The Role of Intensive Glycemic Control in the Management of Patients who have Acute Myocardial Infarction

Division of Cardiovascular Medicine, Department of Medicine, Bridgeport Hospital, 267 Grant Street, Bridgeport, CT 06610, USA Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA Individuals who have diabetes mellitus (DM) have a twofold to fourfold increased risk of cardiovascular disease and nearly twice the early mortality from acute myocardial infarction (AMI) compared with nondiabetic subjects 1-5 . Furthermore, the mortality difference between diabetics and...

Mechanism of action

The mechanism of action of the nonsulfonylurea insulin secretagogues repaglinide a benzoic acid derivative and nateglinide a phenylalanine derivative is similar to that of sulfonylureas interaction with voltage-dependent KATP channels on cells. They are distinguished from the sulfonylureas by their short metabolic half-lives, which result in brief episodic stimulation of insulin secretion 60 . There are two important consequences from this difference. First, postprandial glucose excursions are...

Is lifestyle modification adequate to prevent onset of diabetes

Metabolic syndrome carries with it the underlying pathophysiologic feature of insulin resistance with tissue resistance to insulin action, compensatory hyperinsulinemia, and excessive circulating free fatty acids 78,79 . In addition, cardiovascular risk factors of low HDL and high triglyceride levels, hypertension, and lack of physical activity have all been shown to be predictors of non-insulin-dependent diabetes 80 . The relationships between metabolic syndrome and cardiovascular mortality as...

Role of the renin angiotensin aldosterone system in vascular endothelial function

The endothelium has numerous vital functions. First, it acts as a permeability barrier preventing exocytosis of macrophage and small, dense low-density lipoprotein LDL entering the subendo-thelial layer from initiating the genesis of the fatty streak, the first step in atherosclerosis. Second, it is important in maintaining vascular tone by releasing angiotensin II and endothelin, powerful vasoconstrictors, and balancing that release by the release of nitric oxide, a potent vasodilator. The...

Individual drug review

Angiotensin-converting enzyme inhibitors Angiotensin-converting-enzyme ACE inhibitors are the initial drug choice for patients who have diabetes and hypertension, especially those who have albuminuria. Although initially recommended based on a small set of data, several recent RCTs clearly support the use of ACE inhibitors based on their favorable impact on CV and renal outcomes. ACE is responsible for the conversion of angiotensin I to angiotensin II, which elevates BP by direct...

Intracellular calcium levels Decrease myocardial apoptosis post reperfusion

Adjacent nonischemic myocardium is exposed to an acute pressure load during AMI that resulted, experimentally, in diminished levels of high energy substrate and accelerated ventricular failure 34 . Augmenting glucose oxidation maintained ventricular function in the above murine model of acute pressure during AMI overload. Thus, acutely loaded nonischemic myocardium may benefit markedly from increased glucose uptake and oxidation in the setting of GIK. Experimental data also support a direct...

Clinical studies of renin angiotensin aldosterone system inhibition and outcomes of insulin resistance

ACE inhibition with captopril improves insulin sensitivity 107 , in some cases allowing withdrawal of sulfonylurea and reduction of the insulin dose 108,109 . Hence, a few randomized trials have attempted to assess changes in insulin sensitivity comparing ACE inhibitor and placebo Table 8 110-117 . The results were heterogeneous, but the use of ARBs to assess insulin sensitivity seemed to show some promise, and these results were not quite as heterogeneous as those seen with ACE inhibitors. Of...

Freed M Et Al. Diabetologia 2000 43 Suppl 1 A267

Diabetes and cardiovascular disease. The Framingham study. JAMA 1979 241 19 2035-8. 2 Haffner SM. Management of dyslipidemia in adults with diabetes. Diabetes Care 1998 21 1 160-78. 3 Stone PH, Muller JE, Hartwell T, York BJ, Rutherford JD, Parker CB, et al. The effect of diabetes mellitus on prognosis and serial left ventricular function after acute myocardial infarction contribution of both coronary disease and diastolic left ventricular dysfunction to the adverse...

Sometimes requires discontinuation Contraindicated in active hepatic renal and coronary artery disease

Insulin levels and corrects many of the nontradi-tional risk factors that are associated with the insulin resistance syndrome 77 . In the UKPDS, treatment with metformin another drug that decreases hyperinsulinemia and insulin resistance produced greater reduction in cardiovascular disease events and mortality than sulfonylureas and insulin 8 . The latter drugs decreased blood glucose level to a similar degree as metformin but did not decrease plasma insulin concentrations. This effect may have...

Role of Insulin Secretagogues and Insulin Sensitizing Agents in the Prevention of Cardiovascular Disease in Patients

Fonseca, MDab aDepartment of Medicine, Section of Endocrinology, Tulane University Medical Center, SL-53, 1430 Tulane Avenue, New Orleans, LA 70112-2699, USA bDepartment of Medicine, Veterans Affairs Medical Center, 1601 Perdido Street, New Orleans, LA 70112, USA Cardiovascular disease is the leading cause of death among patients who have diabetes mellitus. Patients who have diabetes mellitus have a greatly increased relative risk of cardiovascular disease when...

Interaction between angiotensin endothelium and insulin resistance

Insulin resistance is associated with metabolic syndrome, which increases the risk of adverse cardiovascular outcomes. There is definitive evidence that insulin resistance and endothelial dysfunction progress in parallel. As insulin resistance progresses to clinical metabolic syndrome, impaired glucose tolerance, and development of diabetes, there is a parallel track that leads from endothelial dysfunction to inflammation, with increased oxi-dative stress leading to overt atherosclerotic...

Trials examining glycemic targets

The most hotly debated clinical questions in diabetes mellitus are whether glycemic control is associated with a reduction in CVD outcomes and how low a glycemic target should be pursued. Because the risk for severe hypoglycemia increases as lower targets are achieved, there is a floor below which benefits will be counterbalanced by risk. Guidelines suggest that hemoglobin A1c HbAlc targets of less than 7 3 , 6.5 4 , or 6.1 5 are appropriate. These goals have been imputed by examining...