title: Intensive management of hyperglycaemia in acute coronary syndromes. Study design and rationale of the BIOMArCS 2 glucose trial.
abstract: BACKGROUND
  Elevated admission plasma glucose is associated with increased mortality in patients who are admitted with an acute coronary syndrome. This may be mediated by increased inflammation, apoptosis and coagulation, and by a disturbed endothelial function that can be found in hyperglycaemic patients. Insulin has several characteristics that may potentially counteract these mechanisms.
  
  
  METHODS
  The BIOMArCS programme is a multi-centre initiative and currently consists of three different studies. The effects of acute coronary syndrome on acute biomarkers washout are studied in the BIOMArCS pilot and the value of biomarkers in predicting upcoming acute coronary syndrome events is studied in BIOMArCS 1. The third study (BIOMArCS 2 glucose), which will be presented here, investigates the effectiveness and safety of intensive glucose level control compared with conventional glucose management in patients with acute coronary syndrome and an admission plasma glucose of 7.8-16 mmol/l. In BIOMArCS 2 glucose, a total of 300 patients without insulin-treated diabetes mellitus will be randomized in a 1:1 ratio to either intensive or conventional glucose management on top of standard medical care. The primary endpoint is infarct size as expressed by the cardiac troponin T level 72 h after admission. To study the metabolic effects of insulin administration, we will investigate biomarker washout patterns of various metabolic mechanisms up to 7 days after admission. These markers will address inflammation, oxidative stress, hypercoagulability, endothelial activation and vasodilatation.
  
  
  CONCLUSIONS
  Current acute coronary syndrome guidelines lack a clear strategy for hyperglycaemia treatment. This study will extend our knowledge on this matter as it may clarify mechanisms and generate hypotheses of if and how myocardial infarct size may be limited by glucose management at admission.
authors.affiliation: Department of Cardiology, Medical Centre Alkmaar, Alkmaar, The Netherlands.
authors.forename: M
authors.initials: M
authors.lastname: de Mulder
authors.forename: V A
authors.initials: VA
authors.lastname: Umans
authors.forename: F
authors.initials: F
authors.lastname: Stam
authors.forename: J H
authors.initials: JH
authors.lastname: Cornel
authors.forename: R M
authors.initials: RM
authors.lastname: Oemrawsingh
authors.forename: E
authors.initials: E
authors.lastname: Boersma
mesh_terms: D054058:Acute Coronary Syndrome / Q000097:blood / Q000150:complications* / Q000401:mortality; D015415:Biomarkers / Q000097:blood; D001786:Blood Glucose / Q000187:drug effects / Q000378:metabolism*; D003925:Diabetic Angiopathies / Q000097:blood / Q000150:complications / Q000401:mortality; D005260:Female; D005951:Glucose Tolerance Test; D017408:Guidelines as Topic; D017052:Hospital Mortality; D006801:Humans; D006943:Hyperglycemia / Q000097:blood / Q000150:complications / Q000188:drug therapy*; D007328:Insulin / Q000008:administration & dosage*; D008297:Male; D018670:Monitoring, Ambulatory; D009203:Myocardial Infarction / Q000097:blood / Q000150:complications / Q000401:mortality; D011379:Prognosis; D012307:Risk Factors; D016896:Treatment Outcome
chemical_list: D015415:Biomarkers; D001786:Blood Glucose; D007328:Insulin