Tuesday, November 27, 2007

Glucose-Insulin-Potassium Therapy in Patients With ST-Segment Elevation Myocardial

Title: Glucose-Insulin-Potassium Therapy in Patients With ST-Segment Elevation Myocardial

InfarctionTopic: General CardiologyDate Posted: 11/27/2007

Author(s): Diaz R, Goyal A, Mehta S, et al.Citation: JAMA. 2007;298:2399-2405.

Clinical Trial: No

Study Question: What is the impact of glucose-insulin-potassium (GIK) therapy on outcome of patients presenting with ST-segment elevation myocardial infarction (STEMI)?

Methods: The authors present primary outcome data on 2,748 patients randomized in the OASIS-6 GIK study to GIK versus no infusion. They also present a pooled analysis of the OASIS-6 GIK study and the CREATE-ECLA GIK trial (n = 22,943 patients).

Results: In the OASIS-6 GIK trial, there was no difference in the 6-month mortality (10.8% vs. 10.4%; hazard ratio [HR], 1.04; 95% confidence interval [CI], 0.83-1.31; p = 0.72); heart failure (11.1% vs. 13.5%; HR, 0.83; 95% CI, 0.67-1.02; p = 0.08); or composite of heart failure or mortality (17.5% vs. 19.2%; HR, 0.91; 95% CI, 0.76-1.08; p = 0.27) among patients randomized to GIK compared with controls. Within the pooled trial cohort, there was higher mortality in the GIK group at 3 days (6.2% vs. 5.5%; HR, 1.13; 95% CI, 1.02-1.26; p = 0.03), but there was no difference in the 30-day mortality (9.7% vs. 9.3%; HR, 1.04; 95% CI, 0.96-1.13; p = 0.33). GIK therapy was associated with an increase in glucose and potassium levels, along with a positive volume state in some patients. Patients with one or more of these metabolic derangements after GIK were more likely to have an adverse clinical outcome.

Conclusions: GIK does not provide any clinical benefit in patients with STEMI.

Perspective: Prior preclinical studies and meta-analysis had suggested impressive benefits of GIK in patients with STEMI. While some of the small, randomized trials had suggested impressive survival benefits, a possible increase in mortality in others (e.g., Pol-GIK trial) was dismissed as possibly related to chance. The results of the CREATE-ECLA GIK trial and the current analysis clearly establish the lack of benefit (and possible early harm) of GIK: Another beautiful hypothesis slain by an ugly randomized controlled trial (with apologies to Thomas Huxley). Hitinder S. Gurm, M.B.B.S., F.A.C.C.

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