There are a few folks persistently enamored with the use of glucose-insulin-potassium cocktails in the setting of acute coronary syndrome. Two years ago, I reported on the initial results of the IMMEDIATE trial, published in JAMA. At the time, I boggled that such a small, underpowered study – and one that changed their enrollment target and primary endpoint during the trial – would ultimately be accepted into JAMA. It was also subsequently picked up and promoted by ACEPNow as a “promising therapy” that “slashes death risk” (Tweet still visible, site content since deleted).
As I noted last time, the authors reported 30-day outcomes. Now, they’re back, as promised, with 1-year outcomes – hoping to build on the “trends” previously observed.
Did it work? Did a longer follow-up period help? I’ll let the authors answer in their own words:
“The 1-year outcomes (Table 2) generally demonstrate point estimates favoring GIK for individual events and for composites, but CIs overlap 1.0 in most analyses.”
Which is to say, no. Trends stayed trends, for the most part. And, considering the neutral pre-study evidence from such studies as CREATE-ECLA, which enrolled 20,201 patients, even such hopeful interpretations of these data should not inspire a change in practice.
It is still reasonable, however, as these authors suggest, to continue studying this treatment. There are small differences in important patient-oriented outcomes (10.9% vs. 13.0% in 1-year mortality) favoring the intervention. These effects were even more pronounced in the subgroup of patients for whom ST-elevation was present on the pre-hospital ECG. Considering there’s not much room left in acute medical management of STEMI offering a survival advantage – if there is, in fact, a 4.3% absolute 1-year survival attributable to GIK, it is worth continuing to investigate and tailor trials to the subgroup most likely to benefit.
“One-Year Outcomes of Out-of-Hospital Administration of Intravenous Glucose, Insulin, and Potassium (GIK) in Patients With Suspected Acute Coronary Syndromes”
http://www.ncbi.nlm.nih.gov/pubmed/24792735