Lowering Glucose in AMI Patients Improves Survival 

Adding to evidence linking hyperglycemia and mortality in acute myocardial infarction (AMI) patients, a new observational study indicates that AMI patients with hyperglycemia at the time of hospital admission whose glucose levels fall to normal ranges during their hospital stay are more likely to survive.

Adding to evidence linking hyperglycemia and mortality in acute myocardial infarction (AMI) patients, a new observational study indicates that AMI patients with hyperglycemia at the time of hospital admission whose glucose levels fall to normal ranges during their hospital stay are more likely to survive.

The study, showed that survival rates were no different in people given insulin than in those whose glucose normalized spontaneously.

“We know elevated glucose is common in the setting of AMI, and we know that it’s associated with very bad outcomes — mortality, complications in the hospital, etc…; what has been less clear is whether a patient who is hyperglycemic at the time of admission to the hospital but whose glucose normalizes during the hospital stay has outcomes actually better than patients who remain hyperglycemic.” First author on the study, Dr Mikhail Kosiborod (Saint Luke’s Hospital, Kansas City, MO), explained that, “What we definitively showed, from an epidemiologic standpoint, is that there is clearly an association between normalization of glucose levels in patients who are initially hyperglycemic and better survival.”

Kosiborod and colleagues collected data on 7,820 AMI patients with admission glucose levels ≥ 140 mg/dL, looking at whether or not their glucose levels fell during hospitalization and further, whether they survived their hospital stay. Roughly 50% of patients had diabetes and 39% were given insulin during their hospitalization.

They found that patients with lower mean postadmission glucose levels were associated with better survival and, specifically, that levels in the range of 80 to 130 mg/dL were associated with the lowest mortality risk. This range is even lower than that recommended in last year’s American Heart Association (AHA) scientific statement on hyperglycemia and acute coronary syndrome (ACS), which emphasizes that while the ideal treatment goal is unknown, a level below 140 mg/dL is reasonable.
Adjusted Odds Ratio for Mortality, as Compared With Postadmission Glucose Levels < 110 mg/dL

Group	110 – 140 mg/dL	140 – 170 mg/dL	> 200 mg/dL
All	2.1*	5.3	13.0
Insulin-treated	1.6	4.3	9.4
Non-insulin-treated	2.9	6.6	18.1

In an analysis that took into account whether insulin was used to bring glucose levels down, Kosiborod et al found no differences in survival rates.

“There’s a very lively debate over whether insulin might have certain effects on cardiovascular outcomes above and beyond glucose-lowering effects,” Kosiborod explained, giving myocardial blood flow and anti-inflammatory effects as hypothetical examples. “Our data would suggest that the effect on prognosis in AMI patients was purely driven by whether their glucose was normal or not, regardless of whether that normalization occurred spontaneously or whether it was patients who were normalized after initiation of insulin. That doesn’t mean insulin has no role; all it means is that the prognosis is probably determined by glucose.”

The study, he emphasized, is purely “hypothesis-generating” but paves the way for a randomized controlled trial in which the 80- to 130-mg/dL glucose range is used as a target to test whether glucose-lowering leads to improved outcomes.

“These are observational data,” he said. “All we can say is that there is a statistical association, it’s very strong, and it’s very compelling, but it’s just an association.”

Practice Pearls:

• Lower mean postadmission glucose levels were associated with better survival rates, after multivariable adjustment. Patients with postadmission glucose levels of 80 to 130 mg/dL had the lowest mortality rates.
• The findings were similar in patients who did and did not receive insulin therapy. Mortality rates were similar between insulin-treated and non-insulin-treated patients across the spectrum of mean postadmission glucose levels.

Kosiborod M, Inzucchi SE, Krumholz HM, et al. Glucose normalization and outcomes in patients with acute myocardial infarction. Arch Intern Med. 2009;169:438-446.

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