Performed in Australia, the Quality in Acute Stroke Care (QASC) trial was the first study to demonstrate a reduction in death and dependency following stroke with a treatment protocol which included glucose control (1).
QASC was a single blind cluster randomised trial with 19 acute stroke units (ASUs) randomised to control (n=9) or an intervention (n=10) utilising three treatment protocols for hyperglycaemia, fever and swallowing management implemented following local barrier assessments, education and using reminders. The glucose protocol comprised an algorithm for 4-6 hourly glucose monitoring and hyperglycaemia management (including insulin infusion if glucose level ≥11 mmol/L for patients with diabetes, and ≥16 mmol/L for patients with new onset hyperglycaemia) for the first 72 hours. Our sub-analysis examines the predictive value of glucose parameters for 90-day death and dependency (modified Rankin Scale [mRS] ≥2).
There were 1126 participants with a significant reduction in death and dependency at 90 days in the intervention ASU subjects (42% vs 58%, p=0.002). The mean glucose was 7.0±2.0 mmol/L in the intervention and 6.8±1.8 mmol/L in the control ASU subjects (absolute difference 0.54, 95%CI 0.08-1.01, p=0.02). Patients with a lower mean glucose in the first 72 hours of admission (p=0.003); those who had a formal venous glucose measurement taken in the Emergency Department (p=0.05); and those who had at least one finger prick glucose in the first 72 hours of admission to an ASU (p=0.03) were significantly less likely to be dead or dependent 90-days post stroke. More patients dead or dependent at 90-days had at least one finger prick blood glucose reading >11mMol/L (p=0.02).Implementation of a protocol which included glucose control improved stroke outcomes. Patients who were alive and independent 90-days post stroke had lower glucose levels and were more likely to have been managed in accordance with elements of the glucose protocol.