Identifying and Managing Hyperglycaemia in ACS

Chris Redford, CT2

Mark Williams, F1

DIGAMIMulti-centred non-blinded RCT.CCU patients with CBG >11.

• Treated with IV insulin for the first 24 hours. • Following this period, QDS SC Insulin• Vs Standard treatment

Tight glycaemic control improves long-term survival

• Mortality significantly lower (19 versus 26 percent) and at 3.4 years (33 versus 44 percent).

• Greatest reduction in low-risk patients who had not been receiving insulin prior to the infarction.

• Since DIGAMI also included an outpatient insulin therapy component, the isolated effect of glycemic control in-hospital could therefore not be easily assessed

DIGAMI 2Multiple interventions studied, T2DM, Acute MI:

• SS followed by long-term, QDS insulin• SS followed by standard O/P glucose control• Routine glucose management according to local practice.

No difference in mortality.• Low event rate.• All three groups had similar glycaemic control.• Failed to recruit enough patients.

Original AuditAims• Improve blood sugar control in the acute phase

following an acute coronary event.• Maintain good glycaemic control in the long term.

Population• ACS – STEMI + NSTEMI • All with sugar >11 on admission

Admission• 21 patients all started on SS 10% Dextrose at 25mls/hr • Suboptimal with CBG rising whilst on them

Proposed• IV insulin using algorithm adjustment• 20% dextrose + KCL 20mmol 25ml/h• Aim sugar 6 – 10• Stabilise sugars regardless of insulin requirement

NICE (Oct 2011)- Managing hyperglycaemia in inpatients within 48 hours of ACS

1.1.1 Manage hyperglycaemia in patients admitted to hospital for an ACS by keeping blood glucose levels below 11.0 mmol/litre while avoiding hypoglycaemia. In the first instance, consider a dose-adjusted insulin infusion with regular monitoring of blood glucose levels.

1.1.2 Do not routinely offer intensive insulin therapy (an intravenous infusion of insulin and glucose with or without potassium) to manage hyperglycaemia (blood glucose above 11.0 mmol/litre) in patients admitted to hospital for an ACS unless clinically indicated.

Identifying patients with hyperglycaemia after ACS who are at high risk of developing diabetes

1.1.3 Offer all patients with hyperglycaemia after ACS and without known diabetes tests for: HbA1c levels before discharge and fasting blood glucose levels no earlier than 4 days after the onset of ACS.

Recent AuditWider reaching audit of 79 patients

ACS (Trop T > 15 and clinically relevant) treated as per trust protocol

ACS occuring in RD&E (Patients transferred from other trusts excluded)

Data: Notes pull from coding, Pathology system, D/C Summary

StandardsExpected standard - 100%

1. CBG recorded at admission for all patients admitted to RD&E.

2. All ACS patients with CBG >11 should be treated with IV insulin for the first 24 hours.

3. CBG should be maintained between 6 to 10 on IV insulin

4. HbA1c requested for all patients with CBG >11.0

5. Diabetic medication should be reviewed if HbA1C >58 (7.5%)

GenderCases

Mean age ± SD (range)

ACS Type Diabetes type

STEMI NSTEMINo DM

DMT1 DMT2

Male 47 70.3±15.6 (44-97) 5 42 37 1 9

Female 32 81.0±10.3 (44-95) 7 25 22 1 9

Total 79 74.6±14.6 (44-97) 12 67 59 2 18

Demographic

1. CBG done in 84.8% patients [100% standard not met]

not recorded

3.5 - 11.0

<3.5

>11

•

CBG > 11

T1DM T2DM No known DMSliding scale

startedDiabetic review

Total 1 (0.1) 7 (0.7) 2 (0.2) 3 (0.3) 3 (0.3)

2. 3/10 sliding scales started (for the highest CBG; 21.6, 30.7 and 32.7). 3. One hypoglycaemic episode whilst on the sliding scale.

4. 3/10 had a recent HbA1c result – neither known DM.

5. 2/10 diabetic R/V - resulting in one medication alteration

[100% standard not met]

Key findings. 1. No documentation of CBG in 15% - only not known DM

missed

2. Poor initiation of SS 3/10 (2 inappropriate, but 5/10 patient who may have benefited)

3. Non diabetic patients at risk not followed up

Recommendations1. CBG to be completed on admission to RD&E on all

patients.

2. New guidance on SS for all appropriate patients with CBG >11.0.

3. HbA1c for all diabetic patients and non-diabetic patients with CBG >11.0 and referral to diabetic team as appropriate.

Recommendations4. Trust Guidelines to be published for management of

hyperglycaemia in ACS to conform to those of NICE.

5. Re-audit in 6 months to ensure improvement.

Discussion• Is tight glycaemic control really beneficial in most

patients with ACS?