Intensive Glucose Regulation in Hyperglycemic Acute Coronary Syndrome: Results of the Randomized BIOMarker Study to Identify the Acute Risk of a Coronary Syndrome-2 (BIOMArCS-2) Glucose Trial

Study Questions:

What is the effectiveness and safety of intensive glucose management in hyperglycemic patients with acute coronary syndrome (ACS)?

Methods:

This was a single-center, prospective, open-label, randomized clinical trial in which patients with ACS (n = 294, 93.6%) received percutaneous coronary intervention (PCI) with an admission plasma glucose level of 140-288 mg/dl, and were randomized to an intensive glucose management strategy (goal plasma glucose level of 85-110 mg/dl) with intravenous insulin (administered through a nurse-driven protocol) or the conventional standard of care (insulin was not started if glucose levels remained below 288 mg/dl at serial time points). Patients with insulin-dependent diabetes mellitus were excluded. The primary endpoint was high-sensitivity troponin T value 72 hours after admission (hs-TropT72). A secondary outcome was findings on myocardial perfusion scintigraphy (MPS) at 6 ± 1 weeks after the index event.

Results:

There were no significant differences in enzymatic infarct size with a median hs-TropT72 of 1197 ng/L in the intensive management group, compared to 1354 ng/L in the conventional group (p = 0.41). There was no difference in the extent of myocardial injury, as assessed by MPS (2% vs. 4%, p = 0.07). The composite endpoint of death or second spontaneous myocardial infarction (prior to discharge) occurred in eight patients (5.7%) in the intensive glucose management group, compared to one patient in the conventional treatment group (0.7%).

Conclusions:

The authors concluded that an intensive glucose management strategy did not reduce infarct size in hyperglycemic patients with ACS, and may be associated with harm.

Perspective:

The limitations of this single-center experience aside, the authors provide cogent evidence that the practice of rapidly establishing (near) normalization of blood glucose levels in hyperglycemic patients with ACS is not associated with enzymatic or scintigraphic reduction of infarct size. The practice may actually be harmful. Of note, and as acknowledged by the authors, patients were enrolled at a median of 4.1 hours after symptom onset and the post-PCI evolution of myocardial infarction may have been too small to influence with an intensive glucose management strategy. Future studies should clarify the best practices for strictness (or leniency) of glucose control in ACS patients, and emphasize those patients who are persistently hyperglycemic after PCI.

Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, ACS and Cardiac Biomarkers, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Myocardial Perfusion Imaging, Insulin, Acute Coronary Syndrome, Myocardial Infarction, Heart Injuries, Standard of Care, Troponin T, Angioplasty, Perfusion Imaging, Percutaneous Coronary Intervention, Biological Markers, Coronary Angiography, Blood Glucose, Cardiovascular Diseases, Diabetes Mellitus


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