A total of 327 patient with diabetes were admitted with AMI over a 1-year period; 297 at the academic medical center and 30 at the affiliated community hospital (n=30). Of these we excluded 110 patient for the following reasons: (1) no documentation of AHT prior to admission (n=37), (2) no documented history of DM prior to admission (18), (3) chart not available at time of review (18), (4) transfer to another facility (16), (5) AMI was not the primary diagnosis (13), and (6) death during hospitalization (8). Of the 217 meeting all inclusion criteria, 97 (45%) were being treated with metformin, 86 (40%) with insulin secretagogues (mostly sulfonylureas), 81 (37%) with insulin, 30 (14%) with thiazolidinediones, and 14 (6%) with other anti-hyperglycemic medications (drug categories not mutually exclusive due to the use of combination regimens). Of the 217 included patients, 25 (11.5%) were discharged off AHT, 24 (96%) of whom received some AHT in the hospital. Of these, 16 (64%) were treated as inpatients with regular insulin sliding scale (RISS), 7 (28%) with a basal insulin plus RISS, 1 (4%) with basal insulin only, 5 (20%) with an oral anti-hyperglycemic agent. Prior to admission, these 25 patients were treated with metformin in (n=10), insulin (n=10), sulfonylurea in (n=6), thiazolidinediones (n=4), and other medicines (n=3). Of these 25 patients 19 (76%) were treated with one anti-hyperglycemic agent, 4 (16%) with 2 agents, and 2 (8%) with 3 agents.
Only one patient (4%) had a documented explanation (change in goals of care) and 2 other (8%) were deemed to have a justifiable explanation for discontinuation of AHT at discharge after the detailed chart review. One of these individuals developed recurrent hypoglycemia (capillary blood glucose levels by point-of-care meter of 43, 50, 56, and 59 mg/dl) while hospitalized both on and off of an oral hypoglycemic agent (sulfonylurea). A second individual had entirely normal in-hospital blood glucose levels after AHT was discontinued, with an average morning serum glucose of 103 mg/dl and a range of 85–128 mg/dl. We categorized the remaining 88% as being discharged off AHT without justification.
The demographic and clinical characteristics of those discharged on versus off AHM were similar, as shown in the Table. The sole exception was better left ventricular ejection fraction (LVEF) in the latter group. More specifically, there was no statistical difference in the rate of hypoglycemic or hyperglycemic episodes, nor in the serum creatinine concentration at discharge. Additionally, there were no statistical differences in glycemic measures, such as mean laboratory plasma glucose level during hospitalization, as well as Hb-A1c obtained over the past six months, when it was available. For example, among the 218 charts reviewed, 90 (41%) had Hb-A1c obtained in the past six months available for review. Of these, 35 patients had a Hb-A1c <7%, 7 (20%) of whom were discharged off of AHM, whereas 55 patients had a Hb-A1c > 7%, of whom 5 (9%) were discharged off of AHM, (P=0.20).
We also examined the percentage of patients discharged on other standard cardiovascular therapies following AMI such as aspirin, beta blocker, and hmg coa reductase inhibitor. The reasons for omission of these agents were not addressed by our investigation.
Finally, 40% of the 25 patients discharged off AHT, had follow up office or clinic visit dates documented on their discharge summaries, which was not statistically significant from those discharged on AHT (30%)(p=0.32).