How should we manage acute cardiovascular events in diabetes?

Approximately one-third of patients admitted to hospitals for acute cardiovascular events have diabetes. Coronary artery disease associated with diabetes tends to be more extensive than in non-diabetic subjects. Diabetic cardiomyopathy may impair functioning of the non-infarcted myocardium, and autonomic neuropathy may critically diminish pain detection that could delay a person from seeking treatment. In the resting state, approximately 60% of myocardial energy is supplied by oxidation of free fatty acids, with the remainder coming from glucose. Insulin resistance and post-infarction myocardial free fatty acid utilisation may be arrhythmogenic and toxic to the myocardium. The Diabetes Mellitus Insulin Glucose Infusion in Acute Myocardial Infarction (DIGAMI) study tested the hypothesis that high-dose insulin infusion followed by subcutaneous insulin at the time of infarction would improve survival in patients with diabetes. The study found a significant reduction in mortality rate through the 5-year follow-up. This result suggests that post-infarction treatments should include intensive insulin therapy to address the intrinsic metabolic status of diabetes.