Glucose-insulin-potassium infusion inpatients treated with primary angioplasty for acute myocardial infarction: the glucose-insulin-potassium study: a randomized trial

excess of bleeding complications. Although fewer patients needed urgent PCI after combination therapy with abciximab and enoxaparin, clinical outcomes were less favorable in this selected population, particularly with abciximab. The clinical benefits of combination therapy in patients with ST elevation MI subsequently undergoing PCI remain uncertain. DM

Glucose-Insulin-Potassium Infusion Inpatients Treated With Primary Angioplasty for Acute Myocardial Infarction: The Glucose-InsulinPotassium Study: A Randomized Trial

The Incidence, Predictors and Outcomes of Early Reinfarction After Primary Angioplasty for Acute Myocardial Infarction

Study Question: The investigators evaluated whether adjunctive glucose-insulin-potassium (GIK) infusion with primary coronary transluminal angioplasty (PTCA) is beneficial in patients with an acute myocardial infarction (MI). Methods: The study design was an open-label randomized clinical trial. From April 1998 to September 2001, 940 patients with an acute MI and eligible for PTCA were randomly assigned to either a continuous GIK infusion for 8 –12 hours or no infusion. The primary end point of the study was 30-day mortality. Results: The 30-day mortality was 23 of 476 patients (4.8%) receiving GIK compared with 27 of 464 patients (5.8%) in the control group (relative risk [RR] 0.82, 95% confidence interval [CI] 0.46 –1.46). In 856 patients (91.1%) without signs of heart failure (HF) (Killip class 1), 30-day mortality was five of 426 patients (1.2%) in the GIK group vs. 18 of 430 patients (4.2%) in the control group (RR 0.28, 95% CI 0.1– 0.75). In 84 patients (8.9%) with signs of HF (Killip class ⱖ2), 30-day mortality was 18 of 50 patients (36%) in the GIK group vs. nine of 34 patients (26.5%) in the control group (RR 1.44, 95% CI 0.65–3.22). Conclusions: The authors concluded that glucose-insulinpotassium infusion as adjunctive therapy to PTCA in acute MI did not result in a significant mortality reduction in all patients. In the subgroup of 856 patients without signs of HF, a significant reduction was seen. The effect of GIK infusion in patients with signs of HF (Killip class ⱖ2) at admission is uncertain. Perspective: Prior studies have suggested that GIK might play a role in reducing in-hospital mortality after acute MI. The current study found no significant overall beneficial effect of GIK. The survival advantage in the subgroup of patients without signs of HF should be viewed with caution since the investigators did not use a method to correct for multiple comparisons to analyze subgroups. DM

van der Horst ICC, Zijlstra F, Arnoud WJ, van’t Hof AWJ, et al., on behalf of the Zwolle Infarct Study Group. J Am Coll Cardiol 2003;42:784 –91.

Kernis SJ, Harjai KJ, Stone GW, et al. J Am Coll Cardiol 2003;42: 1173–7. Study Question: The investigators sought to identify the incidence, predictors and clinical consequences of 1-month reinfarction (RE-MI) in patients undergoing primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). Methods: The study design was a post-hoc subgroup analysis of a randomized clinical trial. The investigators analyzed data from 3646 patients who underwent primary PCI in the Primary Angioplasty in Acute Myocardial Infarction (PAMI) studies. They studied the incidence, correlates and clinical outcomes of 30-day RE-MI. Results: Reinfarction within 1 month of index hospitalization occurred in 77 (2.1%) of patients. In multivariate analysis, admission Killip class ⬎1 (odds ratio [OR] 2.02, 95% confidence interval [CI] 1.09 –3.76), left ventricular ejection fraction ⬍50% (OR 2.49, 95% CI 1.30 – 4.74), final coronary stenosis ⬎30% (OR 2.57, 95% CI 1.28 – 5.15) and presence of coronary dissection (OR 2.40, 95% CI 1.36 – 4.24) and thrombus (OR 2.36, 95% CI 1.23– 4.53) on the final angiogram were independent correlates of RE-MI. One-month reinfarction was independently associated with death (OR 7.14, 95% CI 3.28 –15.5) and ischemic target vessel revascularization (I-TVR) (OR 15.0, 95% CI 8.68 –26.0) at 6 months. Conclusions: The authors concluded that although early RE-MI is uncommon in patients treated by primary PCI, it is a significant independent predictor of death and ischemic TVR at 6 months. Admission Killip class ⬎1 and left ventricular systolic dysfunction were associated with higher incidence of RE-MI. Their results suggest that optimal revascularization during primary PCI may decrease RE-MI rates. Perspective: Reinfarction is significantly less common with primary PCI compared to fibrinolytic therapy for ST-elevation MI. The investigators found one clinical characteristic and several angiographic variables that were associated with higher RE-MI risk. RE-MI, although infrequent, appears to be associated with a significantly higher risk of future revascularization and death. The study suggests that reinfarction may be preventable by optimal coronary revascularization and aggressive treatment of post-PCI dissection and thrombus. This may in turn improve long-term outcomes. DM

Relation Between Hospital Intra-Aortic Balloon Counterpulsation Volume and Mortality in Acute Myocardial Infarction Complicated by Cardiogenic Shock Chen EW, Canto JG, Parsons LS, et al., for the Investigators in the National Registry of Myocardial Infarction (NRMI) 2. Circulation 2003;108:951–7. Study Question: The objective of the present study was to determine if an inverse relationship exists between the

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