Canadian 2018 Guidelines on Management of Acute Coronary Syndromes in Diabetics
Diabetes Canada Clinical Practice Guidelines Expert Committee has released its latest 2018 Guidelines on Management of Acute Coronary Syndromes in Diabetics.The Guidelines have been published in Journal Canadian Journal Of Diabetes.Various issues covered in the Guidelines include Risk Stratification of People With Diabetes and ACS, Identification of Diabetes in People with ACS, Management of ACS in People With Diabetes, Anti-Platelet Therapy and ACS in People With Diabetes, Glycemic Control and Revascularization.
Diabetes (together with lipid abnormalities, smoking, and hypertension) is one of the top 4 independent risk factors for myocardial infarction (MI). Today, approximately 15% to 35% of people admitted with an acute coronary syndrome (ACS) have known diabetes, and as many as a further 15% have undiagnosed diabetes. Between 1990 and 2010, there was a 67.8% reduction in the rates of acute MI in people with diabetes, compared to a 32% reduction in individuals without diabetes. However, as a result of the substantial increase in the prevalence of diabetes over this period, the public health burden of MI in people with diabetes continues to rise.
Compared to individuals without diabetes, people with diabetes have:
- A 3-fold increased risk of ACS
- The occurrence of acute coronary events 15 years earlier
- A 2-fold increased short- (6, 7) and long-term mortality
- An increased incidence of post-infarction recurrent ischemic events, heart failure and cardiogenic shock
Key Recommendations :
- 1.In all people with ACS, a random BG and an A1C (if not done in the 3 months prior to admission) should be measured:
- a.For people with a history of diabetes, to identify individuals that would benefit from glycemic optimization [Grade D, Consensus]
- b.For people without a history of diabetes, to identify individuals at risk for ongoing dysglycemia [Grade D, Consensus]
- i.If the A1C is ≥6.5% and/or random BG is >11.0 mmol/L, in-hospital capillary blood glucose monitoring should be initiated [Grade D, Consensus]
- ii.If A1C is 5.5–6.4%, repeat screening for diabetes should be performed after discharge as per diabetes screening recommendations [Grade D, Consensus])
- 2.In-hospital management of diabetes in ACS should include strategies to avoid both hyperglycemia and hypoglycemia:
- a.People with ACS and a random BG of >11.0 mmol/L on admission may be treated to achieve BG levels in the range of 7.0–10.0 mmol/L followed by strategies to achieve recommended BG targets long-term [Grade C, Level 2. Insulin therapy may be required to achieve these targets [Grade D, Consensus]
- b.An appropriate protocol should be developed and staff trained to ensure the safe and effective implementation of this therapy and to minimize the likelihood of hypoglycemia [Grade D, Consensus].
- 3.People with diabetes and ACS should receive the same treatments that are recommended for people with ACS without diabetes since they benefit equally [Grade D, Consensus].
- a.In people with diabetes and ACS undergoing PCI, antiplatelet therapy with prasugrel (if clopidogrel naïve, <75 years of age, weight >60 kg, and no history of stroke) [Grade A, Level 1 or ticagrelor [Grade B, Level 1, rather than clopidogrel, should be used to further reduce recurrent ischemic events. People with diabetes and non-STE ACS and higher risk features destined for a selective invasive strategy should receive ticagrelor, rather than clopidogrel Grade B, Level 2
- b.In people with diabetes and ACS, at very high risk of recurrent ischemic events and at average or low bleeding risk, prolonged (up to 3 years post-ACS) treatment with ticagrelor 60 mg twice daily should be considered [Grade B, Level 2 (45]
- c.In people with diabetes and non-STE ACS and high-risk features, an early invasive approach, rather than a selective invasive approach to revascularization, should be used to reduce recurrent coronary events, unless contraindicated [Grade B, Level 2
- d.For people with diabetes with NSTE-ACS and complex coronary anatomy, CABG should be considered rather than complex PCI [Grade A, Level 1 (62]
- e.In people with diabetes and STE-ACS, the selection of the reperfusion modality (PPCI vs. fibrinolysis) should not differ from people with STE-ACS without diabetes; the presence of retinopathy should not be a contraindication to fibrinolysis [Grade B, Level 2
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