Piloting a Novel Algorithm for Glucose Control in the Coronary Care Unit The RECREATE (REsearching Coronary REduction by Appropriately Targeting Euglycemia) trial

• Type of Material: Article
• Authors: Kara A. Nerenberg, McMaster University; Abhinav Goyal, Emory University; Denis Xavier, St. John’s Medical School; Alben Sigamani, St. John’s Research Institute; Jennifer Ng, McMaster University; Shamir R. Mehta, McMaster University; Rafael Diaz, Etudios Cardiologica Latin America; Mikhail Kosiborod, University of Missouri; Salim Yusuf, McMaster University; Hertzel C. Gerstein, McMaster University
• Language: English
• Date: 2012-01
• Publisher: American Diabetes Association
• Publication Version: Final Published Version
• Copyright Statement: © 2012 by the American Diabetes Association.
• License: Creative Commons Attribution-NonCommerical-NoDerivs 3.0 Unported
• Final Published Version (URL): http://dx.doi.org/10.2337/dc11-0706
• Title of Journal or Parent Work: Diabetes Care
• ISSN: 0149-5992
• Volume: 35
• Issue: 1
• Start Page: 19
• End Page: 24
• Grant/Funding Information: This trial was funded by an unrestricted grant by sanofi-aventis. sanofi-aventis had no role in the design and conduct of the trial; in site monitoring; in data collection, analysis, and interpretation; or in preparation of the manuscript.
• Keywords: INSULIN THERAPY; RISK; ENDOCRINOLOGY & METABOLISM; Endocrinology & Metabolism; HYPERGLYCEMIA; ACUTE MYOCARDIAL-INFARCTION; ARTERY-DISEASE; INFUSION; DIABETES-MELLITUS; Science & Technology; EURO HEART; Life Sciences & Biomedicine; RANDOMIZED CONTROLLED-TRIAL; MORTALITY
• Research Categories: Health Sciences, Public Health; Health Sciences, Pharmacology

Abstract

OBJECTIVE - Elevated glucose levels are common after an acute myocardial infarction (AMI) and increase the risk of death. Prior trials of glucose control after AMI have been inconsistent in thei r ability to lower glucose levels and have reportedmixed effects on mortality. We developed a paper-based glucose-lowering algorithm and assessed its feasibility and safety in the setting of AMI. RESEARCH DESIGN AND METHODS - A total of 287 participants with an acute ST segment elevation myocardial infarction (STEMI) and a capillary glucose level ≥8.0 mmol/L were randomly allocated to glucose management with intravenous glulisine insulin using this algorithmin the coronary care unit (CCU), followed by once-daily subcutaneous insulin glargine for 30 days versus standard glycemic approaches. The primary outcome was a difference inmean glucose levels at 24 h. Participants were followed for clinical outcomes through 90 days. RESULTS - At 24 h, themean glucose level was 1.41mmol/L (95%CI 0.69-2.13) lower in the insulin (6.53 vs. 7.94mmol/L). Differences in glucose levels weremaintained at 72 h and 30 days. A total of 22.7% of the insulin group versus 4.4% of the standard group had biochemical hypoglycemia (with neither signs nor symptoms) in the CCU because of lower glycemic goals. However, there were no differences in symptomatic hypoglycemia or clinical outcomes between the groups. CONCLUSIONS - A paper-based insulin algorithm targeting glucose levels of 5.0-6.5 mmol/L (90-117 mg/dL) can be feasibly implemented in the CCU. A cardiovascular outcomes trial using this approach can determine whether targeted glucose lowering improves patient outcomes.