CORRESPONDENCE: LETTER TO THE EDITOR
Reply
Antonio Ceriello, MD*
* Warwick Medical School, Clinical Science Research Institute, Clinical Science Building, University Hospital, Walsgrave Campus, Clifford Bridge Road, Coventry CV2 2DX, United Kingdom (Email: antonio.ceriello{at}warwick.ac.uk).
I thank Drs. Kapoor and Kapoor for their letter concerning our recent paper (1). They question the evidence that a strict glycemic control might be beneficial in cardiac intensive care unit.
First of all, I would like to underline that the available evidence has been considered strong enough to induce the American Heart Association to suggest controlling hyperglycemia during acute coronary syndrome (2).
Furthermore, certainly the letter has been written before the publication from Kosiborod et al. (3), who definitively show—following 7,820 patients—that glucose normalization after admission is associated with better survival in hyperglycemic patients hospitalized with acute myocardial infarction whether or not they receive insulin therapy.
My worry is that we are still debating about the usefulness of lowering glucose, although evidence is forthcoming suggesting that this might not be enough, because the "variability of glucose" is also probably involved in worsening the prognosis of patients in the critical care setting (4,5).
The hypothesis that maintaining the level of glycemia under very strict control would be relevant in any clinical setting is, in my opinion, stressed by the recent evidence that in normal people glycemia is always maintained in a very narrow range of 70 to 140 mg/dl (6). One can argue that, if the human body spends so much energy to maintain the blood glucose level under so strict a range, it is because otherwise it could be deleterious. So, in my opinion—while waiting for more detailed, ad hoc designed studies, particularly intervention studies—it is already the time for a step ahead and to raise attention to this new therapeutic challenge not only for diabetes but also for a number of critical conditions.
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1. Ceriello A, Zarich SW, Testa R. Lowering glucose to prevent adverse cardiovascular outcomes in a critical care setting J Am Coll Cardiol 2009;53(Suppl):S9-S13.[Abstract/Free Full Text]2. Deedwania P, Kosiborod M, Barrett E, et al. American Heart Association Diabetes Committee of the Council on Nutrition, Physical Activity, and Metabolism Hyperglycemia and acute coronary syndrome: a scientific statement from the American Heart Association Diabetes Committee of the Council on Nutrition, Physical Activity, and Metabolism Circulation 2008;117:1610-1619.[Abstract/Free Full Text] 3. Kosiborod M, Inzucchi SE, Krumholz HM, et al. Glucose normalization and outcomes in patients with acute myocardial infarction Arch Intern Med 2009;169:438-446.[Abstract/Free Full Text] 4. Egi M, Bellomo R, Stachowski E, French CJ, Hart G. Variability of blood glucose concentration and short-term mortality in critically ill patients Anesthesiology 2006;105:244-252.[CrossRef][Web of Science][Medline] 5. Krinsley JS. Glycemic variability: a strong independent predictor of mortality in critically ill patients Crit Care Med 2008;36:3008-3013.[CrossRef][Web of Science][Medline] 6. Mazze RS, Strock E, Wesley D, et al. Characterizing glucose exposure for individuals with normal glucose tolerance using continuous glucose monitoring and ambulatory glucose profile analysis Diabetes Technol Ther 2008;10:149-159.[CrossRef][Web of Science][Medline]
Related Article
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Strict Glucose Control in the Cardiac Intensive Care Unit: Poised for Real Time?
- John R. Kapoor and Roger Kapoor
J. Am. Coll. Cardiol. 2009 54: 373-374.
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