Excerpt

This guideline partially updates recommendation 1.12.3.6 in ‘Type 1 diabetes’ (NICE clinical guideline 15). Recommendation 1.12.3.6 is updated for the treatment of patients with threatened or actual MI, but not stroke.

This guideline covers the role of intensive insulin therapy in managing hyperglycaemia within the first 48 hours in people admitted to hospital for acute coronary syndromes (ACS). Intensive insulin therapy is defined as an intravenous infusion of insulin and glucose with or without potassium. For the purposes of this guideline, hyperglycaemia is defined as a blood glucose level above 11 mmol/litre. This definition was based on the expert opinion of the Guideline Development Group (GDG) and was agreed by consensus.

ACS encompass a spectrum of unstable coronary artery disease, ranging from unstable angina to transmural myocardial infarction. All forms of ACS begin with an inflamed and complicated fatty deposit (known as an atheromatous plaque) in a blood vessel, followed by blood clots forming on the plaque. The principles behind the presentation, investigation and management of these syndromes are similar, but there are important distinctions depending on the category of ACS.

Hyperglycaemia is common in people admitted to hospital with ACS. Recent studies 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.

A wide range of national guidance is available for the care of people with diabetes in hospital with relevance to ACS patients. For example the NHS Institute for Innovation and Improvement recommends that all patients with ACS and known diabetes are referred to the inpatient diabetes team.

Contents

• Introduction
• Patient-centred care
• 1. Recommendations
  • 1.1. List of all recommendations
• 2. Care pathway
• 3. Evidence review and recommendations
  • 3.1. Adults with acute coronary syndromes and hyperglycaemia with a diagnosis of diabetes
  • 3.2. Adults with acute coronary syndromes and hyperglycaemia without a previous diagnosis of diabetes
  • 3.3. Identifying people who are at high risk of developing diabetes
  • 3.4. Patient information
• 4. Notes on the scope of the guideline
• 5. Implementation
• 6. Other versions of this guideline
  • 6.1. NICE pathway
  • 6.2. ‘Understanding NICE guidance’
• 7. Related NICE guidance
• 8. Updating the guideline
• 9 References
• 10. Glossary and abbreviations
• Appendix A. Contributors and declarations of interests
• Appendix B. Research recommendation
• Appendix C. Guideline scope
• Appendix D. How this guideline was developed
• Appendix E. Evidence tables

This guideline partially updates recommendation 1.12.3.6 in ‘Type 1 diabetes’ (NICE clinical guideline 15). Recommendation 1.12.3.6 is updated for the treatment of patients with threatened or actual MI, but not stroke.

NICE clinical guidelines are recommendations about the treatment and care of people with specific diseases and conditions in the NHS in England and Wales.

This guidance represents the view of NICE, which was arrived at after careful consideration of the evidence available. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. However, the guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, and informed by the summary of product characteristics of any drugs they are considering.

Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.