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Treatment of acute myocardial infarction in diabetes mellitus

Richard W Nesto, MD
Section Editors
Christopher P Cannon, MD
David M Nathan, MD
Deputy Editor
Gordon M Saperia, MD, FACC


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".)


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 [1]. 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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Literature review current through: Nov 2017. | This topic last updated: Apr 12, 2016.
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  1. Haffner SM, Lehto S, Rönnemaa T, et al. Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. N Engl J Med 1998; 339:229.
  2. Norhammar A, Tenerz A, Nilsson G, et al. Glucose metabolism in patients with acute myocardial infarction and no previous diagnosis of diabetes mellitus: a prospective study. Lancet 2002; 359:2140.
  3. Granger CB, Califf RM, Young S, et al. Outcome of patients with diabetes mellitus and acute myocardial infarction treated with thrombolytic agents. The Thrombolysis and Angioplasty in Myocardial Infarction (TAMI) Study Group. J Am Coll Cardiol 1993; 21:920.
  4. Stone PH, Muller JE, Hartwell T, et al. The effect of diabetes mellitus on prognosis and serial left ventricular function after acute myocardial infarction: contribution of both coronary disease and diastolic left ventricular dysfunction to the adverse prognosis. The MILIS Study Group. J Am Coll Cardiol 1989; 14:49.
  5. Savage MP, Krolewski AS, Kenien GG, et al. Acute myocardial infarction in diabetes mellitus and significance of congestive heart failure as a prognostic factor. Am J Cardiol 1988; 62:665.
  6. Jaffe AS, Spadaro JJ, Schechtman K, et al. Increased congestive heart failure after myocardial infarction of modest extent in patients with diabetes mellitus. Am Heart J 1984; 108:31.
  7. Mak KH, Moliterno DJ, Granger CB, et al. Influence of diabetes mellitus on clinical outcome in the thrombolytic era of acute myocardial infarction. GUSTO-I Investigators. Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries. J Am Coll Cardiol 1997; 30:171.
  8. Stein B, Weintraub WS, Gebhart SP, et al. Influence of diabetes mellitus on early and late outcome after percutaneous transluminal coronary angioplasty. Circulation 1995; 91:979.
  9. Yudkin JS, Oswald GA. Determinants of hospital admission and case fatality in diabetic patients with myocardial infarction. Diabetes Care 1988; 11:351.
  10. Franklin K, Goldberg RJ, Spencer F, et al. Implications of diabetes in patients with acute coronary syndromes. The Global Registry of Acute Coronary Events. Arch Intern Med 2004; 164:1457.
  11. Aguilar D, Solomon SD, Køber L, et al. Newly diagnosed and previously known diabetes mellitus and 1-year outcomes of acute myocardial infarction: the VALsartan In Acute myocardial iNfarcTion (VALIANT) trial. Circulation 2004; 110:1572.
  12. Zuanetti G, Latini R, Maggioni AP, et al. Influence of diabetes on mortality in acute myocardial infarction: data from the GISSI-2 study. J Am Coll Cardiol 1993; 22:1788.
  13. Mak KH, Topol EJ. Emerging concepts in the management of acute myocardial infarction in patients with diabetes mellitus. J Am Coll Cardiol 2000; 35:563.
  14. Hammoud T, Tanguay JF, Bourassa MG. Management of coronary artery disease: therapeutic options in patients with diabetes. J Am Coll Cardiol 2000; 36:355.
  15. Timmer JR, Ottervanger JP, de Boer MJ, et al. Primary percutaneous coronary intervention compared with fibrinolysis for myocardial infarction in diabetes mellitus: results from the Primary Coronary Angioplasty vs Thrombolysis-2 trial. Arch Intern Med 2007; 167:1353.
  16. Stone GW, Grines CL, Cox DA, et al. Comparison of angioplasty with stenting, with or without abciximab, in acute myocardial infarction. N Engl J Med 2002; 346:957.
