This Article  • Full text  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Contact me when this article is cited  Related Content  • Similar articles in JAMA  Topic Collections  • Nutritional and Metabolic Disorders  • Nutritional and Metabolic Disorders, Other  • Cardiovascular System  • Cardiovascular Disease/ Myocardial Infarction  • Drug Therapy  • Adverse Effects  • Endocrine Diseases  • Diabetes Mellitus  • Alert me on articles by topic  Social Bookmarking   What's this?

Mikhail Kosiborod, MD; Silvio E. Inzucchi, MD; Abhinav Goyal, MD, MHS; Harlan M. Krumholz, MD, SM; Frederick A. Masoudi, MD, MSPH; Lan Xiao, PhD; John A. Spertus, MD, MPH

JAMA. 2009;301(15):1556-1564.

Context  While glucose control is recommended by professional societies for patients with hyperglycemia hospitalized with acute myocardial infarction (AMI), enthusiasm for glucose lowering is tempered, in part, by concerns of inducing hypoglycemia. Yet, whether episodic hypoglycemia that occurs as a result of glucose-lowering therapy is harmful in patients with AMI is unknown.

Objective  To determine whether the mortality risk associated with hypoglycemic events is similar in patients who develop hypoglycemia spontaneously and those who develop it as a result of insulin therapy.

Design, Setting, and Patients  Retrospective cohort study using data from Health Facts, a contemporary database of patients hospitalized across the United States in 40 hospitals between January 1, 2000, and December 31, 2005. Of all the patients in the database, 7820 patients were hospitalized with AMI and were hyperglycemic on admission (glucose level 140 mg/dL). Patients were stratified based on whether they developed a hypoglycemic event (random glucose level <60 mg/dL) during subsequent hospitalization. Logistic regression models were used to evaluate the association between hypoglycemia and in-hospital mortality within subgroups of patients who were and were not treated with insulin therapy.

Main Outcome Measure  All-cause in-hospital mortality.

Results  Among patients treated or not treated with insulin, those with hypoglycemia were older and had more comorbidity. Hypoglycemia was associated with increased mortality in patients not treated with insulin (18.4% [25/136] mortality in patients with hypoglycemia vs 9.2% [425/4639] in those without hypoglycemia; P<.001), but not in those treated with insulin (10.4% [36/346] mortality in patients with hypoglycemia vs 10.2% [276/2699] in those without hypoglycemia; P = .92). After multivariable adjustment, there was a significant interaction between hypoglycemia and insulin therapy (P value for interaction = .01). Hypoglycemia was a predictor of higher mortality in patients who were not treated with insulin (odds ratio, 2.32 [95% confidence interval, 1.31-4.12] vs patients without hypoglycemia), but not in patients treated with insulin (odds ratio, 0.92 [95% confidence interval, 0.58-1.45] vs patients without hypoglycemia).

Conclusions  While hypoglycemia was associated with increased mortality in patients with AMI, this risk was confined to patients who developed hypoglycemia spontaneously. In contrast, iatrogenic hypoglycemia after insulin therapy was not associated with higher mortality risk.

Author Affiliations: Mid America Heart Institute of Saint Luke's Hospital, Kansas City, Missouri (Drs Kosiborod, Xiao, and Spertus); Department of Medicine, University of Missouri, Kansas City (Drs Kosiborod and Spertus); Department of Medicine, Yale University and Yale-New Haven Hospital, New Haven, Connecticut (Drs Inzucchi and Krumholz); Emory Rollins School of Public Health and Emory School of Medicine, Atlanta, Georgia (Dr Goyal); and Denver Health Medical Center and Department of Medicine, University of Colorado Health Sciences Center, Denver (Dr Masoudi).

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati    Twitter     What's this?

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Reply.
Lazar and McDonnell
Ann. Thorac. Surg. 2009;88:1385-1386.
FULL TEXT  

Is Insulin the Preferred Compound in Lowering Glucose Levels in Patients After a Myocardial Infarction?--Reply
Kosiborod et al.
Arch Intern Med 2009;169:1637-1638.
FULL TEXT  

Aiming for the best control of glycemia in patients with heart failure and type 2 diabetes the "sweet spot".
Weinrauch and Lewis
J Am Coll Cardiol 2009;54:429-431.
FULL TEXT  

Insulin-Induced Hypoglycemia and Mortality After Acute MI
Journal Watch Cardiology 2009;2009:2-2.
FULL TEXT  

All you need to read in the other general journals
BMJ 2009;338:b1617-b1617.
FULL TEXT  

Progress in Diabetes Research--What's Next
Nathan
JAMA 2009;301:1599-1601.
FULL TEXT