Diabetic patients with ACS mew

1. DiabetIC PATIENTS WITH ACUTE CORONERY SYNCROME who should I treat Professor mohammed Ahmed Bamashmos Professor of internal medicine and endocrinology Sanaa University

2. Introduction 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 Compared to individuals without diabetes, people with diabetes have: - 3-fold increased risk of ACS -Occurrence of acute coronary events 15 years earlier - 2-fold increased short and long-term mortality -An increased incidence of post-infarction recurrent ischemic events, heart failure and cardiogenic shock

3. Glycemic Control Hyperglycemia during the first 24 to 48 hours after admission for ACS is associated with an increased early mortality, whether or not the person has diabetes). Furthermore, in-hospital mortality has a closer relationship to hyperglycemia than to diabetic status Higher baseline blood glucose (BG) and a failure of BG to decrease are independent predictors of mortality (50). For people undergoing primary angioplasty, mortality increases when the plasma glucose (PG) is >10.0 mmol/L

4. GLUCOSE-LOWERING AGENTS DURING HOSPITAL STAY 1- insulin therapy ; is considered the drug of choice for the treatment of hyperglycaemia in the acute setting because of its pharmacokinetic and pharmacodynamic profile, allowing prompt correction of blood glucose levels. methods ;

6. Treatment after discharge 1- treatment target ; HbA1C ; target - HbA1C target for most adult is less than 7 - or less than 6.5 if this can be achived without significant hypoglycemia or other adverse effect of treatment - in elderly patients less than 8 or up to 9

7. Treatment types; 1- if patients on insulin. Continuous insulin therapy 2- if patients not on insulin Start oral anti diabetic drugs according to new guidelines

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10. Benefit of established versus new drugs Point to be considered when we choice oral antidiabetic drugs 1- no risk of hypoglycemia 2- no risk of weight gain or reduce weight 3- reduce BP 4- improve dyslipidemia 5- reduce MAC E ; coronary artery diseases ( MI, coronary artery bypass grafting and PCI) , stroke and PVD 6- reduce the risk of HHF

11. Established oral anti diabetic drugs ; 1- Sulfonylurea ; - risk of hypoglycemia - weight gain - they interact directly with myocardiocytes , blocking an ATP dependent potassium channel involved in myocardial adaptation to ischemia - no effect in reducing MACE 2- Thiazolidenedione ; - risk of hypoglycemia - weight gain - fluid retention - increased risk of HHF - possible CV benefit

12. 3- alpha glucosidase inhibitor ; it does not alter the MACE 4- metformin ; - no risk of hypoglycemia - induce weight loss + - improve dyslipedemia - beneficial effect in ASCVD - reduction in major diabetic complication , MI , and all cause mortility

13. Novel oral anti diabetic drugs; Based on the available evidence, SGLT2 inhibitors and GLP-1 RAs are considered the best options for the long-term treatment of T2DM in patients with established atherosclerotic CVD or at high/very high CV risk. These drugs are safe, effective, and generally well tolerated and can be started already during the hospitalisation for ACS or elective PCI, if indicated. Data from trials with liraglutide and empagliflozin suggest that at least some of the drugs of these two classes could also reduce mortality. Benefits with GLP-1 RAs seem to be related to an anti-atherosclerotic effect, whereas SGLT2 inhibitors appear to reduce HF-related endpoints and have specific advantages in patients with or at high risk for HF. Although the trial-based

14. 1- SGLT2 Inhibitor - no risk of hypoglycemia - induce weight loss ++ - reduce dyslipedemia and atherosclerosis - reduce BP - reduce MACE - reduce rate of HHF - reduce micro albuminurea - beneficial effect in patients with established ASCVD and HF - reduction in the MACE and HHF with canagliflozin and empagliflozin - reduction in HHF and CV mortality Indication in established ASCVD or at rlsk for CVD as first line therapy in patient with native drugs or add to metformin erespicative to HbA1C

16. 2- GLP 1 receptor agonist ; - no risk of hypoglycemia - induce weight loss +++ - reduce dyslipedemia and atherosclerosis - reduce BP - reduce MACE with dulaglutide , liraglutide - reduce rate of HHF - beneficial effect in patients with established ASCVD

18. 3- DPP type 4 inhibitor - no risk of hypoglycemia - effect in weight ; neutral - beneficial effect in ASCVD ; no - safe in CVD - increased risk of HHF particularly with saxagleptin

19. Cardiovascular benefits of the new antidiabetic drugs

21. Patients with ASCVD Patients on metformin 1- add eithe SGLT2 I or GLPIRA errespective of glycemic target 2-check HbA1C after 3 months If treatment target is reached. Continue treatment If treatment target is not reached .add other drugs with proven benefits in patients with ASCVD -SGLT2I -GLP1RA Drug native patients • Start SGLT1 I or GLP1 RA. Check HbA1C after 3 months If HbA1C not in target 2- add metformin Check HbA1C .not on target 3- add drugs with proven benefits on ASCVD

22. Conclusion • . Extensive research efforts have led to improved outcomes for patients with dysglycaemic states in recent decades. Still, the rate of adverse events remains higher in patients with diabetes following PCI. Some important open issues that future research efforts must address are the following: • 1. Optimal glycaemic control for the outcome of ACS, CCS and post-coronary revascularisation interventions remains to be established. • 2. The role of hypoglycaemia in the occurrence of CV events/mortality remains to be fully elucidated. • 3. Further trials with SGLT2 inhibitors and GLP-1 RAs in patients with coronary syndromes/undergoing PCI without diabetes would eventually provide further knowledge as to the potential benefits of these drugs irrespective of glucose control, possibly expanding their present indications