  17. Prasad A, Stone GW, Stuckey TD, et al. Impact of diabetes mellitus on myocardial perfusion after primary angioplasty in patients with acute myocardial infarction. J Am Coll Cardiol 2005; 45:508.
  18. Timmer JR, van der Horst IC, de Luca G, et al. Comparison of myocardial perfusion after successful primary percutaneous coronary intervention in patients with ST-elevation myocardial infarction with versus without diabetes mellitus. Am J Cardiol 2005; 95:1375.
  19. Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Lancet 1988; 2:349.
  20. Woodfield SL, Lundergan CF, Reiner JS, et al. Angiographic findings and outcome in diabetic patients treated with thrombolytic therapy for acute myocardial infarction: the GUSTO-I experience. J Am Coll Cardiol 1996; 28:1661.
  21. Mueller HS, Cohen LS, Braunwald E, et al. Predictors of early morbidity and mortality after thrombolytic therapy of acute myocardial infarction. Analyses of patient subgroups in the Thrombolysis in Myocardial Infarction (TIMI) trial, phase II. Circulation 1992; 85:1254.
  22. Mahaffey KW, Granger CB, Toth CA, et al. Diabetic retinopathy should not be a contraindication to thrombolytic therapy for acute myocardial infarction: review of ocular hemorrhage incidence and location in the GUSTO-I trial. Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries. J Am Coll Cardiol 1997; 30:1606.
  23. Ward H, Yudkin JS. Thrombolysis in patients with diabetes. BMJ 1995; 310:3.
  24. Ferreiro JL, Angiolillo DJ. Diabetes and antiplatelet therapy in acute coronary syndrome. Circulation 2011; 123:798.
  25. Ferroni P, Basili S, Falco A, Davì G. Platelet activation in type 2 diabetes mellitus. J Thromb Haemost 2004; 2:1282.
  26. Angiolillo DJ, Bernardo E, Sabaté M, et al. Impact of platelet reactivity on cardiovascular outcomes in patients with type 2 diabetes mellitus and coronary artery disease. J Am Coll Cardiol 2007; 50:1541.
  27. Andersson C, Lyngbæk S, Nguyen CD, et al. Association of clopidogrel treatment with risk of mortality and cardiovascular events following myocardial infarction in patients with and without diabetes. JAMA 2012; 308:882.
  28. Wiviott SD, Braunwald E, Angiolillo DJ, et al. Greater clinical benefit of more intensive oral antiplatelet therapy with prasugrel in patients with diabetes mellitus in the trial to assess improvement in therapeutic outcomes by optimizing platelet inhibition with prasugrel-Thrombolysis in Myocardial Infarction 38. Circulation 2008; 118:1626.
  29. James S, Angiolillo DJ, Cornel JH, et al. Ticagrelor vs. clopidogrel in patients with acute coronary syndromes and diabetes: a substudy from the PLATelet inhibition and patient Outcomes (PLATO) trial. Eur Heart J 2010; 31:3006.
  30. De Luca G, Suryapranata H, Stone GW, et al. Abciximab as adjunctive therapy to reperfusion in acute ST-segment elevation myocardial infarction: a meta-analysis of randomized trials. JAMA 2005; 293:1759.
  31. Boersma E, Harrington RA, Moliterno DJ, et al. Platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: a meta-analysis of all major randomised clinical trials. Lancet 2002; 359:189.
  32. Roffi M, Chew DP, Mukherjee D, et al. Platelet glycoprotein IIb/IIIa inhibitors reduce mortality in diabetic patients with non-ST-segment-elevation acute coronary syndromes. Circulation 2001; 104:2767.
  33. Théroux P, Alexander J Jr, Pharand C, et al. Glycoprotein IIb/IIIa receptor blockade improves outcomes in diabetic patients presenting with unstable angina/non-ST-elevation myocardial infarction: results from the Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms (PRISM-PLUS) study. Circulation 2000; 102:2466.
  34. Gundersen T, Kjekshus J. Timolol treatment after myocardial infarction in diabetic patients. Diabetes Care 1983; 6:285.
