1) The document discusses studies on managing hyperglycemia in patients with acute coronary syndrome (ACS). The DIGAMI study found that tight glycemic control improved long-term survival rates. However, DIGAMI 2 found no difference in mortality between tight control and standard glucose management.
2) An original audit at the hospital aimed to improve blood sugar control in ACS patients in the acute and long-term phases. It found suboptimal control with standard treatments. The proposed new protocol was IV insulin to target blood glucose of 6-10 mmol/L.
3) A recent wider-reaching audit at the hospital assessed 79 ACS patients against standards of care. It found gaps in recording blood glucose, initiating insulin
2. DIGAMI
Multi-centred non-blinded RCT.CCU patients with CBG >11.
•
•
•
Treated with IV insulin for the first 24 hours.
Following this period, QDS SC Insulin
Vs Standard treatment
Tight glycaemic control improves long-term survival
• Mortality significantly lower (19 versus 26 percent) and at 3.4 years
(33 versus 44 percent).
• Greatest reduction in low-risk patients who had not been receiving
insulin prior to the infarction.
• Since DIGAMI also included an outpatient insulin therapy
component, the isolated effect of glycemic control in-hospital could
therefore not be easily assessed
3. DIGAMI 2
Multiple interventions studied, T2DM, Acute MI:
•
•
•
SS followed by long-term, QDS insulin
SS followed by standard O/P glucose control
Routine glucose management according to local practice.
No difference in mortality.
• Low event rate.
• All three groups had similar glycaemic control.
• Failed to recruit enough patients.
4. Original Audit
Aims
• Improve blood sugar control in the acute phase
following an acute coronary event.
• Maintain good glycaemic control in the long term.
Population
• ACS – STEMI + NSTEMI
• All with sugar >11 on admission
5. Admission
• 21 patients all started on SS 10% Dextrose at 25mls/hr
• Suboptimal with CBG rising whilst on them
Proposed
• IV insulin using algorithm adjustment
• 20% dextrose + KCL 20mmol 25ml/h
• Aim sugar 6 – 10
• Stabilise sugars regardless of insulin requirement
6. NICE (Oct 2011)- Managing hyperglycaemia
in inpatients within 48 hours of ACS
1.1.1 Manage hyperglycaemia in patients admitted to hospital for an ACS by
keeping blood glucose levels below 11.0 mmol/litre while avoiding
hypoglycaemia. In the first instance, consider a dose-adjusted insulin
infusion with regular monitoring of blood glucose levels.
1.1.2 Do not routinely offer intensive insulin therapy (an intravenous infusion of
insulin and glucose with or without potassium) to manage hyperglycaemia
(blood glucose above 11.0 mmol/litre) in patients admitted to hospital for an
ACS unless clinically indicated.
Identifying patients with hyperglycaemia after ACS who are at high risk of
developing diabetes
1.1.3 Offer all patients with hyperglycaemia after ACS and without known
diabetes tests for: HbA1c levels before discharge and fasting blood glucose
levels no earlier than 4 days after the onset of ACS.
7. Recent Audit
Wider reaching audit of 79 patients
ACS (Trop T > 15 and clinically relevant) treated as per
trust protocol
ACS occuring in RD&E (Patients transferred from other
trusts excluded)
Data: Notes pull from coding, Pathology system, D/C
Summary
8. Standards
Expected standard - 100%
1. CBG recorded at admission for all patients admitted to
RD&E.
2. All ACS patients with CBG >11 should be treated with IV
insulin for the first 24 hours.
3. CBG should be maintained between 6 to 10 on IV insulin
4. HbA1c requested for all patients with CBG >11.0
5. Diabetic medication should be reviewed if HbA1C >58
(7.5%)
9. Demographic
ACS Type
Gender
Cases
Mean age ± SD
(range)
STEMI NSTEMI
Diabetes type
No
DM
DMT1 DMT2
Male
47
70.3±15.6 (44-97)
5
42
37
1
9
Female
32
81.0±10.3 (44-95)
7
25
22
1
9
Total
79
74.6±14.6 (44-97)
12
67
59
2
18
11. CBG > 11
T1DM
•
Total
T2DM
No known DM
Sliding
scale
started
1 (0.1)
7 (0.7)
2 (0.2)
3 (0.3)
Diabetic review
3 (0.3)
2. 3/10 sliding scales started (for the highest CBG; 21.6, 30.7 and 32.7).
3. One hypoglycaemic episode whilst on the sliding scale.
4. 3/10 had a recent HbA1c result – neither known DM.
5. 2/10 diabetic R/V - resulting in one medication alteration
[100% standard not met]
12. Key findings.
1. No documentation of CBG in 15% - only not known DM
missed
2. Poor initiation of SS 3/10 (2 inappropriate, but 5/10
patient who may have benefited)
3. Non diabetic patients at risk not followed up
13. Recommendations
1. CBG to be completed on admission to RD&E on all
patients.
2. New guidance on SS for all appropriate patients with
CBG >11.0.
3. HbA1c for all diabetic patients and non-diabetic patients
with CBG >11.0 and referral to diabetic team as
appropriate.
14. Recommendations
4. Trust Guidelines to be published for management of
hyperglycaemia in ACS to conform to those of NICE.
5. Re-audit in 6 months to ensure improvement.
15. Discussion
• Is tight glycaemic control really beneficial in most
patients with ACS?
Notas do Editor
As shown in Table 1, 79 cases were audited; STEMI (n=12) and NSTEMI (n=67). 25% of patients had recorded diabetes on admission; DMT1 (n=2) and DMT2 (n=18). The average age of the sample was 74.6 ± 14.6 years old. The average age was 70.3 ± 15.6 and 81 ± 10.3 for males and females respectively, representing a statistically significant 10.7 year difference (p=0.001) [T-test independent sample – equal variance].
able 2 highlights that sliding scales were commenced for three CBG >11 patients (the three highest CBG recorded; 21.6, 30.7 and 32.7). Only one of these patients experienced an episode of hypoglycaemia whilst on the sliding scale. A diabetic review occurred for two CBG>11 patients and one for a patient with a CBG <3, resulting in the addition of insulin to one patient’s medications. Three of the patients with a CBG >11 subsequently died during their hospital admission. Five patients in the sample died; three STEMIs and two NSTEMIs. Of the patients with a CBG >11, seven had DMT2, one had DMT2 and two had were not known to be diabetic.
