الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Diabetes is an important health condition and the number of individuals with diabetes can be expected to grow rapidly over the coming decades. Specific metabolic abnormalities induced by diabetes can adversely affect the mechanical performance or increase the myocardial vulnerability to ischemic insults. Evidence is emerging and suggests that insulin per se is therapeutic for critically ill patients; insulin administration and improved metabolic control during the acute phase of AMI reduce myocardial damage, improve contractility and decrease mortality.
Hyperglycemia and large fluctuations in glycemic values increase the risk of morbidity and mortality among critically ill patients and those with cardiovascular disease. A significant body of evidence supports the use of insulin therapy for glucose control in appropriately selected critically ill patients.
Patients with stress hyperglycemia and no previous diagnosis of diabetes face worse consequences at a given severity of hyperglycemia than do those with preexisting diabetes. Stress induced hyperglycemia per se causes harm or may be a marker of severity of counter regulatory hormone release, inflammatory response and degree of illness. Chronic hyperglycemia may induce protective cellular conditioning for example, down regulation of glucose transporters which would protect cells from unchecked glucose ingress. Such a response would be lacking in those developing stress related hyperglycemia.
Intensive glycemic control may reduce macrovascular events for newly diag¬nosed patients but once significant macro¬vascular disease is present, it may not be beneficial and even may be harmful this supported the call to refrain from tight glycemic control in patients with known macrovascular disease or ACS patients.
The debate regarding best targets is ongoing, the NICE-SUGAR trial, a large multicenter randomized trial comparing the effects of intensive glucose control
(target glucose 81-108 mg/dl) and conventional glucose control (target glucose
< 180 mg/dl) on death from any cause within 90 days of randomization. Severe hypoglycemia and mortality were reported more in those randomized to intensive than to conventional control and there was no significant difference in the length of stay in the ICU and median days of mechanical ventilation.
The current study included 30 patients admitted with acute coronary syndrome in the coronary care unit of Alexandria Main University Hospital, in whom random blood glucose (RBG) was above 140 mg/dl and aimed at determining the outcomes of coronary events in case of achievement of glycemic target between (110-140 mg/dl) using the Atlanta protocol and to evaluate the incidence of different complications including hypoglycemia, cardiac arrhythmia, need for mechanical ventilation, infection,
re-infarction, heart failure and mortality during hospital admission.
All individuals included in the study were subjected to thorough history taking, complete clinical examination routine laboratory investigations. Every individual had his blood glucose level measured hourly and the rate of insulin infusion was changed accordingly for 72 hours. IV insulin infusion using either infusion pump or automatic insulin syringe pump was used to control blood glucose level with a target RBG of
110-140 mg/dl. Continuous Variable Rate IV Insulin Drip was used, based on a computerized program, using a specific multiplier, based on the Atlanta Protocol to obtain glucose in the target range.
Glycemic protocol utilizing a computerized system for IV insulin infusion and transition to SC basal-bolus insulin therapy provided through Atlanta protocol was highly effective in normalizing glucose without significant hypoglycemia.
The study showed that Atlanta protocol was effective in that glycemic target was achieved within a reasonable time with no incidence of severe hypoglycemia, mortality or repeated coronary revascularization and very low incidence of coronary events and total clinical complications. Increased blood glucose on admission was associated with a statistically significant increased incidence of clinical events (p=0.005). The patients admitted with no past history of diabetes had higher incidence of clinical complications than those admitted with a known history of diabetes although statistically non significant (p=0.315). The study also showed that increased number of hyperglycemic episodes was associated with increased incidence of both coronary events and total clinical events (p=0.085).
Similarly, no statistically significant relationship was illustrated between the number of undesired blood glucose level episodes between 70 and 109 mg/dl and the incidence of coronary events or total clinical events. Also, hypoglycemia during hospitalization for a myocardial infarction is not an independent risk factor for mortality and cardiovascular morbidity this is explained by frequent monitoring of blood glucose , small insulin doses that allow rapid adjustment of doses and the proper strategy for addressing hypoglycemia so hypoglycemia, if happened, is short lasting, moreover the alarm system for a trend towards hypoglycemia made the risk of severe disabling hypoglycemia (<40 mg/dl) that often resulted in morbidity and mortality is quite away .
The current study did show that glycemic target 110-140 mg/dl was proved to be the best, it possesses most of the beneficial criteria of the tight control without increasing the risk of hypoglycemia together with most of the beneficial criteria of the glycemic target (140-180 mg/dl). It keeps most readings within the currently accepted glycemic values for normal individuals this is to say that the lower limit of this target represents the upper limit fasting glucose level for normal individuals and the upper limit of this target represents the optimal post prandial glycemia.
Future research should further evaluate this target to show whether it is the most appropriate for ACS patients or show it’s deficiencies through wide scale application.
Two other relevant studies on glycemic control using computerized program based on the Atlanta protocol in the Alexandria Main University Hospital ,Department of Diabetes and Metabolism for the CCU glycemia management of ACS patients, have been recently finished both results agreed with ours ,have proved the efficacy of the computerized program of the Atlanta protocol in all aspects ,targets achieved within a reasonable time frames ,maintained most of time , glycemic excursions were minimized, ease of application, less decision making points, less complications improved overall inpatients outcomes including the cardiac related complications and reported no mortality cases.