  35. Malmberg K, Herlitz J, Hjalmarson A, Rydén L. Effects of metoprolol on mortality and late infarction in diabetics with suspected acute myocardial infarction. Retrospective data from two large studies. Eur Heart J 1989; 10:423.
  36. Chen J, Marciniak TA, Radford MJ, et al. Beta-blocker therapy for secondary prevention of myocardial infarction in elderly diabetic patients. Results from the National Cooperative Cardiovascular Project. J Am Coll Cardiol 1999; 34:1388.
  37. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:2354.
  38. Zuanetti G, Latini R, Maggioni AP, et al. Effect of the ACE inhibitor lisinopril on mortality in diabetic patients with acute myocardial infarction: data from the GISSI-3 study. Circulation 1997; 96:4239.
  39. Gustafsson I, Torp-Pedersen C, Køber L, et al. Effect of the angiotensin-converting enzyme inhibitor trandolapril on mortality and morbidity in diabetic patients with left ventricular dysfunction after acute myocardial infarction. Trace Study Group. J Am Coll Cardiol 1999; 34:83.
  40. Pitt B, Remme W, Zannad F, et al. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med 2003; 348:1309.
  41. Berger AK, Breall JA, Gersh BJ, et al. Effect of diabetes mellitus and insulin use on survival after acute myocardial infarction in the elderly (the Cooperative Cardiovascular Project). Am J Cardiol 2001; 87:272.
  42. Murcia AM, Hennekens CH, Lamas GA, et al. Impact of diabetes on mortality in patients with myocardial infarction and left ventricular dysfunction. Arch Intern Med 2004; 164:2273.
  43. Gilpin E, Ricou F, Dittrich H, et al. Factors associated with recurrent myocardial infarction within one year after acute myocardial infarction. Am Heart J 1991; 121:457.
  44. Nicod P, Lewis SE, Corbett JC, et al. Increased incidence and clinical correlation of persistently abnormal technetium pyrophosphate myocardial scintigrams following acute myocardial infarction in patients with diabetes mellitus. Am Heart J 1982; 103:822.
  45. Silva JA, Escobar A, Collins TJ, et al. Unstable angina. A comparison of angioscopic findings between diabetic and nondiabetic patients. Circulation 1995; 92:1731.
  46. Ueda Y, Asakura M, Yamaguchi O, et al. The healing process of infarct-related plaques. Insights from 18 months of serial angioscopic follow-up. J Am Coll Cardiol 2001; 38:1916.
  47. Barzilay JI, Kronmal RA, Bittner V, et al. Coronary artery disease and coronary artery bypass grafting in diabetic patients aged > or = 65 years (report from the Coronary Artery Surgery Study [CASS] Registry). Am J Cardiol 1994; 74:334.
  48. Ganda OP, Arkin CF. Hyperfibrinogenemia. An important risk factor for vascular complications in diabetes. Diabetes Care 1992; 15:1245.
  49. Gruden G, Cavallo-Perin P, Bazzan M, et al. PAI-1 and factor VII activity are higher in IDDM patients with microalbuminuria. Diabetes 1994; 43:426.
  50. Malmberg K, Yusuf S, Gerstein HC, et al. Impact of diabetes on long-term prognosis in patients with unstable angina and non-Q-wave myocardial infarction: results of the OASIS (Organization to Assess Strategies for Ischemic Syndromes) Registry. Circulation 2000; 102:1014.
  51. Peduzzi P, Detre K, Murphy ML, et al. Ten-year incidence of myocardial infarction and prognosis after infarction. Department of Veterans Affairs Cooperative Study of Coronary Artery Bypass Surgery. Circulation 1991; 83:747.
  52. Detre KM, Lombardero MS, Brooks MM, et al. The effect of previous coronary-artery bypass surgery on the prognosis of patients with diabetes who have acute myocardial infarction. Bypass Angioplasty Revascularization Investigation Investigators. N Engl J Med 2000; 342:989.