Managing the diabetic patient with acute myocardial infarction.

The diabetic patient has a substantially increased in-hospital mortality after acute myocardial infarction, which is around twice that of non-diabetic subjects. A number of interventions can substantially improve this outcome. The use of thrombolytic therapy reduces case fatality proportionately to a similar degree to that in non-diabetic patients, but because of the higher background risk, absolute benefits are substantially greater. In the world literature, there is just one reported case of intraocular haemorrhage after thrombolysis in a diabetic patient, and that resolved in 3 weeks, meaning that anxieties around theoretical adverse effects of thrombolysis should not preclude its use. There is no evidence regarding the advantages of any one thrombolytic agent in these subjects. Aspirin treatment again has similar benefits to those in non-diabetic subjects, and should be administered at presentation. Some evidence suggests that a higher dose of aspirin should be used in diabetic, compared to non-diabetic, patients. Finally, the DIGAMI Study has shown that insulin and glucose infusion during the hospital admission, followed by multiple injection therapy thereafter, reduces mortality by around one-third, both at 12 months and at around 3 1/2 years. Whether these advantages are because of improved early or late glycaemic control, or because of withdrawal of sulphonylureas, is still unclear, but this uncertainty should not stand in the way of introducing policies for insulin infusion in all diabetic patients admitted with acute myocardial infarction.