Aims of MINAPTo audit the quality of care of patients with acute coronary syndrome and provide a resource for academic research.Quality of care interventionsFeedback to hospitals, ambulance services and cardiac networks regarding benchmarking of performance against national standards and targets.SettingAll 230 acute hospitals in England and Wales. Years: 2000-present.PopulationConsecutive patients, unconsented. Current number of records: 735 000.StartpointsAny acute coronary syndrome, including non-ST-elevation myocardial infarction, ST-elevation myocardial infarction and unstable angina.Baseline data123 fields covering demographic factors, co-morbid conditions and treatment in hospital. No blood resource.Data captureManual entry by clerks, nurses or doctors onto Lotus Notes; non-financial incentives at hospital level.Data qualityHospitals perform an annual data validation study, where data are re-entered from the case notes in 20 randomly selected records that are held on the server. In 2008 data were >90% complete for 20 key fields, with >80% completeness for all but four of the remaining fields.Endpoints and linkages to other dataAll-cause mortality is obtained through linkage with Office for National Statistics. No other linkages exist at present.Access to dataAvailable for research and audit by application to the MINAP Academic Group. http://www.rcplondon.ac.uk/CLINICAL-STANDARDS/ORGANISATION/PARTNERSHIP/Pages/MINAP-.aspx.
Objective: To determine the effect of insulin for the management of hyperglycaemia in non-diabetic patients presenting with acute coronary syndrome. Methods: An observational study from the MINAP (National Audit of Myocardial Infarction Project) database during 2003-5 in 201 hospitals in England and Wales. Patients were those with a final diagnosis of troponinpositive acute coronary syndrome who were not previously known to have diabetes mellitus and whose blood glucose on admission was >11 mmol/l. The main outcome measure was death at 7 and 30 days. Results: Of 38 864 patients who were not previously known to be diabetic, 3835 (9.9%) had an admission glucose >11 mmol/l. Of patients having a clear treatment strategy, 36% received diabetic treatment (31% with insulin). Mortality at 7 and 30 days was 11.6% and 15.8%, respectively, for those receiving insulin, and 16.5% and 22.1%, respectively, for those who did not. Compared with those who received insulin, after adjustment for age, gender, co-morbidities and admission blood glucose concentration, patients who were not treated with insulin had a relative increased risk of death of 56% at 7 days and 51% at 30 days (HR 1.56, 95% CI 1.22 to 2.0, p,0.001 at 7 days; HR 1.51, 95% CI 1.22 to 1.86, p,0.001 at 30 days). Conclusion: In non-diabetic patients with acute coronary syndrome and hyperglycaemia, treatment with insulin was associated with a reduction in the relative risk of death, evident within 7 days of admission, which persists at 30 days.
GRADE (Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study) is a 36-center unmasked, parallel treatment group, randomized controlled trial evaluating four diabetes medications added to metformin in people with type 2 diabetes (T2DM). We report baseline characteristics and compare GRADE participants to a National Health and Nutrition Examination Survey (NHANES) cohort. RESEARCH DESIGN AND METHODS Participants were age ‡30 years at the time of diagnosis, with duration of T2DM <10 years, HbA 1c 6.8-8.5% (51-69 mmol/mol), prescribed metformin monotherapy, and randomized to glimepiride, sitagliptin, liraglutide, or insulin glargine. RESULTS At baseline, GRADE's 5,047 randomized participants were 57.2 6 10.0 years of age, 63.6% male, with racial/ethnic breakdown of 65.7% white, 19.8% African American, 3.6% Asian, 2.7% Native American, 7.6% other or unknown, and 18.4% Hispanic/ Latino. Duration of diabetes was 4.2 6 2.8 years, with mean HbA 1c of 7.5 6 0.5% (58 6 5.3 mmol/mol), BMI of 34.3 6 6.8 kg/m 2 , and metformin dose of 1,944 6 204 mg/day. Among the cohort, 67% reported a history of hypertension, 72% a history of hyperlipidemia, and 6.5% a history of heart attack or stroke. Applying GRADE inclusion criteria to NHANES indicates enrollment of a representative cohort with T2DM on metformin monotherapy (NHANES cohort average age, 57.9 years; mean HbA 1c , 7.4% [57 mmol/mol]; BMI, 33.2 kg/m 2 ; duration, 4.2 6 2.5 years; and 7.2% with a history of cardiovascular disease). CONCLUSIONS The GRADE cohort represents patients with T2DM treated with metformin requiring a second diabetes medication. GRADE will inform decisions about the clinical effectiveness of the addition of four classes of diabetes medications to metformin. The optimal medication management of hyperglycemia in type 2 diabetes (T2DM) is not established. In addition to lifestyle intervention, metformin is the recommended initial medication in T2DM due to its glycemic effectiveness, lack of associated hypoglycemia or weight gain, low cost, and evidence of long-term benefit and safety
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