Identifying and Managing Hyperglycaemia in Acute Coronary Syndromes

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  • As shown in Table 1, 79 cases were audited; STEMI (n=12) and NSTEMI (n=67). 25% of patients had recorded diabetes on admission; DMT1 (n=2) and DMT2 (n=18). The average age of the sample was 74.6 ± 14.6 years old. The average age was 70.3 ± 15.6 and 81 ± 10.3 for males and females respectively, representing a statistically significant 10.7 year difference (p=0.001) [T-test independent sample – equal variance].
  • able 2 highlights that sliding scales were commenced for three CBG >11 patients (the three highest CBG recorded; 21.6, 30.7 and 32.7). Only one of these patients experienced an episode of hypoglycaemia whilst on the sliding scale. A diabetic review occurred for two CBG>11 patients and one for a patient with a CBG <3, resulting in the addition of insulin to one patient’s medications. Three of the patients with a CBG >11 subsequently died during their hospital admission. Five patients in the sample died; three STEMIs and two NSTEMIs. Of the patients with a CBG >11, seven had DMT2, one had DMT2 and two had were not known to be diabetic.
  • Identifying and Managing Hyperglycaemia in Acute Coronary Syndromes

    1. 1. Identifying and Managing Hyperglycaemia in ACS Chris Redford, CT2 Mark Williams, F1
    2. 2. DIGAMI Multi-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
    3. 3. DIGAMI 2 Multiple 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.
    4. 4. Original Audit Aims • 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
    5. 5. 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
    6. 6. 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.
    7. 7. Recent Audit Wider 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
    8. 8. Standards Expected 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%)
    9. 9. Demographic ACS Type Gender Cases Mean age ± SD (range) STEMI NSTEMI Diabetes type No 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
    10. 10. not recorded <3.5 >11 3.5 - 11.0 1. CBG done in 84.8% patients [100% standard not met]
    11. 11. CBG > 11 T1DM • Total T2DM No known DM Sliding scale started 1 (0.1) 7 (0.7) 2 (0.2) 3 (0.3) Diabetic review 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]
    12. 12. 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
    13. 13. Recommendations 1. 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.
    14. 14. Recommendations 4. 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.
    15. 15. Discussion • Is tight glycaemic control really beneficial in most patients with ACS?

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