Myocardial infarction: admission glucose 11.0 mmol/l or more: insulin-glucose infusion followed by subcutaneous insulin reduced mortality.

Clinical bottom line (level 1b)

  1. Patients with a myocardial infarction and an admission blood glucose 11.0 mmol/l or more who received an insulin-glucose infusion for at least 24 hours followed by subcutaneous insulin four times a day for at least 3 months compared with no treatment were less likely to die (NNT = 9 at 3.4 years) .
Malmberg et al: Journal of the American College of Cardiology 1995; 26 (1): 57-65
Malmberg et al: British Medical Journal 1997; 314: 1512-1515
Expires March 2003

The study

Double-blinded concealed randomised trial with intention-to-treat
Setting: coronary care units, 19 acute hospitals, Sweden

620 patients (aged mean 68, 63% male) with a myocardial infarction (at least 2 of: 15 minutes or more of chest pain, elevation of CK or CK-MB or development of new Q waves in at least 2 ECG leads) and an admission blood glucose level 11.0 mmol/l or more.

Excluded if
  • inability to participate (too sick or unable to handle multi-dose insulin treatment)
  • living outside hospital catchment area
  • enrollment in other studies or previous participation in DIGAMI


Note:
  • Patients were stratified for previous diabetes and risk (based on two or more of previous MI, history of congestive heart failure, concurrent treatment with digitalis, age > 70) before randomisation.


Control Group: (n = 314, 314 analysed): standard care
Experimental Group: (n = 306, 306 analysed): insulin-glucose infusion for at least 24 hours adjusted to maintain blood glucose 7 to 10 mmol/l; followed by subcutaneous insulin 4 times daily for at least 3 months.
Almost half of patients had thrombolysis. 80% received aspirin and 70% beta-blockers.
100% followed for 3.4 years
Outcome notes:
  • death : at 1 year
  • death : at 3.4 years

The evidence

Outcome Time to outcome CEREERRRR
(95% CI)		ARR
(95% CI)		NNT
(95% CI)
death 12 months 82
(26.1%)		 57
(18.6%)		 29%
(4% to 47%)		 7.49%
(0.96% to 14.0%)		 13
(7 to 100)
death 3.4 years 138
(44.0%)		 102
(33.3%)		 24%
(7% to 38%)		 10.6%
(3.00% to 18.2%)		 9
(5 to 33)

Comments

  1. Patients without previous insulin treatment and at a low cardiovascular risk received the most benefit from therapy.

Citation

  1. Malmberg K, Ryden L, Efendic S, et al: Randomized trial of insulin-glucose infusion followed by subcutaneous insulin treatment in diabetic patients with acute myocardial infarction (DIGAMI Study): effects on mortality at 1 year. Journal of the American College of Cardiology 1995; 26 (1): 57-65
  2. Malmberg K, et al: Prospective randomised study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus. British Medical Journal 1997; 314: 1512-1515
Search Terms: DIGAMI in Cochrane
Contributor: Chris Ball and Clare Wotton, February 2000
Reviewer:

Clinical Question.
Patient myocardial infarction and blood glucose 11.0 mmol/l or more
Intervention or Exposure insulin-glucose infusion followed by subcutaneous insulin
Comparison standard care
Outcome death