EC Cardiology

Background: Hyperglycemia is a common and serious complication among patients admitted with acute coronary syndrome (ACS) and is associated with increased mortality, prolonged hospitalization, and adverse cardiovascular outcomes. Several insulin regimens exist for inpatient glycemic control, yet comparative evidence specific to ACS remains limited. This study evaluated the effectiveness and safety of four commonly used insulin strategies-Sliding Scale (SS), Basal-Bolus (BB), Carbohydrate Index-based dosing (CI), and Premixed insulin (PM)-in managing hyperglycemia among ACS patients in Gaza hospitals.

Methods: A multimodal comparative study was conducted at Shifa Medical Complex and European Gaza Hospital from January 2023 to January 2024. A total of 350 ACS patients with hyperglycemia were included and allocated into four insulin-regimen groups based on clinical practice: SS (n = 110), BB (n = 95), CI (n = 75), and PM (n = 70). Data were collected from medical records and bedside glucose monitoring. Outcomes included glycemic control metrics (mean glucose, variability, hypoglycemia), clinical outcomes (mortality, major complications, reinfarction), and length of stay. Multivariate logistic regression was performed to identify independent predictors of mortality.

Results: Basal-Bolus therapy resulted in significantly better glycemic control, with the lowest mean glucose (156 ± 33 mg/dL), lowest glucose variability, and highest time-in-range (72%) (p < 0.001). The Sliding-Scale group showed the poorest control and highest variability. In-hospital mortality differed significantly among the groups: SS (14.5%), BB (6.3%), CI (8.0%), PM (12.8%) (p = 0.03). Basal-Bolus therapy also achieved the shortest mean length of stay (5.1 ± 2.4 days), while Sliding Scale had the longest (7.8 ± 3.1 days) (p < 0.001). In multivariate analysis, Sliding-Scale therapy was independently associated with higher mortality (Adjusted OR 2.90, 95% CI 1.21-6.96, p = 0.016), along with higher admission glucose and increased glycemic variability.

Conclusion: Among insulin regimens used for ACS-related hyperglycemia, Basal-Bolus therapy provided superior glycemic stability and was associated with lower mortality and shorter hospitalization. Sliding-Scale insulin was linked to poor glycemic control, greater glucose variability, and independently increased mortality risk. Implementing physiologic insulin strategies-particularly Basal-Bolus-may improve outcomes in ACS patients with hyperglycemia, especially in resource-limited settings.

 Keywords: Basal-Bolus Insulin; Sliding Scale; Acute Coronary Syndrome; Hyperglycemia Management; In-Hospital Mortality

