Glucose - Insulin - Potassium

[Alexey Dyachkov]

JAMA. Published online March 27, 2012.

Out-of-Hospital Administration of Intravenous Glucose-Insulin-Potassium in Patients With Suspected Acute Coronary Syndromes

Design, Setting, and Participants Randomized, placebo-controlled, doubleblind
effectiveness trial in 13 US cities (36 EMS agencies), from December 2006 through
July 31, 2011, in which paramedics, aided by electrocardiograph (ECG)-based decision
support, randomized 911 (871 enrolled) patients (mean age, 63.6 years; 71.0%
men) with high probability of ACS.

Intervention Intravenous GIK solution (n=411) or identical-appearing 5% glucose
placebo (n=460) administered by paramedics in the out-of-hospital setting and continued
for 12 hours.

Main Outcome Measures The prespecified primary end point was progression of
ACS to myocardial infarction (MI) within 24 hours, as assessed by biomarkers and ECG
evidence. Prespecified secondary end points included survival at 30 days and a composite
of prehospital or in-hospital cardiac arrest or in-hospital mortality, analyzed by
intent-to-treat and by presentation with ST-segment elevation.

Results There was no significant difference in the rate of progression to MI among patients
who received GIK (n=200; 48.7%) vs those who received placebo (n=242; 52.6%)
(odds ratio [OR], 0.88; 95% CI, 0.66-1.13; P=.28). Thirty-day mortality was 4.4% with
GIK vs 6.1% with placebo (hazard ratio [HR], 0.72;95%CI, 0.40-1.29; P=.27). The composite
of cardiac arrest or in-hospital mortality occurred in 4.4% with GIK vs 8.7% with
placebo (OR, 0.48; 95% CI, 0.27-0.85; P=.01). Among patients with ST-segment elevation
(163 with GIK and 194 with placebo), progression to MI was 85.3% with GIK vs
88.7% with placebo (OR, 0.74; 95% CI, 0.40-1.38; P=.34); 30-day mortality was 4.9%
with GIK vs 7.7% with placebo (HR, 0.63; 95% CI, 0.27-1.49; P=.29). The composite
outcome of cardiac arrest or in-hospital mortality was 6.1% with GIK vs 14.4% with placebo
(OR, 0.39; 95% CI, 0.18-0.82; P=.01). Serious adverse events occurred in 6.8%
(n=28) with GIK vs 8.9% (n=41) with placebo (P=.26).

Conclusions Among patients with suspected ACS, out-of-hospital administration
of intravenous GIK, compared with glucose placebo, did not reduce progression to
MI. Compared with placebo, GIK administration was not associated with improvement
in 30-day survival but was associated with lower rates of the composite outcome
of cardiac arrest or in-hospital mortality