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Original Investigation
March 9, 2009

Glucose Normalization and Outcomes in Patients With Acute Myocardial Infarction

Author Affiliations

Author Affiliations: Department of Cardiovascular Research, Mid America Heart Institute (Drs Kosiborod, Xiao, and Spertus and Mr Jones), Department of Internal Medicine (Cardiology), University of Missouri—Kansas City School of Medicine (Drs Kosiborod and Spertus), and Cerner Corporation (Ms Fiske), Kansas City, Missouri; Department of Internal Medicine (Endocrinology) (Dr Inzucchi) and (Cardiology) (Dr Krumholz), Yale University School of Medicine, New Haven, Connecticut; Department of Internal Medicine (Cardiology), Denver Health Medical Center and University of Colorado Denver Health Sciences Center, Denver (Dr Masoudi); and Department of Epidemiology, Emory School of Public Health and Department of Internal Medicine (Cardiology), Emory University School of Medicine, Atlanta, Georgia (Dr Goyal).

Arch Intern Med. 2009;169(5):438-446. doi:10.1001/archinternmed.2008.593
Abstract

Background  Elevated blood glucose levels on admission are associated with increased mortality in patients with acute myocardial infarction. Whether glucose normalization after admission is associated with improved survival remains controversial. In addition, whether outcomes differ in patients who have spontaneous resolution of hyperglycemia vs those who achieve normoglycemia after treatment with insulin is also unknown.

Methods  We studied 7820 hyperglycemic (admission glucose level, ≥140 mg/dL [to convert glucose to millimoles per liter, multiply by 0.0555]) patients with acute myocardial infarction hospitalized between January 1, 2000, and December 31, 2005, in 40 US hospitals. Patients were stratified according to their mean glucose levels after admission and were divided into those who did and did not receive insulin therapy. Multivariable logistic regression models were developed to examine whether lower glucose levels after admission are independently associated with better survival. Propensity-matching methods were then used to compare in-hospital mortality in patients who did and did not receive insulin therapy.

Results  After multivariable adjustment, lower mean postadmission glucose levels were associated with better survival (for mean postadmission glucose levels of 110 to <140, 140 to <170, 170 to <200, and ≥200 mg/dL, the odds ratios [95% confidence intervals] were 2.1 [1.3-3.5], 5.3 [3.0-8.6], 6.9 [4.1-11.4], and 13.0 [8.0-21.3], respectively, vs <110 mg/dL). Similar results were seen in patients who did and did not receive insulin therapy (P =.74 for insulin therapy × postadmission glucose level interaction). In propensity-matched analysis, mortality rates were similar between insulin-treated and non–insulin-treated patients across the spectrum of mean postadmission glucose levels (range, P = .15 to P = .91).

Conclusions  Glucose normalization after admission is associated with better survival in hyperglycemic patients hospitalized with acute myocardial infarction whether or not they receive insulin therapy. A strategy of intentional glucose lowering with insulin therapy needs to be further tested in future randomized controlled trials.

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