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Cardio Diabetes Medicine 2017 95

2 insulin based glucose control strategies. No differ- covering function was significantly less. In one par-
ence in survival, length of mechanical ventilation or ticular review of observational studies examining the
length of hospital stay was observed. A meta-anal- prognostic significance of hyperglycemia in stroke,
ysis of 26 trials investigating the use of intensive the unadjusted relative risk of in-hospital or 30 day
insulin therapy in patients admitted to an intensive mortality was 3.07 95 % CI 2.5-3.79 in patients with
care unit did not show a beneficial effect(7). Another stress hyperglycemia with admission glucose levels
meta analysis of nine randomized studies and ten greater than 108-144 mg/dl. The risk was compara-
observational studies also failed to show any advan- tively lower with subjects with known diabetes at 1.3
tage for intensive insulin therapy, except for a small fold (95% CI 0.49-3.43). The relative risk of poor func-
reduction on the occurrence of infections. tional outcome in patients with stress hyperglycemia
was worse at 1.41(95% CI 1.16- 1.73)(10). It seems from
Management of glucose levels in ACS and available data that patients with sudden increase in
stroke glucose levels fair poorer compared to patients with
known diabetes.
There is good evidence that aggressive manage-
ment of glycemia during management of myocardi-
al infarction, acute coronary syndromes and stroke Sepsis
is beneficial. The incidence of stress hyperglycemia The Surviving Sepsis Campaign guidelines recom-
at presentation of acute myocardial infarction ranges mend starting insulin therapy after two consecutive
from 10-16%. The estimated prevalence of diabetes blood glucose measurements greater than 180 mg/
at presentation of acute myocardial infarction is 25- dl. Several studies have examined the relationship
32%. It would be prudent to measure plasma glucose between glycemic control and severity of sepsis. One
levels on admission to hospital with suspected acute such study which looked at a cohort of 191 patients
coronary syndrome and rapid correction of hypergly- treated with intensive glucose control with a target of
cemia initiated. The MINAP project (Myocardial Isch- between 80-140mg/dl found that rates of both hy-
aemia National project) demonstrated that patients perglycemia and hypoglycemia to be higher. In the
with troponin positive acute coronary syndrome VISEP study (The Efficacy of Volume substitution and
presenting with blood glucose greater than 170 mg/ Insulin therapy in Severe Sepsis), conventional insu-
dl had a higher 30 day mortality compared to 3.3 % lin was compared to intensive insulin therapy and
in patients with lower glucose levels. Of the 38,864 also differing fluids for resuscitation were assessed.
individuals in the MINAP database 10% had blood There were high rates of hypoglycemia in severe sep-
glucose levels greater than 250mg/dl suggestive of sis and the trial was topped early. These results were
stress hyperglycaemia or undetected diabetes. Pa- also replicated in the NICE-SUGAR trial, which failed
tients who did not receive insulin had a relative risk to show any mortality benefits in patients with se-
of death of 56 % and 51% at 30 days(8). In patients vere sepsis. But, there is emerging data that patients
with myocardial infarction form the New York munic- receiving parenteral nutrition may benefit from good
ipal hospital cohort the 3-year mortality was 52 %in glucose control.
stress hyperglycemia, 42% in pre-existing diabetes
and 24% in normal individuals. A meta-analysis of 15 Summary
studies showed a blood glucose levels greater that Glucose control in an intensive care setting is chal-
120 mg/dl with or without diabetes was associated lenging in an ill patient with multiple co-morbidities
with increased risk of mortality and heart failure. Re- and multi-organ dysfunction. Some studies have
sults from one of the largest observational data from shown intensive glucose control to be beneficial but
the Portland Diabetic project suggests that treatment many studies have failed to replicate promising re-
of hyperglycemia post-cardiac surgery with intrave- sults from earlier studies. These contradictory results
nous insulin for 3 days improved mortality, reduction can be argued to be due to differing patient profiles,
in sternal wound infections and favorably reducing nature of their illness and different intensive care pro-
hospital stay. tocols. But treatment areas such as acute coronary
Glucose levels at presentation during acute stroke re- syndrome have shown better results with strict glu-
mains an important prognostic factor. A single series cose control and improvement in mortality. In acute
suggested that patients with acute stroke with blood stroke glucose levels at presentation remains a great
glucose levels less than 144 mg/dl had full functional prognostic marker.
recovery at 4 weeks(9). Patients with higher glucose
levels faired badly and the proportion of patients re-

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