Hyperglycaemia and diabetes mellitus management in patients admitted with acute coronary syndromes

Publication: 21/02/2020  --
Last review: 01/01/1900  
Next review: 21/02/2023  
Clinical Guideline
CURRENT 
ID: 6296 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2020  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Hyperglycaemia and diabetes mellitus management in patients admitted with acute coronary syndromes

Summary of Guideline

Hyperglycaemia in the setting of acute coronary syndrome is common and associated with increased mortality. There is inconsistency in patient management, reflecting conflicting trial outcomes and a lack of consensus in national guidelines.

This guideline provides a practical approach to optimising care of patients with hyperglycaemia in the setting of hospital admission with acute coronary syndromes. In addition, it provides guidance on assessment of glycaemic control and communication with the diabetes team and primary care for patients with established diabetes mellitus and patients without known diabetes.

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Aims

To standardise the diagnosis and management of hyperglycaemia in patients admitted to Leeds Teaching Hospitals NHS Trust (LTHT) with Acute Coronary Syndrome (STEMI/NSTEMI/unstable angina).

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Background

Hyperglycaemia (blood glucose>11.0mmol/L) in the setting of acute coronary syndrome is associated with increased mortality and worse clinical outcome1,2. The DIGAMI study published in 1995 indicated intensive treatment of hyperglycaemia with glucose-insulin infusion followed by subcutaneous insulin led to improved mortality in patients with acute myocardial infarction. Subsequent trials (DIGAMI-2, BIO-MArCS-2, HI-5) failed to show mortality benefit or reduced infarct size with treatment of hyperglycaemia, although these studies had methodological limitations and none were large, dedicated trials of hyperglycaemia management in patients with acute myocardial infarction4,5,6. Retrospective registry data from the MINAP database suggest that  intra-venous insulin infusion appears to be of benefit only for patients with STEMI and hyperglycaemia, predominantly those who are not known to have diabetes, and was associated with adverse early outcomes in patients with NSTEMI7.

These conflicting findings, along with lack of consensus in national guidelines, has led to uncertainty and lack of consistency in the optimum management of patients with hyperglycaemia and acute coronary syndrome in the modern era. A recent audit of current clinical practice in the Yorkshire Heart Centre at LTHT indicated only 11% of patients with hyperglycaemia in the setting of acute coronary syndrome received any treatment for blood glucose. The current ABCD position on ‘Good inpatient diabetes service’ published in July 2019 and majority of other society guidelines suggest target glucose of <10mmol/litre. 

In this guidance, we propose a pragmatic strategy for the management of hyperglycaemia in patients admitted to LTHT with acute coronary syndrome. The guidance was written jointly by Consultants from the Departments of Cardiology, Diabetes and Pharmacy at LTHT and draw on current European Society of Cardiology and NICE guidelines as well as the 2018 American Diabetes Association (ADA) guidelines outlining the management of all in-patients with hyperglycaemia8,9.

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Diagnosis

Hyperglycaemia is defined as plasma blood glucose of >11.0mmol/L in the setting of any form of acute coronary syndrome. A capillary blood glucose of >11.0mmol/L should prompt repeat plasma blood glucose AND measurement of HbA1c given the implication of diabetes diagnosis. (Level of evidence A)

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Investigation

  • Measure capillary blood glucose on hospital admission for all patients with suspected acute coronary syndrome (Level of evidence A)
  • If capillary blood glucose >11.0mmol/L – repeat capillary blood glucose together with plasma glucose AND HbA1c during initial assessment. If available, capillary blood glucose readings from paramedics/ambulance or Emergency Departments should be used as the initial reading (Level of evidence D)
  • Measure HbA1c for all patients without known diabetes and all patients with known diabetes and no recorded HbA1c in the preceding three months (Level of evidence B)
  • If blood glucose >11.0 mmol/L in patient with new hyperglycaemia – check capillary blood ketones (see LTHT ketone guidelines)
  • Check capillary blood ketones in ALL patients with pre-existing diagnosis of diabetes with capillary glucose >16mmol/L(see LTHT ketone guidelines)

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Treatment / Management

Refer to the algorithm in Appendix A for recommendations on management of hyperglycaemia in patients admitted to LTHT with acute coronary syndrome.

