Intensive insulin has lasting benefits for diabetic MI survivors

By Eleanor McDermid, Senior medwireNews Reporter

Patients with diabetes given intensive insulin treatment following an acute myocardial infarction (MI) had improved survival over 20 years of follow-up of the DIGAMI 1 trial, report the investigators.

However, they caution that advances in medicine since the trial was conducted, between 1990 and 1993, mean that the benefits of intensive glucose control may be less marked in today’s patients.

In a commentary accompanying the study in The Lancet Diabetes and Endocrinology, Denise Bonds (National Heart Lung and Blood Institute, Bethesda, Maryland, USA) agrees with this view, noting that clinicians these days routinely try to achieve the blood glucose targets specified in DIGAMI 1.

“Instead, the value of this paper lies in its history”, she says. It reiterates the value of glucose control, even if other risk factors cannot be controlled, and “provides an important reminder of how quickly medicine is advancing, something that is often forgotten in the busy day-to-day practice of medicine.”

The DIGAMI (Diabetes Mellitus Insulin Glucose Infusion in Acute Myocardial Infarction) 1 investigators aimed to achieve blood glucose levels of between 7.0 and 10.9 mmol/L in the 306 patients randomly assigned within 24 hours of a MI to the intensive treatment group. To this end, these patients received an insulin-glucose infusion for at least 24 hours, followed by subcutaneous insulin for at least 3 months. The 314 patients in the control group received insulin only if considered clinically necessary.

At 1 year after randomisation, the intensive-treatment group had achieved a 0.9% reduction in glycated haemoglobin levels, compared with a 0.4% reduction in the control group. Over follow-up lasting a maximum of 22 years, 89% of the patients in the intensive treatment group died, compared with 91% of those in the control group.

The median survival times were 7.0 years for patients in the intensive treatment group versus 4.7 years for those in the control group, which was a significant difference, report lead study author Viveca Ritsinger (Karolinska Institute, Stockholm, Sweden) and team. The main benefit seemed to be during the first 8 years, they say, and was confined to low-risk patients who had not previously used insulin.

“This finding strengthens the assumption that, if instituted early, intensified glycaemic control might indeed have a beneficial effect on mortality, underlining the fact that there is no reason to withhold a therapeutic strategy of this kind in younger patients who have a first myocardial infarction with deranged glucose concentrations at admission”, say Ritsinger et al.

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