Management of the patient with diabetes mellitus and myocardial infarction: clinical trials update

The increasing prevalence of diabetes mellitus and its association with cardiovascular disease have become serious public health issues. Although diabetes and coronary artery disease (CAD) may have different clinical manifestations, their atherosclerotic burden and prognosis are quite similar. However, patients with diabetes who have underlying CAD have a different, more complex pathophysiology and a worse prognosis. Optimal management of these patients requires a comprehensive multifactorial approach to prevent microvascular and macrovascular events. In the setting of an acute myocardial infarction (MI), immediate management should focus on limiting infarct size. This can be achieved by using fibrinolytic agents, primary percutaneous intervention (in ST-segment elevation MI), or glycoprotein IIb/IIIa inhibitors followed by coronary angiography within 24 to 48 hours and, when appropriate, by coronary intervention (in non–ST-segment elevation MI). Drug-eluting stents may have an important role in patients with diabetes, who have a higher rate of postintervention coronary restenosis than do nondiabetic individuals. In addition, all patients with an acute MI (ST- and non–ST-segment elevation) should be given aspirin, nitrates, β-blockers, and angiotensin-converting enzyme (ACE) inhibitors. The long-term pharmacologic management after MI is similar in all patients, regardless of the initial presentation. Antiplatelet agents (aspirin and/or clopidogrel), ACE inhibitors, β-blockers, lipid-lowering agents, and glycemic control have all been shown to be effective in decreasing long-term mortality. Despite advances in the management of MI, the mortality rates of patients with diabetes remain 1.5- to 2-fold greater than those of persons without diabetes. Maximizing the use of lifesaving therapies proved effective in large randomized clinical trials and tight metabolic control can further decrease mortality rates. However, many of these lifesaving therapies are underused in patients with diabetes because of the misconception that potential adverse effects may outweigh their benefits. New programs aimed at improving postinfarction quality of care in patients with diabetes, based on guidelines and expert recommendations, have shown promise. However, more effort must be devoted to the improvement of outcomes related to these public health problems.