which is available to authorized users.

Impact of acute diabetes decompensation on outcomes of diabetic patients admitted with ST-elevation myocardial infarction

BACKGROUND

Acute hyperglycemia is associated with worse outcomes in diabetic patients admitted with ST-elevation myocardial infarction (STEMI). However, the impact of full-scale decompensated diabetes on STEMI outcomes has not been investigated.

METHODS

We utilized the national inpatient sample (2003-2014) to identify adult diabetic patients admitted with STEMI. We defined decompensated diabetes as the presence of diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar state (HHS). We compared in-hospital morbidity and mortality and cost between patients with and without diabetes decompensation before and after propensity-score matching.

RESULTS

A total of 73,722 diabetic patients admitted with STEMI were included in the study. Of those, 1131 (1.5%) suffered DKA or HSS during the hospitalization. After propensity-score matching, DKA/HHS remained associated with a significant 32% increase in in-hospital mortality (25.6% vs. 19.4%, p = 0.001). The DKA/HHS group also had higher incidences of acute kidney injury (39.4% vs. 18.9%, p < 0.001), sepsis (7.3% vs. 4.9%, p = 0.022), blood transfusion (11.3% vs. 8.2%) and a non-significant trend towards higher incidence of stroke (3.8% vs. 2.4%, p = 0.087). Also, DKA/HHS diagnosis was associated with lower rates of referral to coronary angiography (51.5% vs. 55.5%, p = 0.023), coronary stenting (26.1% vs. 34.8%, p < 0.001), or bypass grafting (6.2% vs. 8.7%, p = 0.033). Referral for invasive angiography was associated with lower odds of death during the hospitalization (adjusted OR 0.66, 95%CI 0.44-0.98, p = 0.039).

CONCLUSIONS

Decompensated diabetes complicates ~ 1.5% of STEMI admissions in diabetic patients. It is associated with lower rates of referral for angiography and revascularization, and a negative differential impact on in-hospital morbidity and mortality and cost.