الفهرس 
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Abstract
Patients with diabetes have an increased incidence of atherosclerotic cardiovascular disease and acute coronary syndrome. Acute hyperglycemia has numerous effects on the cardiovascular system, including abnormalities in endothelial and vascular smooth muscle cell function, abnormalities in cardiac energy metabolism, acting as a prothrombotic state, and causing inflammatory changes.
In 2005, the ADA added recommendations for treatment of hyperglycemia in the hospital to its annual standards of medical care. In the critical care setting, continuous intravenous (IV) insulin infusion has been shown to be the most effective method for achieving specific glycemic targets. The medical literature supports the use of intravenous (IV) insulin infusion in preference to the subcutaneous (SC) route of insulin administration for several clinical indications, including myocardial infarction.
IV insulin therapy is ideally administrated by means of written or computerized protocols that allow for adjustments in the insulin infusion rate based on glycemic fluctuations and insulin dose. There are several applied (IV) insulin protocols but the more recent Atlanta protocol proved to be better in controlling blood glucose level. This protocol is unique in that it makes changes based on multiplier for insulin sensitivity. It then changes the insulin rate hourly based on the difference between the measured blood glucose and a target blood glucose.
The level of blood glucose recommended to improve the outcome in the CCU has undergone several changes. In 2001, Van den Berghe et al, reported a dramatic reduction in mortality in the surgical ICU when blood glucose was normalized to 80 to 110 mg/dl by means of insulin infusion. Recently, two multicenter studies called into question the Leuven findings. Both reported high rates of hypoglycemia due to tight glycemic control, and one trial was prematurely terminated for this reason.
Into this controversy came the NICE-SUGAR trial. Intensive and conventional glycemic control were compared in a randomized fashion in 6104 patients in the ICU, involving the use of intravenous insulin to achieve a blood glucose level of 81 to 108 mg/dl or a level of 144 to 180 mg/dl, respectively. In this large trial, it was found that intensive glucose control increased mortality among adults in the ICU: a blood glucose target of 180 mg or less per deciliter resulted in lower mortality than did a target of 81 to 108 mg/dl.
The current study aimed at determining the outcome of coronary events in case of achievement of glycemic target between 140 and 180 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 examinationandroutine laboratory investigations. Every individual had his blood glucose level measured hourly 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 140-180 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. The random blood glucose was measured every hour and the rate of insulin infusion was changed accordingly.
The study showed that Atlanta protocol was effective in that glycemic target was achieved within a reasonable period of 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 increased incidence of clinical events although this was not statistically significant. The patients admitted with no past history of diabetes had significantly higher incidence of clinical complications than those admitted with a known history of diabetes (p=0.014). The study also showed that increased number of hyperglycemic episodes was associated with significantly increased incidence of both coronary events and total clinical events (p=0.006). On the contrary, no statistically significant relationship was illustrated between the number of undesired blood glucose level episodes between 90 and 109 mg/dl and episodes between 70 and 89 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