Insulin therapy myocardial infarction with diabetes

Macrovascular Complications. The connection between high insulin levels (hyperinsulinemia), insulin resistance, and cardiovascular events incorrectly leads some clinicians to believe that insulin therapy may cause macrovascular complications. The UKPDS and DCCT found no differences in macrovascular outcomes with intensive insulin therapy. One study, the Diabetes Mellitus, Insulin Glucose Infusion in Acute Myocardial Infarction study " reported reductions in mortality with insulin therapy. This group assessed the effect of an insulin-glucose infusion in type 2 DM patients who had experienced an acute myocardial infarction. Those randomized to insulin infusion followed by intensive insulin therapy lowered their absolute mortality risk by 11% over a mean follow-up period of approximately 3 years. This was most evident in subjects who were insulin-naive or had a low cardiovascular risk prior to the acute myocardial infarction. " ... 

Individuals with type 1 diabetes are also at risk of subsequent ketoacidotic crises. One common cause of DKA is noncompliance with insulin therapy. Infections, (including subclinical infections) and physiological stressors (such as myocardial infarction) can also precipitate DKA. Since the mortality rate associated with DKA can be as high as 10%, successfully educating patients about the early warning signs of the condition and providing a plan for early intervention is crucial to its effective prevention. 

A series of trials in elderly hypertensive subjects has shown a very pronounced reduction in cardiac events as a result of treatment based on thiazide diuretics. In the European Working Party on Hypertension in the Elderly (EWPHE) trial (13), total cardiovascular deaths were reduced by 38%, all cardiac deaths by 43%, and deaths due to myocardial infarction by 60%. Benefits in the Systolic Hypertension in the Elderly Program (SHEP) included a reduction in fatal and non-fatal myocardial infarction of 25% and major cardiovascular events of 32% (14) and were seen in those with and without electrocardiographic abnormalities at entry. The risk of heart failure was also reduced in patients taking chlortalidone-based therapy (15). Relative risk was similar in patients with and without non-insulin dependent diabetes meUitus absolute risk reduction was twice as great in the diabetic subjects (16). The Swedish Trial of Old Patients with Hypertension (STOP-Hypertension) reported a significant reduction in myocardial infarction and all-cause mortahty (17). In the MRC Trial in elderly adults (18), diuretic treatment reduced coronary events by 44% and fatal cardiovascular events by 35%. 

Macrovascular Complications. Metformin reduced macro vascular complications in obese subjects in the UKPDS. " Metformin significantly reduced all-cause mortality and risk of stroke vs. intensive treatment with sulfonylureas or insulin. Metformin also reduced diabetes-related death and myocardial infarctions vs. the conventional treatment arm of the UKPDS. Metformin should be included in the therapy for all type 2 DM patients, if tolerated and not contraindicated, as it is the only oral antihyperglycemic medication proven to reduce the risk of total mortality and cardiovascular death. 

It is well known that diabetic patients undergoing coronary interventions have worse chnical and angiographic outcomes in comparison with nondiabetic patients. In the retrospective analysis of the PRESTO (Prevention of Restenosis with Tranilast and its Outcomes) trial the effect of different anti-diabetic treatment was analysed [40] in 1,110 diabetic patients who received non-sensitizer therapy (insulin and/or sulfonylureas) and in 887 patients who were treated with sensitizers (metformin with or without additional therapy). Compared with patients on non-sensitizer therapy, those on sensitizer therapy showed an adjusted OR of 0.72 p = 0.005 for any clinical event. The differences between the non-sensitizer therapy group and the sensitizer group were attributable mainly to decreased rates of death (OR = 0.39 p = 0.007) and myocardial infarction (OR = 0.31 p = 0.002). In this retrospective analysis, use of metformin in diabetics undergoing coronary interventions appeared to decrease adverse clinical events, especially death and myocardial infarction, compared with diabetic patients treated with non-sensitizer therapy. 

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