Diabetes and myocardial infarction: revisiting the conundrum

doi:10.15406/jdmdc.2018.05.00160

Journal of

eISSN: 2374-6947

Diabetes, Metabolic Disorders & Control

Mini Review Volume 5 Issue 5

Diabetes and myocardial infarction: revisiting the conundrum

Akshyaya Pradhan,

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Rishi Sethi

Department of Cardiology, King George’s Medical University, India

Correspondence: Akshyaya Pradhan, Department of Cardiology, King George’s Medical University, India, Tel +91 8400813739

Received: October 01, 2018 | Published: October 8, 2018

Citation: Pradhan A, Sethi R. Diabetes and myocardial infarction: revisiting the conundrum! J Diabetes Metab Disord Control. 2018;5(5):174-175. DOI: 10.15406/jdmdc.2018.05.00160

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Mini review

The idea of Diabetes Mellitus as a Myocardial infarction (MI) equivalent was first postulated by Haffner et al in their seminal article twenty years back.¹ and was reaffirmed again in 2005 by Juutilainen et al.² Although recent studies have challenged the concept,^3‒4 the is no confusion as to the pivotal role of diabetes in driving coronary artery disease (CAD) and diabetes remains one of the most important risk factor for developing CAD. Not only diabetic patients have more prevalence of coronary artery disease, it is clearly more extensive too.⁵Unfortunately, mortality rates with acute coronary syndromes in such patients is 1.5-2 times higher than non diabetic cohorts.⁶Increased incidence of congestive heart failure, decreased vasodilatory reserve of coronary tree, abnormal myocardial metabolism, endothelial dysfunction, altered platelet reactivity and elevated reinfarction rates are putative causative elements. Nevertheless, diminished pain perception may lead to episodes of so called “silent infarction” or atypical symptoms causing delayed presentation to emergency department, both leading to delay in timely reperfusion in STEMI.

Establishment of prompt reperfusion of infarct related artery remains the goal in STEMI management. ST segment resolution is rapid and inexpensive tool to assess efficacy of reperfusion therapy in STEMI at bedside.⁷Various studies have also documented the poor prognosis associated with non resolution of ST segment following thrombolysis.^8,9 Thrombolytic therapy fails to achieve effective reperfusion in diabetic subset even in a setting of early presentation.¹⁰

In resource poor developing countries the goal of Primary PCI for all STEMI patients remains elusive. Recently, the STREAM trial investigators have shown non inferiority of a pharmacoinvasive strategy compared to Primary PCI.¹¹ Even then transferring all patients to PCI capable centers after thrombolytic would impose a huge financial and logistic challenge. Then how to triage patients for a pharmacoinvasive approach? In light of the previous discussion, it suffices to say that Diabetic patients irrespective of ST segment resolution status and STEMI patients without ST segment resolution or partial resolution after an initial thrombolytic should be primarily candidates for this approach. Even in a pharmacoinvasive approach, use of a third generation fibrin specific fibrinolytic for a diabetic patient is preferable to achieve an early reperfusion enabling the diminished risk during transfer.

However the story does not end here. Diabetes also remains a predictor of adverse events in setting of PCI in acute MI. Diabetes remains a primary mechanism for “Slow flow” or “No reflow” phenomenon in acute coronary syndrome with consistent role in adverse outcomes.¹³ Diabetes mellitus also predicts increased risk of stent thrombosis after percutaneous coronary intervention in the setting of acute MI.¹² Etiology of stent thrombosis is multifactorial including diffuse disease, low calibre vessels and altered platelet as well as endothelial function.

A pragmatic approach is needed for management of acute MI in diabetes. Use of potent third generation fibrinolytic like tenecteplase would be an initial step in the cascade. Novel anti platelet agent Prasugel has been to reduce stent thrombosis and mortality in diabetes with STEMI.¹⁴ Parenteral Glycoprotein IIb/IIIa antagonist and thrombus aspiration are useful for prevention and treatment of slow flow.¹⁵Third generation thin strut drug eluting stents have reduced both acute thrombosis and late restenosis too.¹⁶ High dose statins and other drugs for secondary prevention also improve outcomes.

To summarize, diabetes remains a high risk if not equivalent condition for development of Myocardial infarction. Appropriate selection of treatment strategies is need of hour to mitigate the risk associated with it.