Detailed specific guidance on different subgroup of patients

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1. Patients with acute STEMI and blood glucose >11mmol/L

1.1 Start variable rate insulin infusion using ‘Variable Rate Insulin Infusion (VRII) Prescription Chart for Adult Medical Patients’ for period of 24 to 48 hours.
1.2 Start VRII for all patients unless it is certain the patient will be repatriated to another hospital within 6 hours. VRII should be interrupted for the ambulance transfer to the base hospital.
1.3 If VRII is not started prior to repatriation, advise the base hospital to check BG on arrival and consider starting VRII if BG>11.0mmol/L
1.4 Ensure long acting insulin is continued in patients with an established insulin regime in patients who are able to eat and drink
1.5 Stop all other insulin and oral agents for the duration of VRII
1.6 Instructions on discontinuation of VRII:

Pre-existing diabetes:
1.6.1.1
Give normal treatment prior to discontinuing VRII.
1.6.1.2 Be prepared to withhold or reduce sulphonylureas if the food intake is likely to be reduced. Consult the diabetes team for advice if needed
1.6.1.3 For patients requiring switching back to their usual insulin regime see 'How to switch from VRII to subcutaneous insulin on Adult Diabetes'. Avoid stopping VRII at bedtime where there is less observation by staff.
1.6.1.4 If transferring patients to another hospital within 24 to 48 hours of acute STEMI, discontinue VRII and re-start pre-existing diabetes treatment. Ensure instructions are given to local team for further follow up and management.
1.6.1.5 Continue capillary blood glucose monitoring according to LTHT protocol
1.6.1.6 Escalate treatment if appropriate depending on capillary blood glucose reading and recent HbA1c measurement

Not Known Diabetes:
1.6.1.7 Check capillary blood glucose one hour after discontinuing VRII and 4 times a day for the first 48 hours after VRII has been discontinued.
1.6.1.8 Consider starting treatment for diabetes according to LTHT guideline 'Cardiovascular Risk Reduction in Patients with Type 2 Diabetes and Cardiovascular Disease' if HbA1c is above 48mmol/mol. If HbA1c is awaited or not immediately available BUT there is high clinical suspicion of diabetes diagnosis, initiate treatment as necessary. Consult in-patient diabetes service for further guidance.

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2. ALL Patients with acute coronary syndromes (except STEMI) with blood glucose > 11mmol/L

2.1 Pre-existing diabetes:
2.1.1.1 Continue normal diabetes treatment.
2.1.1.2 Continue capillary glucose monitoring according to LTHT protocol
2.1.1.3 Escalate treatment if appropriate depending on capillary blood glucose reading and recent HbA1c measurement.

2.2 Not Known Diabetes:
2.2.1.1 Continue to check capillary glucose monitoring for 48 hours
2.2.1.2 Perform HbA1c measurement
2.2.1.3 Consider starting treatment according to LTHT guideline 'Cardiovascular Risk Reduction in Patients with Type 2 Diabetes and Cardiovascular Disease' if HbA1c above 47mmol/mol. If HbA1c is awaited or not immediately available BUT there is high clinical suspicion of diabetes diagnosis based on capillary blood glucose readings, initiate treatment as necessary. Consult in-patient diabetes service for further guidance.

