ReviewAntiplatelet therapy for patients with diabetes mellitus and acute coronary syndrome
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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2020, JACC: Cardiovascular InterventionsCitation Excerpt :Other studies evidenced the efficacy of ticagrelor in patients with DM undergoing high-risk PCI (14) and those with previous myocardial infarction (15) or stable coronary artery disease (16). A comparison of absolute reductions by prasugrel over clopidogrel in the TRITON-TIMI 38 and PLATO trials (6,10) has led to the suggestion that prasugrel might be better than ticagrelor in patients with ACS with DM (17). However, these observations should be interpreted with great caution, given the marked differences between the trials.
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