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Managing the diabetic patient with acute myocardial infarction
1Centre for Diabetes and Cardiovascular Risk, University College London, UK.
Insights
Diabetic patients with acute myocardial infarction face higher mortality. Prompt thrombolysis, aspirin, and insulin-glucose infusion significantly improve outcomes, reducing deaths by about one-third.
Area of Science:
- Cardiology
- Diabetology
- Internal Medicine
Background:
- Diabetic patients experience nearly double the in-hospital mortality after acute myocardial infarction (AMI) compared to non-diabetic individuals.
- Despite higher risks, several interventions can significantly improve outcomes for diabetic patients with AMI.
Purpose of the Study:
- To review interventions that improve outcomes for diabetic patients experiencing acute myocardial infarction.
- To assess the efficacy and safety of thrombolytic therapy, aspirin, and insulin-glucose infusion in this high-risk population.
Main Methods:
- Literature review of studies examining interventions for diabetic patients with AMI.
- Analysis of data on thrombolytic therapy, aspirin administration, and the impact of the DIGAMI (Diabetes Mellitus, Insulin Glucose infusion in Acute Myocardial Infarction) study protocols.
Main Results:
- Thrombolytic therapy offers similar proportional benefits to non-diabetics, with greater absolute benefits due to higher baseline risk. Intraocular hemorrhage is rare.
- Aspirin administration at presentation is beneficial, with potential advantages for higher doses in diabetic patients.
- The DIGAMI study demonstrated that insulin-glucose infusion followed by multiple injections reduces mortality by approximately one-third at 12 months and 3.5 years.
Conclusions:
- Thrombolytic therapy and aspirin should be used in diabetic patients with AMI, despite theoretical concerns.
- Insulin-glucose infusion protocols, as shown by the DIGAMI study, significantly reduce mortality and should be implemented for all admitted diabetic patients with AMI.
- The benefits of insulin therapy may relate to glycemic control or sulfonylurea withdrawal, but its efficacy warrants immediate clinical application.
Abstract:
The diabetic patient has a substantially increased in-hospital mortality after acute myocardial infarction, which is around twice that of non-diabetic subjects. A number of interventions can substantially improve this outcome. The use of thrombolytic therapy reduces case fatality proportionately to a similar degree to that in non-diabetic patients, but because of the higher background risk, absolute benefits are substantially greater. In the world literature, there is just one reported case of intraocular haemorrhage after thrombolysis in a diabetic patient, and that resolved in 3 weeks, meaning that anxieties around theoretical adverse effects of thrombolysis should not preclude its use. There is no evidence regarding the advantages of any one thrombolytic agent in these subjects. Aspirin treatment again has similar benefits to those in non-diabetic subjects, and should be administered at presentation. Some evidence suggests that a higher dose of aspirin should be used in diabetic, compared to non-diabetic, patients. Finally, the DIGAMI Study has shown that insulin and glucose infusion during the hospital admission, followed by multiple injection therapy thereafter, reduces mortality by around one-third, both at 12 months and at around 3 1/2 years. Whether these advantages are because of improved early or late glycaemic control, or because of withdrawal of sulphonylureas, is still unclear, but this uncertainty should not stand in the way of introducing policies for insulin infusion in all diabetic patients admitted with acute myocardial infarction.