Intensive treatment of hyperglycemia in the acute phase of myocardial infarction: the tenuous balance between effectiveness and safety – a systematic review and meta-analysis of randomized clinical trials
Key result
Intensive insulin or GIK therapy shows no mortality benefit over control in acute MI.
- RR 1.03
- 95% CI 0.96-1.10
- P=0.41
- n=28,151
Why the study?
Strategies to reduce blood glucose in the acute phase of myocardial infarction have not shown encouraging results despite the association of hyperglycemia with increased mortality.
Does intensive insulin or GIK therapy reduce total mortality in patients in the acute phase of myocardial infarction?
Comparison
Intensive insulin or GIK therapy vs control group
Design
Systematic review and meta-analysis of randomized clinical trials
Authors
Discussion
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Implication
Intensive insulin or GIK therapy should not be routine in acute MI; confirms lack of mortality benefit in high-level evidence.
Key Points
- To evaluate the efficacy and safety of intensive blood glucose lowering, including insulin and glucose-insulin-potassium therapies, in the acute phase of myocardial infarction.
- Systematic search of Medline and Cochrane Library databases from 1995 to 2017 for randomized clinical trials evaluating intensive glucose lowering or glucose-insulin-potassium (GIK) therapy in acute myocardial infarction.
- Included 8 randomized trials comprising 28,151 patients: 1,379 received intensive insulin, 13,031 received GIK therapy, and 13,741 received control care.
- Calculated pooled risk ratios (RR) using fixed- and random-effects models and performed meta-regression based on glucose reductions relative to estimated baseline HbA1c.
- Total mortality was 10.5% (n=2,961), with no significant difference observed between combined intensive interventions and control therapy (RR 1.03, 95% CI 0.96–1.10; I² = 31%; p = 0.41).
- Meta-regression showed that aggressive glucose reductions exceeding 36 mg/dL relative to estimated average glucose (HbA1c) were significantly associated with increased mortality, whereas reductions under 36 mg/dL showed no such association.
- Lowering acute blood glucose levels by approximately 18 mg/dL relative to the estimated baseline average represented the most effective and safe target window.
Study Design
Type
Meta-Analysis (n=28,151)
Structured PICO
Does intensive insulin or GIK therapy reduce total mortality in patients in the acute phase of myocardial infarction?
P
Population
28,151 patients from 8 randomized clinical trials evaluating intensive insulin or GIK therapy for blood glucose control during the acute stage of myocardial infarction.
I
Intervention
Intensive strategy or GIK (glucose-insulin-potassium) therapy for blood glucose control (1,379 intensively treated with insulin, 13,031 in GIK group).
C
Comparator
Control group (n=13,741).
O
Outcome
Total mortalityhard clinical
Main Result
Relative Risk: 1.03 (95% CI 0.96–1.1)
p-value: p=0.41
Intensive blood glucose reduction in acute MI does not reduce overall mortality, and reductions >36 mg/dL from estimated average may increase mortality.
Cite This Study
Negreiros et al. (2019) conducted a meta-analysis in acute myocardial infarction (n=28,151). Intensive insulin or GIK therapy vs. Control was evaluated on Total mortality (RR 1.03, 95% CI 0.96-1.10, p=0.41). Intensive insulin or GIK therapy in the acute phase of myocardial infarction did not significantly reduce total mortality compared to control (RR 1.03; 95% CI 0.96-1.10; p=0.41).