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3. ALL Patients with acute coronary syndromes (STEMI/NSTEMI/Unstable angina) with blood glucose < 11mmol/L

3.1 Pre-existing diabetes:
3.1.1.1 Continue normal diabetes treatment
3.1.1.2 Continue capillary glucose monitoring according to LTHT protocol
3.1.1.3 Escalate treatment if appropriate once uptodate HbA1c is available

3.2 Not known diabetes:
3.2.1.1 Check HbA1c
3.2.1.2 Initiate treatment once result of HbA1c is available

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4. Criteria for referral to in-patient diabetes service

4.1 Erratic glucose control or recurrent hypoglycaemia
4.2 HbA1c > 75mmol/mol
4.3 Plasma or capillary blood glucose above 25mmol/L in patients not known to have diabetes
4.4 Patient on CSII who are unable to manage insulin pump.

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5. Metformin and Contrast Media

5.1 See LTHT Guidance ‘Metformin in Patients undergoing Invasive Procedures with Iodinated-Contrast Media’ for instructions on metformin. Do not routinely discontinue metformin in patients admitted with acute coronary syndrome.

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6. Patients with new diagnosis of prediabetes (HbA1c 42 to 47 mmol/mol)

6.1 Give lifestyle advice
6.2 Consider referral to in-patient diabetes service for specialist diabetes dietitian input (part of inpatient diabetes service) if body mass index above 30
6.3 Consider starting oral metformin if appropriate to reduce future risk of developing diabetes.
6.4 Ensure recommendations are included in discharge letter for annual follow up in primary care.
6.5 Recommend GP refers patient to the National Diabetes Prevention Program.

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7. Diabetic ketoacidosis (DKA) or Hyperosmolar Hyperglycaemia State (HHS)

7.1 If there is evidence of diabetic ketoacidosis (DKA) or Hyperosmolar Hyperglycaemia State (HHS) on admission– treat along DKA or HHS pathway - see ‘LTHT Guidelines for the Management of Diabetic Ketoacidosis in Adults (aged 18 years and over)

7.2 Refer patient to in-patient diabetes service for further guidance as follow up management post DKA/HHS management needs to be tailored accordingly and may not follow usual treatment protocol.

General summary of glycaemic management in patients presenting with Acute Coronary Syndrome
(Also refer to the flowchart in appendix for a summary of management of hyperglycaemia in patients admitted with suspected acute coronary syndrome)

  1. Patients with acute STEMI and capillary glucose > 11mmol/L should be started on variable rate intravenous insulin for the duration of 48 hours. Ensure long acting insulin is continued in patients with established insulin treatment.
  2. Patients with non ST-segment elevation acute coronary syndromes and capillary glucose >11mmol/L do not routinely need variable rate insulin infusion unless there are other clinical indications identified by clinician.
  3. If evidence of diabetic ketoacidosis (DKA) or Hyperosmolar Hyperglycaemia State (HHS) after above investigations– treat along DKA or HHS pathway - see ‘LTHT Guidelines for the Management of Diabetic Ketoacidosis in Adults (aged 18 years and over)
  4. If known diabetes – ensure usual medications prescribed EXCEPT if variable rate insulin infusion is commenced.
  5. If patient is already taking insulin – prescribe usual insulin dose and monitor response. See - ‘Guidance for the Self Administration & Self-Management of Diabetes, Including Blood Glucose Monitoring, by Adults in Leeds Teaching Hospitals Trust’.
  6. Monitor capillary blood glucose before meals and reassess as appropriate.
  7. All patients with erratic glucose or recurrent hypoglycaemia should be referred to in-patient diabetes specialist service. Erratic glucose control is defined as persistent high glucose >15mmol/L despite adjustment in oral agents/insulin or large fluctuations in glucose levels (< 3.6mmol/Land >15.0 mmol/L)
  8. All patients should have HbA1c checked during admission (or within the last three months if established diabetes) regardless of admission blood glucose
  9. If HbA1c not available at time of discharge, ensure documented in eDAN for review by primary care or once transferred back to parent hospital.
  10. If HbA1c result available during admission and indicates new diagnosis of diabetes (>48mmol/mol) –give lifestyle advice and start treatment if clinically appropriate by referring to LTHT guideline 'Cardiovascular Risk Reduction in Patients with Type 2 Diabetes and Cardiovascular Disease'
  11. If HbA1c result available during admission indicates new diagnosis of prediabetes (42-47 mmol/mol) – communicate this to patient and provide lifestyle advice. Ask primary care to repeat HbA1c and treat accordingly. For overweight individuals, consider starting metformin if appropriate.
  12. If HbA1c <42mmol/mol, give lifestyle advice and advise to see GP for annual HbA1c or if symptoms develop

