The need for increased vigilance in managing hyperglycaemia during acute coronary syndrome in the emergency department: An introduction to the evidence

Until recently, increased blood glucose levels in those with and without diabetes with critical illnesses were perceived to be adaptive and benign responses to physiological stress in the critical care environment. In a landmark study published in 2001, Van den Berghe and colleagues demonstrated stress hyperglycaemia was not beneficial for patients who were experiencing critical illness. Instead, they found it resulted in significant increases in mortality. Several clinical trials and meta-analyses have since reported early management of hyperglycaemia in acute coronary syndrome (ACS), and many other critical illnesses to be advantageous. Not all evidence supports tight glycaemic control however. In this paper, we examine possible mechanisms by which increased blood glucose may harm patients with ACS and explain how insulin may be protective. We introduce evidence for and against increased glucose control in the emergency department. Given the increased mortality and morbidity associated with high blood glucose in ACS, we recommend increased diligence in the management of hyperglycaemic patients with ACS upon presentation to emergency departments.