Test Your Knowledge Answer #404

This patient has multiple cardiac risk factors and is at significant risk for future morbidity and mortality from coronary artery disease. The Diabetes and Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) study showed a significant reduction in mortality in patients with diabetes who received intravenous insulin and glucose for the first 24 to 36 hours of hospitalization regardless of blood glucose levels. 

 

Tight glycemic control has been shown to be beneficial in this setting and reduces mortality for years after the acute event; therefore it is imperative that diabetes care not be neglected during this time. Although controversial, evidence also suggests that higher dosages of sulfonylureas may increase cardiac mortality; therefore, these drugs are usually avoided in patients with acute myocardial injury. Although the patient may eventually benefit from the addition of an insulin sensitizer such as metformin, which can improve lipid profile and glycemic control, its initiation at this point would be unwise because the patient may require cardiac catheterization, which could compromise his renal function. Similarly, a thiazolidinedione might be a useful future addition to his regimen, but its delayed onset of action and tendency to promote fluid retention, especially in the setting of insulin use, do not make it a good choice at this time. 

 

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