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MI & Hyperglycaemia: Intensive insulin therapy reduces mortality!

In patients with a blood glucose > 11 mmol/L following a heart attack, for every 9 patients given an insulin-glucose infusion for ³ 24 hrs then qid subcutaneous insulin for ³ 3 months, compared to standard therapy, one less death occurs over the next 3.5 years.  (95% CI 5 to 34)

Level 1+ evidence   

 

Citation/s: Prospective randomised study of intensive insulin treatment on long term survival after acute MI in patients with diabetes mellitus. BMJ 1997; 314(7093): 1512-1515.


Lead author's name and fax: Klas Malmberg, DIGAMI study group, Dept of Cardiology, Karolinska Hospital, S-171 76 Stockholm, Sweden

 

Three-part Clinical Question: Among hyperglycaemic patients with acute myocardial infarction, does more intensive insulin therapy reduce mortality?


Search Terms: hyperglycaemia AND myocardial infarction

 

The Study:    Non-blinded concealed randomised controlled trial with intention-to-treat.


The Study Patients: All patients admitted to CCU with an acute MI within the previous 24 hours (with or without a previous diagnosis of diabetes mellitus) whom had a blood glucose >11 mmol/L.


Control group (N = 314; 314 analysed): Standard CCU care. These patients did not receive any insulin unless clinically indicated.   The clinical indications were not clearly stated either in this paper or in the previous one J Am Col Cardiology 1995; 26: 57-65. If there were no contraindications, thrombolysis, B blockers & aspirin was started.


Experimental group (N = 306; 306 analysed): Standard CCU care plus an insulin-glucose infusion for ³ 24 hours and then qid subcutaneous insulin for ³ 3 months. If there were no contraindications, thrombolysis, B blockers & aspirin was started.

 

The Evidence:

 

Outcome

Time to Outcome

CER

EER

RRR

ARR

NNT

Mortality at 1 year

1 year

0.261

0.190

27%

0.071

14

95% Confidence Intervals:

2% to 52%

0.005 to 0.137

7 to 182

Mortality at end of follow up (Median 3.5yrs)

End of follow up 3.5 years

0.439

0.333

24%

0.106

9

95% Confidence Intervals:

7% to 41%

0.030 to 0.182

5 to 34

 

Comments:

  1. Benefit greatest in low risk patients (<70 years old, no prior MI, no CHF, no digoxin therapy) not previously on insulin.

  2. 50% thrombolysed; by discharge 80% given aspirin, 70% given beta-blockers, and 31% given ACE-inhibitors.  No difference between groups.

  3. 72 % in the infusion group & 49% in the control group were taking insulin at 1 year.

  4. The infusion group required 2 extra hospital days.

Appraised by: Kevin Rooney, Department of Anaesthesia & Intensive Care Medicine, Royal Alexandra Hospital, Paisley; 30 December 2002   Email: kd.rooney@virgin.net

Kill or Update By: December 2004

 

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