Hyperglycaemia is common in people admitted to hospital with ACS. Studies have found that approximately 65% of patients with acute myocardial infarction who were not known to have diabetes had impaired glucose regulation when given a glucose tolerance test.

Hyperglycaemia at the time of admission with ACS is a powerful predictor of poorer survival and increased risk of complications while in hospital, regardless of whether or not the patient has diabetes. Despite this, hyperglycaemia remains underappreciated as a risk factor in ACS and is frequently untreated.

Persistently elevated blood glucose levels during acute myocardial infarction have been shown to be associated with increased in-hospital mortality, and to be a better predictor of outcome than admission blood glucose.

Management of hyperglycaemia after ACS is therefore an important clinical issue.

NICE CG130 recommends that hyperglycaemia in patients admitted to hospital for acute coronary syndromes should be managed by keeping blood glucose levels below 11.0 mmol/L while avoiding hypoglycaemia.

NICE CG130 also recommends that all patients with hyperglycaemia with confirmed ACS without known diabetes should be offered tests for HBA1C levels and fasting blood glucose. These tests should not delay discharge.

In addition, these patients should receive lifestyle advice on the following:

Healthy eating in line with

‘MI: secondary prevention’ (NICE CG 48)

‘Obesity’ (NICE CG 43)

Physical exercise in line with

‘MI: secondary prevention’ (NICE CG 48)

‘Four commonly used methods to increase physical activity’ (NICE public health guidance 2)

Weight management in line with

‘MI: secondary prevention’ (NICE CG 48)

‘Obesity’ (NICE CG 43)

Smoking cessation in line with

‘Unstable angina and NSTEMI’ 9NICE CG 94),

‘Smoking cessation services’ (NICE CG 48)

‘Brief interventions and referral for smoking cessation’ (NICE public health guidance 1)

Alcohol consumption in line with

‘MI: secondary prevention’ (NICE CG 48).

1. Norhammar, A. M., Ryden, L., Malmberg, K. (1999) 'Admission plasma glucose. Independent risk factor for long-term prognosis after myocardial infarction even in nondiabetic patients', Diabetes care, 22(11), pp.1827-1831. Available at: https://doi.org/10.2337/diacare.22.11.1827 (Accessed: 18 August 2023).

2. Foo, K. et al. (2003) 'A single serum glucose measurement predicts adverse outcomes across the whole range of acute coronary syndromes', Heart, 89(5), pp. 512-516. Available at: 10.1136/heart.89.5.512 (Accessed: 18 August 2023).

3. Weston, C., Walker, L. and Birkhead, J. (2007) 'Early impact of insulin treatment on mortality for hyperglycaemic patients without known diabetes who present with acute coronary syndrome', Heart, 93(12), pp. 1542-1546. Available at: https://heart.bmj.com/content/93/12/1542 (Accessed: 18 August 2023).

4. Kosiborod, M. et al. (2005) 'Admission glucose and mortality in elderly patients hospitalised with acute myocardial infarction: implications for patients with and without recognised diabetes', Circulation, 111(23), pp. 3078-3086. Available at: 10.1161/CIRCULATIONAHA.104.517839 (Accessed: 18 August 2023).

5. Mellbin, L. G. et al. (2008) 'The impact of glucose lowering treatment on long-term prognosis in patients with type 2 diabetes and myocardial infarction: a report from the DIGAMI 2 trial', European Heart Journal, 29(2), pp. 66-176. Available at: 10.1093/eurheartj/ehm518 (Accessed: 18 August 2023).

6. Anselmino, M. et al. (2008) 'Glucose lowering treatment in patients with coronary artery disease is prognostically important not only in established but also in newly detected diabetes mellitus: a report from the Euro Heart Survey on Diabetes and the Heart', European Heart Journal, 29(2), pp. 77-184. Available at: https://doi.org/10.1093/eurheartj/ehm519 (Accessed 18 August 2023).

7. Cheung, N. W., Wong, V. W. and McLean, M. (2006) 'The Hyperglycaemia: Intensive insulin infusion in infraction (Hi-5) Study: A randomized controlled trial of insulin infusion therapy for myocardial infarction', Diabetes Care, 29(4), pp. 765-770. Available at: 10.2337/diacare.29.04.06.dc05-1894 (Accessed: 18 August 2023).

8. Watson C et al. 2007. Early impact of insulin treatment on mortality for hyperglycaemic patients without diabetes who present with acute coronary syndromes. Heart 93;98 3-4.

9. National Institute for Health and Care Excellence [NICE] (2020) Acute coronary syndromes. NG185. Available at: https://www.nice.org.uk/guidance/ng185 (Accessed: 18 August 2023).

10. National Institute for Health and Care Excellence [NICE] (2020) Acute coronary syndromes. NG185. Available at: https://www.nice.org.uk/guidance/ng185 (Accessed: 18 August 2023).

Blood Glucose

• Send lab glucose sample + HbA1c request
• Start a VRIII as below

VRIII

• Aim CBG 6-10

• Must check the CBG hourly

• If the CBG is <6, recheck in 15 mins

• if the CBG is still falling then downgrade the VRIII scale to avoid a hypo and recheck in further 15 mins

• If the CBG ≥ 6, go back to hourly checks.

Fluids

Run the VRIII with 10% dextrose 500 mL 8 hourly with 20 mmol potassium chloride (KCL) once the initial CBG is <12.

We would generally not recommend that a VRIII is run without supplementary fluids but if this is deemed necessary by a senior clinician (in exceptional circumstances) then monitoring of CBGs must take place on an HOURLY BASIS for reasons of safety.

K check

Please check the potassium 12 hourly

If starting a VRIII in a patient with known diabetes

Where relevant, stop the sulfonylurea, DPP4 inhibitor, thiazolidinedione, SGLT-2 inhibitor, GLP-1 agonist or dual GLP-1 – GIP agonist.

Metformin can continue if eGFR is >30 ml/min but should be omitted if an angiogram is planned.

If on a basal insulin, i.e., Glargine / Detemir / Degludec / Insulatard / Humulin I / Insuman Basal®, this can continue.

Stop the VRIII

Known Diabetes
Trace the HBA1C result If the HBA1C is > 58 mmol/mol – ask the DSN to see

NOT known to have diabetes
Trace the HBA1C result + follow the instructions below. Arrange for a follow up fasting glucose on discharge via the GP.

• HBA1C ≥48 mmol/mol – suggests diabetes
  Refer to the DSN + dietitian
• HBA1C 39-47 mmol/mol – suggests ‘non diabetic hyperglycaemia’
  Give hyperglycaemic discharge advice
• HBA1C <39 mmol/mol – does not have diabetes
  Give hyperglycaemic discharge advice

Advise patients without known diabetes that if they have had hyperglycaemia after an ACS they are at increased risk of developing Type 2 Diabetes.

Give lifestyle advice on the following (leaflets available)

• Healthy eating
• Physical Exercise
• Weight management
• Smoking cessation
• Alcohol consumption

Advise them they should consult their GP if they experience the following symptoms

• Frequent urination
• Excessive thirst
• Weight loss
• Fatigue

Patients should be offered tests for diabetes at least annually

GP to arrange annual fasting glucose and HBA1C check

This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

Version History

Related Documents

None