Hyperglycemia in AMI is associated with poor outcome even among patients without known diabetes. This finding underlines the need for aggressive glucose management in this setting and may support a more vigorous screening strategy for early recognition of diabetes.

A n 82-year-old man presenting with acute coronary syndrome (exercise-induced chest pain, ST-T wave changes and troponin I 0.21 µg/L) underwent coronary angiography. The left anterior descending artery (LAD) and right coronary artery (RCA) had minor nonobstructive plaque ( Figures 1A and 1B). Left coronary injection demonstrated a capillary blush draining into the left ventricular (LV) cavity due to multiple microfistulae ( Figure 1C and Video) all along the wall of the left ventricle, extensive enough to images in cardiology

The role of fasting glucose, insulin levels, and C-peptide in coronary heart disease (CHD) in non-diabetic individuals remains uncertain. We examined the association between fasting glucose, insulin and C-peptide with the long-term incidence of CHD in Japanese-American men. In 1980–1982, from a random sample of the Honolulu Heart Program men (n = 1378), aged 61–81 years, data on several CHD and metabolic risk factors were obtained to examine the relation of fasting glucose, insulin and C-peptide to 19-year CHD incidence. Age-adjusted incidence of CHD increased with increasing quintiles of glucose, insulin and C-peptide. Age-adjusted CHD rates in the glucose quintiles were 11.9, 11.6, 14.4, 18.1 and 24.1 per 1000 person-years (trend p < 0.001). In individual Cox models (lowest quintiles of glucose, insulin and C-peptide as reference) the relative risks (95% confidence interval) of CHD incidence for the glucose quintiles adjusting for age, smoking, hypertension, cholesterol, physical activity, and body mass index, were 0.9 (0.6–1.4), 1.2 (0.8–1.8), 1.4 (0.9–2.2), and 1.7 (1.1–2.6), respectively (trend p = 0.004). Insulin and C-peptide were not significantly associated with CHD on multivariate analysis. Fasting glucose remained the only significant predictor of increased CHD risk (p = 0.003) in a model combining all 3 metabolic variables. In this cohort, only fasting glucose independently predicts long-term incidence of CHD. Age-adjusted insulin and C-peptide levels were associated with CHD incidence, but after adjustment for other risk factors, do not independently predict CHD.