Core Curriculum

• Hyperglycemia and Acute Coronary Syndromes

VBWG07_HACS.pdf (10.6MB)VBWG07_HACS.pdf (10.6MB)

Hyperglycemia and Acute Coronary Syndromes

Download VBWG07_HACS1.ppt (9 slides - 1.2MB)

Hyperglycemia andAcute Coronary Syndromes Cardiovascular disease and diabetes Abnormal glucose metabolism in CAD ADA criteria for IGT and T2DM New-onset hyperglycemia linked to highest rate of in-hospital mortality Admission glucose in AMI associated with mortality, independent of T2DM diagnosis Stress hyperglycemia in AMI: Association with mortality risk in patients without known diabetes Baseline fasting plasma glucose levels predict HF hospitalization in high-risk patients Admission glucose and glucose change within 24 hours predict mortality risk

Hyperglycemia at the Vessel Wall

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Hyperglycemia at the Vessel Wall Potential hyperglycemia-induced tissue damage Hyperglycemia in AMI: Treatment targets? Hyperglycemia: Independent predictor of impaired myocardial blood flow in STEMI Hyperglycemia increases endothelial dysfunction Myocardial blood flow response to hyperemia in insulin-resistant states Myocardial blood flow response to cold pressor testing in insulin-resistant states Hyperglycemia associated with increased inflammatory markers in AMI Acute hyperglycemia abolishes ischemic preconditioning in dogs Impact of hyperglycemia on platelet function Glucose fluctuations correlate with oxidative stress

Vascular Effects of Insulin: Implications for Hyperglycemia Management

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Vascular Effects of Insulin: Implications for Hyperglycemia Management Potential beneficial effects of insulin Insulin exerts dose-dependent vasodilatory effect on adenosine-stimulated myocardial blood flow Insulin infusion improves myocardial blood flow in patients with T2DM and CAD Insulin reduces myocardial injury and post-ischemic apoptosis in dogs Insulin improves post-MI cardiac contractile function recovery in dogs Insulin infusion has anti-inflammatory and profibrinolytic effects Insulin infusion with normoglycemia decreases NF-B Intensive insulin reverses impaired platelet response in ACS patients with T2DM

Rationale for Maintaining Glycemic Control in the Hospital

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Rationale for Maintaining Glycemic Control in the Hospital Glucose targets for hospitalized patients Glycemic control in the ICU Intensive insulin therapy in surgical ICU reduces morbidity and mortality IV insulin infusion protocols: Comparison of targets and recommendations Essential elements of an IV insulin protocol ACC/AHA STEMI guidelines: Strict glucose control ACC/AHA NSTEMI guidelines: Diabetes

Glucose-Insulin-Potassium (GIK) in AMI

Download VBWG07_HACS5.ppt (9 slides - 1.2MB)

Glucose-Insulin-Potassium (GIK)in AMI Glucose-insulin-potassium “cocktail” GIK: Summary of early trials in AMI Major trials of GIK in AMI DIGAMI 1: CVD mortality after AMI DIGAMI 2 and CREATE-ECLA outcomes show need for glucose control CREATE-ECLA: Effect of GIK on mortality, glucose CREATE-ECLA: Correlation of baseline glucose with mortality What CREATE-ECLA shows about GIK

Aggressive Hyperglycemia Management

Download VBWG07_HACS6.ppt (14 slides - 1.6MB)

Aggressive Hyperglycemia Management Significant hospital hyperglycemia requires close follow-up Glucose control in ACS patients with diabetes often unknown or undertreated at discharge EPIC-Norfolk: CV risk increases with A1C level UKPDS 33: Glycemic control declines over time Need for insulin increases over time UKPDS 33: Effect of intensive glucose control on T2DM complications UKPDS 34: Glucose control and CV outcomes Limitations of UKPDS DCCT/EDIC: Intensive glucose control associated with reduced long-term CV risk EDIC year 11: Patient characteristics at mean age 45 Glycemic control and vascular disease in T2DM Diabetes management trials: Clinical trial horizon Ongoing trials of glucose lowering and CV outcomes

Practical Considerations in Clinical Management

Download VBWG07_HACS7.ppt (24 slides - 1.5MB)

Practical Considerations in Clinical Management Guideline-recommended glycemic targets in diabetes Glucose dynamics: Basal and prandial Relative contributions of postprandial glucose and FPG to A1C Glycemic control deteriorates with standard therapies A1C reduction with glucose-lowering medications Oral diabetes agents Incretin agents in glucose control ADA: Managing hyperglycemia in T2DM ACE road map to glycemic goals in T2DM: Treated patients Treat-to-Target study: Basal insulin lowers FPG and A1C Treat-to-Target: Nocturnal hypoglycemia vs glycemic control Fewer hypoglycemic episodes withinsulin analogue Insulin glargine + OAD effect on weight, A1C  Glycemic control and weight change with detemir vs NPH insulin Add-on treatment with glargine vs rosiglitazone + SU/MET: A1C and FPG Glargine vs rosiglitazone added to SU + MET: Lipid effects Add-on Rx with glargine vs rosiglitazone + SU/MET: Comparative adverse effects Basal and bolus insulin pharmacodynamics Dispelling misconceptions about insulin ACC/AHA secondary prevention guidelines: Diabetes management Discharge strategies for patients with hyperglycemia Managing glucose in T2DM Continuity of care for diabetes: It takes a health care team
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