Acute coronary syndromes - management in diabetes mellitus

Abstract

Patients with acute coronary syndrome (ACS) and concomitant diabetes mellitus (DM), belonging to a very high risk group, constitute a challenge for therapeutic team. They need more 'aggressive' therapy: intensive insulinotherapy (intravenous infusion in the first day, and multiple subcutaneous injections from the second day to the end of the third month), metabolic compensation, the earliest coronary reperfusion, the use of antiplatelet (acetylsalicylic acid, clopidogrel, glycoprotein IIb/IIIa inhibitors) and anticoagulant agents (heparin). In patients with ST-elevation ACS (STE-ACS), lasting < 12 hours, primary percutaneous coronary intervention (PCI) with stent implantation is recommended. If the time from the onset of chest pain is < 3 hours, thrombolysis is suggested. In the event of ineffective trombolysis, a rescue PCI is proposed. After effective thrombolysis, a delayed PCI should be performed during the first week, if there is the culprit vessel stenosis and rest or inducible ischemia. In patients with STE-ACS and higher risk (with DM, among others), secondary PCI (after thrombolysis) is recommended - rescue, early or facilitated PCI. In non-ST-elevation ACS (NSTE-ACS) patients at higher risk, including ones with DM, invasive strategy is advised: early or immediate PCI together with GPI IIb/IIIa; however, in patients with low risk, conservative strategy is proposed at first, and later the result of stress testing decides about qualification to PCI or non-invasive therapy. In ACS and DM, β-blockers, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, aldosterone antagonist, statins and/or fibrates should be applied as well. In most cases, cooperation of cardiologist and diabetes specialist is mandatory.