1. Ralapanawa U and Sivakanesan R. “Epidemiology and the magnitude of coronary artery disease and acute coronary syndrome: A narrative review”. Journal of Epidemiology and Global Health 2 (2021): 169-177.
2. Cavender MA., et al. “Impact of diabetes mellitus on hospitalization for heart failure, cardiovascular events, and death: Outcomes at 4 years from the REACH registry”. Circulation10 (2015): 923-931.
3. Li Y., et al. “Prevalence of diabetes recorded in mainland China using 2018 ADA diagnostic criteria: National cross-sectional study”. British Medical Journal 369 (2020): m997.
4. Cho NH., et al. “IDF diabetes atlas: Global estimates of diabetes prevalence for 2017 and projections for 2045”. Diabetes Research and Clinical Practice 138 (2018): 271-281.
5. Arnold SV., et al. “Clinical management of stable coronary artery disease in patients with type 2 diabetes mellitus: A scientific statement from the American Heart Association”. Circulation19 (2020): e779-e806.
6. Cosentino F., et al. “2019 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD”. European Heart Journal 2 (2020): 255-323.
7. Zhao D., et al. “Epidemiology of cardiovascular disease in China: Current features and implications”. Nature Reviews Cardiology 4 (2019): 203-212.
8. Tao LC., et al. “Triglyceride-glucose index as a marker in cardiovascular diseases: Landscape and limitations”. Cardiovascular Diabetology 1 (2022): 68.
9. Hill MA., et al. “Insulin resistance, cardiovascular stiffening and cardiovascular disease”. Metabolism 119 (2021): 154766.
10. Ormazabal V., et al. “Association between insulin resistance and the development of cardiovascular disease”. Cardiovascular Diabetology 1 (2018): 122.
11. Patel TP., et al. “Insulin resistance: An additional risk factor in the pathogenesis of cardiovascular disease in type 2 diabetes”. Heart Failure Reviews 1 (2016): 11-23.
12. Hartge MM., et al. “The endothelium and vascular inflammation in diabetes”. Diabetes and Vascular Disease Research 2 (2007): 84-88.
13. Kong P., et al. “Inflammation and atherosclerosis: Signaling pathways and therapeutic intervention”. Signal Transduction and Targeted Therapy 1 (2022): 131.
14. Lawler PR., et al. “Targeting cardiovascular inflammation: Next steps in clinical translation”. European Heart Journal 1 (2021): 113-131.
15. Sharif S., et al. “Low-grade inflammation as a risk factor for cardiovascular events and all-cause mortality in patients with type 2 diabetes”. Cardiovascular Diabetology 1 (2021): 220.
16. Badimon L., et al. “C-reactive protein in atherothrombosis and angiogenesis”. Frontiers in Immunology 9 (2018): 430.
17. Denegri A and Boriani G. “High-sensitivity C-reactive protein and its implications in cardiovascular outcomes”. Current Pharmaceutical Design 2 (2021): 263-275.
18. Puschel GP., et al. “Macrophages, low-grade inflammation, insulin resistance and hyperinsulinemia: A mutual ambiguous relationship in metabolic disease development”. Journal of Clinical Medicine 15 (2022): 4358.
19. Simental-Mendia LE., et al. “The product of fasting glucose and triglycerides as a surrogate for identifying insulin resistance in healthy subjects”. Metabolic Syndrome and Related Disorders 4 (2008): 299-304.
20. Everett BM. “Residual inflammatory risk: A common and important risk factor for recurrent cardiovascular events”. Journal of the American College of Cardiology 19 (2019): 2410-2412.
21. Imai K., et al. “A general approach to causal mediation analysis”. Psychological Methods 4 (2010): 309-334.
22. Laakso M and Kuusisto J. “Insulin resistance and hyperglycaemia in cardiovascular disease development”. Nature Reviews Endocrinology 5 (2014): 293-302.
23. Bassuk SS., et al. “High-sensitivity C-reactive protein: Clinical importance”. Current Problems in Cardiology 8 (2004): 439-493.
24. Boren J., et al. “Metabolism of triglyceride-rich lipoproteins in health and dyslipidaemia”. Nature Reviews Cardiology 9 (2022): 577-592.
25. Jin A., et al. “Mediation of systemic inflammation on insulin resistance and prognosis of nondiabetic patients with ischemic stroke”. Stroke 3 (2023): 759-769.
26. Du X., et al. “Sex differences in clinical profiles and quality of care among patients with STEMI: Insights from the China PEACE-retrospective study”. Journal of the American Heart Association 2 (2016): e002157.
27. Luo JW., et al. “Prognostic significance of triglyceride-glucose index for adverse cardiovascular events in coronary artery disease: Systematic review and meta-analysis”. Frontiers in Cardiovascular Medicine 8 (2021): 774781.
28. Placzkowska S., et al. “Indirect insulin resistance detection: Current clinical trends and laboratory limitations”. Biomedical Papers of the Medical Faculty of the University Palacky, Olomouc, Czech Republic 3 (2019): 187-199.
29. Li T., et al. “Inflammation and insulin resistance in diabetic chronic coronary syndrome patients”. Nutrients12 (2023): 2808.
30. Pandey SK., et al. “The impact of insulin resistance on acute coronary syndrome outcomes in diabetic”. European Journal of Cardiovascular Medicine 15 (2025): 503-508.
31. Reaven GM. “Role of insulin resistance in human disease”. Diabetes 12 (1988): 1595-1607.
32. Ceriello A., et al. “Glycemic variability in diabetes: clinical and therapeutic implications”. The Lancet Diabetes and Endocrinology 3 (2019): 221-230.
33. Shah AD., et al. “Type 2 diabetes and incidence of cardiovascular diseases: a cohort study in 1.9 million people”. The Lancet Diabetes and Endocrinology 2 (2015): 105-113.
34. American Diabetes Association. “Standards of Medical Care in Diabetes-2024”. Diabetes Care1 (2024): S1-289.
35. Rydén L., et al. “ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD”. European Heart Journal 3 (2023): 255-323.