canadian diabetes association clinical practice guidelines acute coronary syndromes and diabetes...

Canadian Diabetes Association Clinical Practice Guidelines

Acute Coronary Syndromes and Diabetes

Chapter 26

Jean-Claude Tardif, Phillipe L. L’Allier,

David H. Fitchett

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association

Acute Coronary Syndrome Checklist

SCREEN for DM among patients with ACS

USE anti-platelet therapies, prasugrel or ticagrelor,

instead of clopidogrel in patients with DM undergoing

percutaneous coronary intervention (PCI)

AVOID both hyper- and hypoglycemia among

patients with DM admitted with ACS

2013


Screen for DM Among Patients with ACS

• Diabetes is a strong risk factor for cardiovascular disease

• A significant proportion of patients with ACS have undiagnosed DM

• Screening for DM is essential among patients with ACS– Can use FPG, A1C or 75g OGTT– Consider standardized order sets


Radke P W ,et al. Eur Heart J 2010;31:2971-3.

ACS Mortality in Diabetes vs. No Diabetes: Changes Across the Eras


All patients with DM and ACS should receive

the same treatments as those without DM …

with some differences


Dual Anti-platelet Therapy in Patients with DM

• Diabetes ↑ risk of recurrent atherothrombotic events, including stent thrombosis

• Low dose ASA (75-150 mg) is effective for secondary prevention

• Dual anti-platelet therapy (ASA + clopidogrel) has been standard of care for non-ST elevation acute coronary syndrome (NSTE ACS) but recurrent events continue to occur, especially in diabetes


TRITON Study: Prasugrel vs. Clopidogrel

Days

% o

f Pa

tien

ts

0

5

10

15

0 30 60 90 180 270 360 450

HR: 0.81(0.73-0.90)

p <.001

Prasugrel (n=6813)

12.1%

9.9%

NNT = 46

Modified from Wiviott SD, et al. N Engl J Med. 2007;357(20):2001-2015.

CV Death/MI/Stroke at 15 monthsn =13,608: ACS (STEMI or NSTE ACS) and Planned PCI

CLOPIDOGREL300 mg LD/ 75 mg MD

PRASUGREL60 mg LD/ 10 mg MD

CV Death / MI / Stroke

ACS = Acute Coronary Syndrome; STEMI = ST-elevation Myocardial Infarction; NSTE ACS = Non-ST-elevation Acute coronary Syndrome; PCI = Percutaneous Coronary Intervention; LD = Loading Dose; MD = Maintenance Dose; NNT = Number Needed to Treat; CV = Cardiovascular


0

2

4

6

8

10

12

14

16

18

0 30 60 90 180 270 360 450Days

En

dp

oin

t (%

)


TIMI Major Non CABG Bleeds

17.0%

12.2%

Modified from Wiviott SD et al. Circulation 10-14-2008;118:1626-1636

TRITON: Diabetes Subgroup - Prasugrel

30%

n = 3146 ACS (STEMI or NSTE ACS) & Planned PCI

PRASUGREL

PRASUGREL

2.6%2.5%

CLOPIDOGREL

CLOPIDOGREL

HR: 0.70p <0.001

NNT 21

ACS = Acute Coronary Syndrome; STEMI = ST-elevation Myocardial Infarction; NSTE ACS = Non-ST-elevation Acute coronary Syndrome; PCI = Percutaneous Coronary Intervention; LD = Loading Dose; MD = Maintenance Dose; NNT = Number Needed to Treat; CV = Cardiovascular


Days after Randomisation0 60 120 180 240 300 360

12

11

10

9

8

7

6

5

4

3

2

10

Cu

mu

lati

ve in

cid

ence

(%

)

9.8%

11.7%

TICAGRELOR

Modified: Wallentin et al. New Eng J Med 2009; 361(11): 1045-1057

PLATO Study: Ticagrelor vs. Clopidogrel

n = 18,624 ACS

CLOPIDOGREL

NNT = 56HR: 0.84

(0.77-0.92) p <0.001


ACS = Acute Coronary Syndrome; PCI = Percutaneous Coronary Intervention; NNT = Number Needed to Treat; CV=Cardiovascular

Dual Anti-platelet Therapy in Patients with DM and ACS

Prasugrel if•About to undergo PCI•Clopidogrel-naïve•<75 yrs of age•>65 kg weight•No history of stroke

OR

RATHER THAN

Ticagrelor if

Clopidogrel to further reduce ischemic events

• No history of hemorrhagic stroke

• No extreme bradycardia



Clopidogrel Prasugrel Ticagrelor

Dosing Oral, once daily

Oral, once daily

Oral, twice daily

Onset 2-6 hours <1 hour <1 hour

Variability High Low Low

Reversible No No Yes

Plt Inhibition ~ 50% 70% at 1 hr 95% at 2hrs

Comparison of Anti-platelet Therapies


Glycemic Control Among Patients with ACS

• Hyperglycemia during the first 24 to 48 hours after admission ↑ early mortality in patients with ACS

• Evidence to support treatment of elevated blood glucose after ACS = inconclusive

• Patients with acute MI and blood glucose (BG) on admission of >11 mmol/L likely benefit from maintaining BG 7.0 -10.0 mmol/L

– Insulin therapy may be required – Helpful to have protocols


Recommendation 1

1. Patients with ACS should be screened for

diabetes with a fasting plasma glucose, A1C or

75 gram OGTT prior to discharge from

hospital. [Grade D consensus]

2013


Recommendation 2

2. All patients with diabetes and ACS should receive

the same treatments that are recommended for

patients with ACS without diabetes since they

benefit equally [Grade D, consensus].


Recommendation 3

3. Patients with diabetes and ACS undergoing PCI

should receive antiplatelet therapy with prasugrel

(if clopidogrel-naïve, <75 years of age, weight

>65kg and no history of stroke) [Grade A, Level 1] or

ticagrelor [Grade B, Level 1], rather than clopidogrel, to

further reduce recurrent ischemic events.

Patients with DM and non-STE ACS and higher risk

features, destined for a selective invasive strategy

should receive ticagrelor, rather than clopidogrel [Grade B level 2]

2013


Recommendation 4

4. Patients with diabetes and non-STE ACS and

high risk features should receive an early

invasive strategy rather than a selective invasive

approach to revascularization to reduce recurrent

coronary events, unless contraindicated [Grade B

Level 2].

2013


Recommendation 5

5. In patients with diabetes and STE-ACS, the

presence of retinopathy should not be a

contraindication to fibrinolysis [Grade B, Level 2].


Recommendation 6

6. In-hospital management of diabetes in ACS should

include strategies to avoid both hyperglycemia and

hypoglycemia:– Blood glucose should be measured on admission and

monitored throughout the hospitalization [Grade D, Consensus]

– Patients with acute MI and blood glucose on admission of

>11 mmol/L may receive glycemic control in the range of

7.0 to 10.0 mmol/L followed by strategies to achieve

recommended glucose targets long term [Grade C, Level 2]


Recommendation 6 (continued)

6. In-hospital management of diabetes in ACS

should include strategies to avoid both

hyperglycemia and hypoglycemia:– Insulin therapy may be required to achieve these targets

[Grade D, consensus]. A similar approach may be taken in those

with diabetes and admission blood glucose <11.0 mmol/L [Grade D, consensus]

– 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].

CDA Clinical Practice Guidelines

www.guidelines.diabetes.ca – for professionals

1-800-BANTING (226-8464)

www.diabetes.ca – for patients


http://guidelines.diabetes.ca/

http://diabetes.ca/

canadian diabetes association clinical practice guidelines acute coronary syndromes and diabetes...

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