[Glycemic control in the coronary care unit: prognostic value and new therapeutic strategies]

Type 2 diabetes and acute coronary syndromes are widely interconnected. Individuals with type 2 diabetes are more likely than non-diabetic subjects to experience silent or manifest episodes of myocardial ischemia as the first presentation of coronary artery disease. Insulin resistance, inflammation, microvascular disease and a tendency to thrombosis are common in these patients. Intensive blood glucose control with intravenous insulin infusion has been demonstrated to significantly reduce morbidity and mortality in critically ill hyperglycemic patients admitted to an intensive care unit. Direct glucose toxicity likely plays a crucial role in explaining the clinical benefits of intensive insulin therapy in such critical patients. However, the difficult implementation of nurse-driven protocols for insulin infusion, able to achieve more rapid and effective blood glucose control without significant episodes of hypoglycemia, has led physicians to consider alternative drugs for this purpose. New intravenous or oral agents include the incretin glucagon-like peptide-1, its analogs, and dipeptidyl peptidase-4 inhibitors, which potentiate the activity of glucagon-like peptide-1 and thus enhance glucose-dependent insulin secretion. Improved glycemic control with protective effects on myocardial and vascular tissue, with lesser side effects and a better therapeutic compliance may represent an important therapeutic potential for this class of drugs in acutely ill patients in general, and in patients with acute coronary syndromes in particular. Such drugs should be known by practicing cardiologists for their possible use in intensive care units in the years to come.