Maimonides Medical Center, 864 49th Street Apt C11, Brooklyn, NY 11220, USA.
Curr Vasc Pharmacol. 2013 Jan;11(1):100-4.
Some early trials comparing intensive glucose control in type 2 diabetics with an acute myocardial infarction (MI) reported a decrease in mortality over a short period of follow up leading to a presumption of improved survival with intensive glucose control. Later data refuted this hypothesis. The 2009 ACC/AHA focused update on ST elevation MI gave a weak recommendation for the use of an insulin based regimen to achieve and maintain blood glucose less than 180 mg/dL. We decided to assess the validity of this recommendation.
The authors searched the Pub- Med, Cochrane CENTRAL and EMBASE databases for randomized controlled trials from 1965 through 2011.Trials included were direct head-to-head comparisons of an intensive blood glucose control strategy using pharmacological means (insulin in most cases) with a less intensive regimen. The primary outcome assessed was the risk of all -cause mortality in the two groups at the end of follow up. Also assessed was the rate of hypoglycemia. The methodological quality of the studies was assessed. Event rates were compared using a forest plot of relative risk (RR; 95% confidence interval [CI]) using a random effects model (Mantel-Haenszel) assuming inter-study heterogeneity. Statistical analysis was done with Review Manager V5.1 and SYSTAT. Meta-regression was done with duration of therapy as covariate.
Three studies (total N = 2113) met the inclusion exclusion criteria. Mortality was not different between the groups (RR 0.94, 95% CI of 0.66-1.34; p=0.73.). Rate of hypoglycemia was significantly higher in the intensive glucose control group (RR 13.40, 95% CI 3.69-48.61; p < 0.01), with a 12% absolute risk increase and a number needed to harm (NNH) of 9 (95% CI 6.8- 9.8)-even without achieving target glycemic control. Neither did intensive control improve CHF, arrhythmias and reinfarction rates. Meta regression revealed that mortality with intensive glycemic control was worse with increased duration of therapy (p=0.001, for trend).
This systematic review suggests limited benefit of intensive glycemic control in type 2 diabetics with an MI, with a significant risk of serious hypoglycemia.
一些比较 2 型糖尿病并发急性心肌梗死（MI）患者强化血糖控制与短期随访死亡率的早期试验，导致人们推测强化血糖控制可改善生存。后来的数据反驳了这一假设。2009 年 ACC/AHA 发布的 ST 段抬高型 MI 重点更新版对使用胰岛素为基础的方案来实现和维持血糖低于 180mg/dL 给出了一个弱推荐。我们决定评估这一推荐的有效性。
作者检索了从 1965 年到 2011 年的 Pub Med、Cochrane CENTRAL 和 EMBASE 数据库的随机对照试验。纳入的试验是直接比较使用药理学手段（大多数情况下是胰岛素）强化血糖控制策略与较不强化方案的头对头比较。主要评估终点是两组在随访结束时的全因死亡率风险。还评估了低血糖发生率。评估了研究的方法学质量。使用森林图比较相对风险（RR；95%置信区间[CI]），使用随机效应模型（Mantel-Haenszel），假设研究间存在异质性。使用 Review Manager V5.1 和 SYSTAT 进行统计分析。用治疗持续时间作为协变量进行元回归。
三项研究（共 N = 2113 例）符合纳入排除标准。两组死亡率无差异（RR 0.94，95%CI 0.66-1.34；p=0.73）。强化血糖控制组低血糖发生率显著升高（RR 13.40，95%CI 3.69-48.61；p < 0.01），绝对风险增加 12%，危害比（NNH）为 9（95%CI 6.8-9.8）-即使没有达到目标血糖控制。强化控制也没有改善心衰、心律失常和再梗死的发生率。元回归显示，随着治疗持续时间的增加，强化血糖控制的死亡率更差（p=0.001，趋势有统计学意义）。
这项系统综述表明，强化血糖控制对 2 型糖尿病并发 MI 患者的益处有限，且严重低血糖的风险显著增加。
