Diabetic Patients With ACS Mew-1

DIABETIC PATIENTS WITH ACUTE
CORONERY SYNCROME
WHO SHOULD I TREAT
Professor mohammed Ahmed Bamashmos

Professor of internal medicine and endocrinology
Sanaa University
Introduction
Diabetes (together with lipid abnormalities, smoking and hypertension) is one of the
top 4 independent risk factors for myocardial infarction (MI) .Today, approximately
15% to 35% of people admitted with an acute coronary syndrome (ACS) have known
diabetes , and as many as a further 15% have undiagnosed diabetes
Compared to individuals without diabetes, people with diabetes have:

- 3-fold increased risk of ACS
-Occurrence of acute coronary events 15 years earlier
- 2-fold increased short and long-term mortality
-An increased incidence of post-infarction recurrent ischemic events, heart failure
and cardiogenic shock
Glycemic Control
Hyperglycemia during the first 24 to 48 hours after admission for ACS is associated
with an increased early mortality, whether or not the person has diabetes).
Furthermore, in-hospital mortality has a closer relationship to hyperglycemia than to
diabetic status Higher baseline blood glucose (BG) and a failure of BG to decrease are
independent predictors of mortality (50). For people undergoing primary angioplasty,
mortality increases when the plasma glucose (PG) is >10.0 mmol/L
GLUCOSE-LOWERING AGENTS DURING HOSPITAL STAY
1- insulin therapy ; is considered the drug of choice for the treatment of
hyperglycaemia in the acute setting because of its pharmacokinetic and
pharmacodynamic profile, allowing prompt correction of blood glucose levels.
methods ;
Treatment after discharge
1- treatment target ;
HbA1C ; target
- HbA1C target for most adult is less than 7
- or less than 6.5 if this can be achived without significant hypoglycemia or other
adverse effect of treatment
- in elderly patients less than 8 or up to 9
Treatment types;
1- if patients on insulin. Continuous insulin therapy
2- if patients not on insulin
Start oral anti diabetic drugs according to new guidelines
a
Benefit of established versus new drugs
Point to be considered when we choice oral antidiabetic drugs
1- no risk of hypoglycemia
2- no risk of weight gain or reduce weight
3- reduce BP
4- improve dyslipidemia
5- reduce MAC E ; coronary artery diseases ( MI,
coronary artery bypass grafting and PCI) , stroke and PVD
6- reduce the risk of HHF
Established oral anti diabetic drugs ;
1- Sulfonylurea ;
- risk of hypoglycemia
- weight gain
- they interact directly with myocardiocytes , blocking an ATP
dependent potassium channel involved in myocardial adaptation to ischemia
- no effect in reducing MACE
2- Thiazolidenedione ;
- risk of hypoglycemia
- weight gain
- fluid retention
- increased risk of HHF
- possible CV benefit
3- alpha glucosidase inhibitor ;
it does not alter the MACE
4- metformin ;
- no risk of hypoglycemia
- induce weight loss +
- improve dyslipedemia
- beneficial effect in ASCVD
- reduction in major diabetic complication , MI , and all cause mortility
Novel oral anti diabetic drugs;
Based on the available evidence, SGLT2 inhibitors and GLP-1 RAs are considered the best
options for the long-term treatment of T2DM in patients with established atherosclerotic CVD
or at high/very high CV risk. These drugs are safe, effective, and generally well tolerated and
can be started already during the hospitalisation for ACS or elective PCI, if indicated. Data
from trials with liraglutide and empagliflozin suggest that at least some of the drugs of these
two classes could also reduce mortality. Benefits with GLP-1 RAs seem to be related to an
anti-atherosclerotic effect, whereas SGLT2 inhibitors appear to reduce HF-related endpoints
and have specific advantages in patients with or at high risk for HF. Although the trial-based
1- SGLT2 Inhibitor
- induce weight loss ++
- reduce dyslipedemia and atherosclerosis
- reduce BP
- reduce MACE
- reduce rate of HHF
- reduce micro albuminurea
- beneficial effect in patients with established ASCVD and HF
- reduction in the MACE and HHF with canagliflozin and empagliflozin
- reduction in HHF and CV mortality
Indication in established ASCVD or at rlsk for CVD
as first line therapy in patient with native drugs
or add to metformin erespicative to HbA1C
2- GLP 1 receptor agonist ;
- induce weight loss +++
- reduce dyslipedemia and atherosclerosis
- reduce BP
- reduce MACE with dulaglutide , liraglutide
- reduce rate of HHF
- beneficial effect in patients with established ASCVD
● 3- DPP type 4 inhibitor
- effect in weight ; neutral
- beneficial effect in ASCVD ; no
- safe in CVD
- increased risk of HHF particularly with saxagleptin
Cardiovascular benefits of the new antidiabetic drugs
Patients with ASCVD
Drug native patients Patients on metformin
• 1- add eithe SGLT2 I or GLPIRA
1. Start SGLT1 I or GLP1 RA.
errespective of glycemic target
Check HbA1C after 3 months

• 2-check HbA1C after 3 months
• If treatment target is reached.
Continue treatment
If HbA1C not in target
• If treatment target is not
2- add metformin reached .add other drugs with
Check HbA1C .not on target proven benefits in patients with
ASCVD
3- add drugs with proven benefits on
ASCVD
• -SGLT2I
• -GLP1RA
Conclusion
● . Extensive research efforts have led to improved outcomes for patients with dysglycaemic states
in recent decades. Still, the rate of adverse events remains higher in patients with diabetes
following PCI. Some important open issues that future research efforts must address are the
following:
● 1. Optimal glycaemic control for the outcome of ACS, CCS and post-coronary revascularisation
interventions remains to be established.
● 2. The role of hypoglycaemia in the occurrence of CV events/mortality remains to be fully
elucidated.
● 3. Further trials with SGLT2 inhibitors and GLP-1 RAs in patients with coronary
syndromes/undergoing PCI without diabetes would eventually provide further knowledge as to
the potential benefits of these drugs irrespective of glucose control, possibly expanding their
present indications

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DIABETIC PATIENTS WITH ACUTE

Professor mohammed Ahmed Bamashmos

Compared to individuals without diabetes, people with diabetes have:

Check HbA1C after 3 months

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