Provenance

Record: 6296
Objective:

To provide evidence-based recommendations for appropriate diagnosis, investigation and management of hyperglycaemia in patients admitted to LTHT with Acute Coronary Syndrome (STEMI/NSTEMI/unstable angina).

Clinical condition:

Acute coronary syndrome, hyperglycaemia

Target patient group:
Target professional group(s): Pharmacists
Secondary Care Doctors
Adapted from:

Evidence base

References

  1. National Institute for Health and Care Excellence. Hyperglycaemia in acute coronary syndromes: management of hyperglycaemia in acute coronary syndromes. Clinical Guideline 130. London: NICE, 2011. Available at: www.nice.org.uk/cg130
  2. Deedwania P, Kosiborod M, Barrett E, et al. Hyperglycemia and Acute Coronary Syndrome. Circulation 2008;117:1610–9. doi:10.1161/circulationaha.107.188629
  3. Malmberg K, Rydén 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. J Am Coll Cardiol 1995; 26 (1): 57–65.
  4. Malmberg K, Rydén L, Wedel H et al. DIGAMI 2 Investigators. Intense metabolic control by means of insulin in patients with diabetes mellitus and acute myocardial infarction (DIGAMI 2): effects on mortality and morbidity. Eur Heart J 2005; 26 (7): 650–661.
  5. de Mulder M, Umans VA, Cornel JH, van der Zant FM, Stam F, Oemrawsingh RM, Akkerhuis KM, Boersma E. Intensive glucose regulation in hyperglycemic acute coronary syndrome: results of the randomized BIOMarker study to identify the acute risk of a coronary syndrome-2 (BIOMArCS-2) glucose trial. JAMA Intern Med. 2013; 173:1896–1904
  6. Cheung N, Wong V, McLean M. The Hyperglycemia: Intensive Insulin Infusion in Infarction (HI-5) study: a randomized controlled trial of insulin infusion therapy for myocardial infarction. Diabetes Care 2006; 29 (4): 765–770.
  7. Birkhead J, Weston C, Timmis A, Chen R. The effects of intravenous insulin infusions on early mortality for patients with acute coronary syndromes who present with hyperglycaemia: A matched propensity analysis using data from the MINAP database 2008-2012. Eur Heart J Acute Cardiovasc Care. 2015;4:344-52.
  8. Cosentino F, Grant PJ, Aboyans V et al. 2019 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD: The Task Force for diabetes, pre-diabetes, and cardiovascular diseases of the European Society of Cardiology (ESC) and the European Association for the Study of Diabetes (EASD). European Heart Journal, ehz486, https://doi.org/10.1093/eurheartj/ehz486
  9. American Diabetes Association. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2018. Diabetes Care 2018 Jan; 41(Supplement 1): S144-S151.
  10. Zinman B, Wanner C, Lachin JM, et al. Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes. N Engl J Med 2015;373:2117–28.
  11. Neal B, Perkovic V, Mahaffey KW, et al. Canagliflozin and Cardiovascular and Renal Events in Type 2 Diabetes. N Engl J Med 2017;377:644–57.
  12. Marso SP, Daniels GH, Brown-Frandsen K, et al. Liraglutide and Cardiovascular Outcomes in Type 2 Diabetes. N Engl J Med 2016;375:311–22.

Evidence levels:
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

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