1. In a 20 year follow-up study (DIGAMI 1 trial), intensive insulin-based glycemic control for 3 months after an initial acute myocardial infarction (MI) in type 2 diabetics increased survival by 2.3 years compared to standard glycemic control.
2. The mortality benefits of intensive insulin-based glycemic control was most apparent within the first 8 years.
Evidence Rating Level: 1 (Excellent)
Study Rundown: Currently, evidence is limited supporting strict insulin-based glucose control in type 2 diabetes patients with a new-onset myocardial infarction (MI). The DIGAMI 1 (Diabetes Mellitus Glucose Infusion in Acute Myocardial Infarction) trial attempts to address this issue, and the results are reported here after a 20-year follow-up. The results showed that intensive insulin-based glycemic control for 3 months after acute MI in patients with type 2 diabetes increased survival by 2.3 years compared to the control group, with the greatest effects apparent for the first 8 years before leveling off. Intensive insulin-based glycemic control had no effect on mortality in patients with high cardiovascular risk without prior insulin use, but did show benefits in low risk patients without previous insulin therapy. The study was limited by the relatively small sample size. Translation to modern practice may also be limited with increasing use of statins and ACE-inhibitors, which may make such beneficial effects of glucose lowering on mortality less apparent today. The results nevertheless provide evidence that early intensive glycemic control after MI may improve mortality, especially in patients with type 2 diabetes.
This study was funded by the Swedish Heart-Lung Foundation and the Kronoberg County Council.
In-Depth [randomized controlled trial]: The DIGAMI 1 (Diabetes Mellitus Glucose Infusion in Acute Myocardial Infarction) trial ran from 1990 to 1993. It included 620 patients with type 2 diabetes and a suspected acute MI in the previous 24 hours. Patients were randomized to receive either intensified insulin-based glycemic control for at least 3 months (n=306) or conventional glucose lowering treatment (n=314). After 3 months, all patients received standard care from their regular physicians. Mortality was the primary endpoint.
During a mean follow-up of 7.3 years (SD 6.6, range 0.0-21.8), 271 patients (89%) died in the intensive control group, compared to 285 (91%) in the control group. The most common causes of mortality in both groups were cardiovascular disease, cancer, and infection. Median survival time was longer in the intensive group vs. control group (7.0 years, interquartile range [IQR] 1.8-12.4 vs. 4.7 years, IQR 1.0-11.4; hazard ratio [HR] 0.83, 95% confidence interval [CI], 0.70-0.98; p=0.27).
Additionally, patients were divided into 4 categories based on cardiovascular risk and previous insulin use: [no insulin, low risk] (n=272); [no insulin, high risk] (n=129); [insulin, low risk] (n=119); or [insulin, high risk] (n=100). High risk was defined as meeting at least 2 of the following: age greater than 70 years, previous MI, or current digitalis treatment. The [no insulin, low risk] group saw significant survival benefit (mean survival time 9.4 years vs. 6.9 years; p=0.048). The survival benefits were not statistically significant for patients in the [no insulin, high risk], [insulin, low risk], and [insulin, high risk] groups (p=0.99, 0.49, and 0.09, respectively).
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