Treatment of acute myocardial infarction in diabetes mellitus
- Richard W Nesto, MD
Richard W Nesto, MD
- Professor of Medicine
- Tufts University School of Medicine
- Section Editors
- Christopher P Cannon, MD
Christopher P Cannon, MD
- Section Editor — Coronary Heart Disease
- Professor of Medicine
- Harvard Medical School
- David M Nathan, MD
David M Nathan, MD
- Editor-in-Chief — Endocrinology
- Section Editor — Diabetes Mellitus
- Professor of Medicine
- Harvard Medical School
Heart disease, particularly coronary heart disease (CHD), is a major cause of morbidity and mortality among patients with diabetes mellitus. Compared with nondiabetics, diabetics are more likely to have CHD, to have multivessel disease when it occurs, and to have episodes of silent ischemia. As a result of these and other factors, diabetics with CHD have a worse outcome and poorer long-term survival compared to nondiabetics with CHD. (See "Prevalence of and risk factors for coronary heart disease in diabetes mellitus".)
The risk and treatment of acute myocardial infarction, both ST elevation (Q wave) and non-ST elevation (non Q-wave), in the diabetic patient will be reviewed here. The use of coronary revascularization in diabetic patients with stable or unstable angina is discussed separately. (See "Coronary artery revascularization in patients with diabetes mellitus and multivessel coronary artery disease".)
RISK OF MI
Diabetes is associated with an increased risk of myocardial infarction (MI)
The importance of diabetes as a risk factor was illustrated in a study that compared the seven-year incidence of MI in 1373 nondiabetics and 1059 patients with type 2 diabetes . Type 2 diabetics without a prior infarction were at the same risk for MI (20 and 19 percent, respectively) and coronary mortality (15 versus 16 percent) as nondiabetics with a prior MI (figure 1). The risk of infarction was greatest in diabetics with a prior MI and lowest in nondiabetics without a prior MI (45 and 4 percent, respectively). These findings were independent of other risk factors such as total cholesterol, hypertension, and smoking.
Other evidence that diabetes is a CHD equivalent comes from the Heart Protection Study, in which simvastatin therapy reduced the risk of major vascular events in diabetic patients, including those with no known history of MI, and those with a normal baseline serum low density lipoprotein concentration. (See "Prevalence of and risk factors for coronary heart disease in diabetes mellitus".)
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- RISK OF MI
- CHD before diabetes
- INCREASED CLINICAL SEVERITY
- Coronary reperfusion in STEMI
- - Primary PCI
- - Thrombolytic therapy
- Antiplatelet drugs
- Beta blockers
- ACE inhibitors
- Aldosterone antagonists
- Glycemic control
- Lipid lowering
- Blood pressure control
- Multifactorial risk factor reduction
- ST elevation MI
- NSTEMI/unstable angina
- Protective effect of previous CABG
- SUMMARY AND RECOMMENDATIONS