Unstable angina / non ST elevation myocardial infarction diabetic patients


 * Associate Editor-In-Chief: Smita Kohli, M.D.

Overview of Diabetic Patients with UA / NSTEMI

 * Patients with diabetes tend to have more extensive noncoronary vascular comorbidities, hypertension, LV hypertrophy, cardiomyopathy, and HF.
 * Coronary artery disease (CAD) accounts for 75% of all deaths in patients with diabetes mellitus.
 * Patients with UA/NSTEMI and diabetes tend to have more severe CAD and have been shown to have worse adverse outcomes as compared to non-diabetic patients.
 * In addition, diabetic patients tend to have autonomic dysfunction which influences the blood pressure and heart rate control as well as they have higher incidence of LV dysfunction.
 * They also tend to have a greater proportion of ulcerated plaques on coronary angiography.

According to American Diabetes Association' standards of care, the relationship of controlled blood glucose levels and reduced mortality in the setting of MI has been demonstrated. The American College of Endocrinology has also emphasized the importance of careful control of blood glucose targets in the range of 110 mg per dL preprandially to a maximum of 180 mg per dL.

The medical management of patients with diabetes who have UA/NSTEMI is the same and these patient should receive all the recommended medications unless contraindicated. Although beta blockers can mask the symptoms of hypoglycemia or lead to it by blunting the hyperglycemic response, they nevertheless should be used with appropriate caution in patients with diabetes mellitus and UA/ NSTEMI.

Diabetes and coronary revascularization
Traditionally, CABG has been recommended over PCI as the choice for revascularization in patients with diabetes who have multivessel CAD.

Clinical trial data:
 * In the BARI trial in which outcomes for CABG in treated patients with diabetes were far better than those for PCI.


 * A 9-year follow-up of the NHLBI registry showed a similar disturbing pattern for patients with diabetes undergoing PCI. Immediate angiographic success and completeness of revascularization were similar, but compared with patients without diabetes, patients with diabetes (who again had more severe CAD and comorbidities) had increased rates of hospital mortality, nonfatal MI, death and MI, and the combined end point of death, MI, and CABG. At 9 years, rates of mortality, MI, repeat PCI, and CABG were all higher in patients with diabetes than in those without diabetes.


 * Perioperative hyperglycemia is an independent predictor of infection in patients with diabetes mellitus, with the lowest mortality in patients with blood glucose less than or equal to 150 mg per dL. Attainment of targeted glucose control in the setting of cardiac surgery is associated with reduced mortality and risk of deep sternal wound infections in cardiac surgery patients with diabetes.


 * In a study with historical controls, the outcome after coronary stenting was superior to that after PTCA in patients with diabetes, and the restenosis rate after stenting was reduced. Three trials have shown that abciximab considerably improved the outcome of PCI in patients with diabetes.

'''To summarize, coronary artery bypass grafting, especially with 1 or both internal mammary arteries, leads to more complete revascularization and a decreased need for reintervention than PCI in diabetic patients with multivessel disease. Given the diffuse nature of diabetic coronary disease, the relative benefits of CABG over PCI may well persist for diabetic patients.'''

==ACC / AHA Guidelines (DO NOT EDIT) == {{cquote|

Class I
1. Medical treatment in the acute phase of UA / NSTEMI and decisions on whether to perform stress testing,angiography, and revascularization should be similar in patients with and without diabetes mellitus. (Level of Evidence: A)

Class IIa
1. For patients with UA / NSTEMI and multi vessel disease, CABG with use of the internal mammary arteries can be beneficial over PCI in patients being treated for diabetes mellitus. (Level of Evidence: B)

2. Percutaneous coronary intervention is reasonable for UA / NSTEMI patients with diabetes mellitus with single-vessel disease and inducible ischemia. (Level of Evidence: B)

3. It is reasonable to use an insulin-based regimen to achieve and maintain glucose levels <180 mg/dL while avoidinghypoglycemia for hospitalized patients with UA / NSTEMI with either a complicated or uncomplicated course. (Level of Evidence: B)}}

Pathology Findings
Images shown below are courtesy of Professor Peter Anderson DVM PhD and published with permission. © PEIR, University of Alabama at Birmingham, Department of Pathology