title: Piloting a novel algorithm for glucose control in the coronary care unit: the RECREATE (REsearching Coronary REduction by Appropriately Targeting Euglycemia) trial.
abstract: OBJECTIVE
  Elevated glucose levels are common after an acute myocardial infarction (AMI) and increase the risk of death. Prior trials of glucose control after AMI have been inconsistent in their ability to lower glucose levels and have reported mixed effects on mortality. We developed a paper-based glucose-lowering algorithm and assessed its feasibility and safety in the setting of AMI.
  
  
  METHODS
  A total of 287 participants with an acute ST segment elevation myocardial infarction (STEMI) and a capillary glucose level ≥8.0 mmol/L were randomly allocated to glucose management with intravenous glulisine insulin using this algorithm in the coronary care unit (CCU), followed by once-daily subcutaneous insulin glargine for 30 days versus standard glycemic approaches. The primary outcome was a difference in mean glucose levels at 24 h. Participants were followed for clinical outcomes through 90 days.
  
  
  RESULTS
  At 24 h, the mean glucose level was 1.41 mmol/L (95% CI 0.69-2.13) lower in the insulin (6.53 vs. 7.94 mmol/L). Differences in glucose levels were maintained at 72 h and 30 days. A total of 22.7% of the insulin group versus 4.4% of the standard group had biochemical hypoglycemia (with neither signs nor symptoms) in the CCU because of lower glycemic goals. However, there were no differences in symptomatic hypoglycemia or clinical outcomes between the groups.
  
  
  CONCLUSIONS
  A paper-based insulin algorithm targeting glucose levels of 5.0-6.5 mmol/L (90-117 mg/dL) can be feasibly implemented in the CCU. A cardiovascular outcomes trial using this approach can determine whether targeted glucose lowering improves patient outcomes.
authors.affiliation: Population Health Research Institute McMaster University, Hamilton, Ontario, Canada. recreate@phri.ca
authors.forename: Kara A
authors.initials: KA
authors.lastname: Nerenberg
authors.forename: Abhinav
authors.initials: A
authors.lastname: Goyal
authors.forename: Denis
authors.initials: D
authors.lastname: Xavier
authors.forename: Alben
authors.initials: A
authors.lastname: Sigamani
authors.forename: Jennifer
authors.initials: J
authors.lastname: Ng
authors.forename: Shamir R
authors.initials: SR
authors.lastname: Mehta
authors.forename: Rafael
authors.initials: R
authors.lastname: Díaz
authors.forename: Mikhail
authors.initials: M
authors.lastname: Kosiborod
authors.forename: Salim
authors.initials: S
authors.lastname: Yusuf
authors.forename: Hertzel C
authors.initials: HC
authors.lastname: Gerstein
mesh_terms: D000368:Aged; D000465:Algorithms; D001786:Blood Glucose / Q000187:drug effects / Q000378:metabolism*; D003325:Coronary Care Units; D005260:Female; D006801:Humans; D007004:Hypoglycemic Agents / Q000627:therapeutic use*; D007328:Insulin / Q000031:analogs & derivatives* / Q000627:therapeutic use; D000069036:Insulin Glargine; D049528:Insulin, Long-Acting / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications*; D010865:Pilot Projects
chemical_list: D001786:Blood Glucose; D007004:Hypoglycemic Agents; D007328:Insulin; D049528:Insulin, Long-Acting; D000069036:Insulin Glargine; C479079:insulin glulisine
references.citation: Eur Heart J. 2004 Nov;25(21):1880-90
references.pmid: 15522466
references.citation: Circulation. 2009 Dec 15;120(24):2429-37
references.pmid: 19948980
references.citation: Eur Heart J. 2006 Nov;27(21):2573-9
references.pmid: 16984927
references.citation: Arch Intern Med. 2004 Oct 11;164(18):2005-11
references.pmid: 15477435
references.citation: Diab Vasc Dis Res. 2008 Nov;5(4):276-84
references.pmid: 18958837
references.citation: Lancet. 2000 Mar 4;355(9206):773-8
references.pmid: 10711923
references.citation: Eur Heart J. 2008 Jan;29(2):177-84
references.pmid: 18156611
references.citation: Circulation. 1999 May 25;99(20):2626-32
references.pmid: 10338454
references.citation: JAMA. 2005 Jan 26;293(4):437-46
references.pmid: 15671428
references.citation: Circulation. 2005 Feb 15;111(6):754-60
references.pmid: 15699267
references.citation: Arch Intern Med. 2009 Mar 9;169(5):438-46
references.pmid: 19273773
references.citation: Diabetes Care. 2006 Apr;29(4):765-70
references.pmid: 16567812
references.citation: Eur Heart J. 2006 Jun;27(11):1289-97
references.pmid: 16611669
references.citation: Eur Heart J. 2005 Apr;26(7):650-61
references.pmid: 15728645
references.citation: J Am Coll Cardiol. 1995 Jul;26(1):57-65
references.pmid: 7797776
references.citation: Circulation. 2005 Jun 14;111(23):3078-86
references.pmid: 15939812