Elsevier

Primary Care Diabetes

Volume 6, Issue 3, October 2012, Pages 167-177
Primary Care Diabetes

Review
Antiplatelet therapy for patients with diabetes mellitus and acute coronary syndrome

https://doi.org/10.1016/j.pcd.2012.02.001Get rights and content

Abstract

In diabetes mellitus, platelet hyperreactivity is common and may contribute to the high incidence of cardiovascular disease; dual antiplatelet therapy reduces the risk of recurrence. Prasugrel or ticagrelor provides a greater, more consistent antiplatelet effect than clopidogrel. Prasugrel provides greater clinical benefit than clopidogrel in patients with diabetes (hazard ratio [HR], 0.70; P < 0.001) versus those without diabetes (HR, 0.86; P = 0.02), due to greater reductions in cardiovascular events and no increased major bleeding. Similar clinical benefits are seen with ticagrelor versus clopidogrel in patients with and without diabetes. Evidence suggests that prasugrel/aspirin may provide particular advantages for patients with diabetes mellitus.

Introduction

Cardiovascular disease (CVD) is the leading cause of death worldwide. A reduction in cardiovascular morbidity and mortality in the US [1] and UK [2] over the last 20 years [3], [4] is linked to a decrease in major cardiovascular risk factors [1], [5]. The exceptions to these encouraging trends are diabetes mellitus and obesity. The prevalence of diabetes is projected to double by 2030, increasing from 171 million to 366 million [6]. Data from the Framingham Heart Study have demonstrated that the proportion of cardiovascular risk attributable to diabetes has increased significantly over the last five decades [7], and mortality rates in patients with diabetes were approximately two-fold greater than those in patients without diabetes [8], indicating that the need for aggressive treatment is particularly important in patients with diabetes experiencing acute events. Moreover, the unmet needs of diabetes patients with acute coronary syndrome (ACS) are exacerbated by the greater propensity for resistance to aspirin therapy in patients with diabetes [9], hence the need for alternative strategies to achieve the desired outcomes.

Section snippets

Diabetes as a risk factor for CVD

Approximately one-third of ACS patients have diabetes [10], [11], [12]. Among patients with ≥3 cardiovascular risk factors enrolled in the Reduction of Atherothrombosis for Continued Health (REACH) registry, the incidence of major adverse cardiovascular events (MACE) after 1 year was higher in patients with diabetes than those without (3.8% vs. 3.0%, respectively; P < 0.001). This highlights the importance of a multifaceted approach to manage all modifiable risk factors effectively, including

ACS in patients with diabetes

Morbidity and mortality are increased after an acute ischemic event in patients with diabetes. Long-term mortality rates after an acute event are also significantly higher in patients with diabetes [15], [16], [17], [18], [19], [20], [21]. An analysis from the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial examined the impact of diabetes on the 30-day net adverse clinical outcomes (including composite ischemia [death from myocardial infarction (MI) or unplanned

Antiplatelet therapy during the acute intervention phase in diabetes

Intravenous GP IIb/IIIa receptor antagonists, oral aspirin, and oral platelet P2Y12 adenosine diphosphate (ADP) receptor antagonists have all been shown to be effective in the acute setting.

Conclusions

Approximately one-third of patients with ACS have diabetes as a risk factor. Improvements in therapy for patients with diabetes are required if further reductions in CVD morbidity and mortality are to be achieved. DAT with an orally administered P2Y12 receptor antagonist plus aspirin is the standard of care for patients with ACS including those undergoing PCI. Prasugrel and ticagrelor provide a greater and more consistent antiplatelet effect than clopidogrel, and prasugrel has been shown to be

Conflict of interest statement

Dr Saucedo has received research money from Merck, Eli Lilly and Company, and The Medicines Company. He has served as a consultant for Merck, Eli Lilly and Company, and Medicure.

Acknowledgements

Medical writing assistance was provided by Raelene Simpson, MK Grandison, PhD, and Mary Hines of Adis Communications, through financial support by Daiichi Sankyo, Inc. and Eli Lilly and Company.

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