Letters Section Editor: Robert M. Golub,
MD, Senior Editor.
To the Editor: I believe that the negative
conclusions of the CREATE-ECLA trial regarding the effect of glucose-insulin-potassium
(GIK) infusion on mortality in acute myocardial infarction (AMI)1 are
not justified because of the late timing of the infusion. The metabolic actions
of GIK can slow the rate of injury during severe ischemia but will not prevent
it indefinitely; thus, GIK increases salvage from subsequent effective reperfusion.2- 5 However,
in CREATE-ECLA, reperfusion therapy was given a median of 3.8 to 3.9 hours
after symptom onset, almost an hour before randomization
to GIK or control groups occurred (a median of 4.7 hours after symptom onset).
Moreover, GIK was not then started immediately but within the next hour (a
median of 4.7-5.7 hours after symptom onset). Experimental studies have demonstrated
marked anti-ischemic protection by GIK when it is started early and well before
reperfusion3; in CREATE-ECLA, only 2.8% of
patients were randomized within an hour of ischemia symptom onset.
Apstein CS. Glucose-Insulin-Potassium Infusion and Mortality in the CREATE-ECLA Trial. JAMA. 2005;293(21):2596-2598. doi:10.1001/jama.293.21.2596