Abstract
Patients with diabetes mellitus presenting with acute coronary syndrome have a higher risk of cardiovascular complications and recurrent ischemic events when compared to nondiabetic counterparts. Different mechanisms including endothelial dysfunction, platelet hyperactivity, and abnormalities in coagulation and fibrinolysis have been implicated for this increased atherothrombotic risk. Platelets play an important role in atherogenesis and its thrombotic complications in diabetic patients with acute coronary syndrome. Hence, potent platelet inhibition is of paramount importance in order to optimise outcomes of diabetic patients with acute coronary syndrome. The aim of this paper is to provide an overview of the increased thrombotic burden in diabetes and acute coronary syndrome, the underlying pathophysiology focussing on endothelial and platelet abnormalities, currently available antiplatelet therapies, their benefits and limitations in diabetic patients, and to describe potential future therapeutic strategies to overcome these limitations.
Highlights
A PubMed (Medline) search was performed using the following terms either singly or in combination: diabetes, type 2diabetes mellitus, cardiovascular risk, hypercoagulability, prothrombotic, acute coronary syndrome, endothelial dysfunction, antiplatelet, platelet dysfunction, aspirin, clopidogrel, and glycoprotein IIb/IIIa inhibitor
Diabetes mellitus (DM) can be described as a metabolic disorder of multiple aetiology characterised by chronic hyperglycaemia with disturbances of carbohydrate, fat, and protein metabolism resulting from defects of insulin secretion, insulin action, or a combination of both [1]
Insulin resistance usually precedes the onset of type 2 diabetes mellitus (T2DM) and is commonly accompanied by other related metabolic abnormalities such as hyperglycaemia, dyslipidaemia, hypertension, and prothrombotic factors, all of which contribute to the increased cardiovascular risk
Summary
A PubMed (Medline) search was performed using the following terms either singly or in combination: diabetes, type 2diabetes mellitus, cardiovascular risk, hypercoagulability, prothrombotic, acute coronary syndrome, endothelial dysfunction, antiplatelet, platelet dysfunction, aspirin, clopidogrel, and glycoprotein IIb/IIIa inhibitor. Insulin resistance usually precedes the onset of T2DM and is commonly accompanied by other related metabolic abnormalities such as hyperglycaemia, dyslipidaemia, hypertension, and prothrombotic factors, all of which contribute to the increased cardiovascular risk This condition is called metabolic syndrome [4, 5]. CVD, coronary artery disease (CAD) resulting from accelerated atherosclerosis, is the leading cause of morbidity and mortality in patients with T2DM. These patients have a higher risk of cardiovascular complications and recurrent atherothrombotic events after an index event than non-DM patients. Hyperglycaemia may play an important role in increased atherothrombotic risk in DM patients This has been supported by the Diabetes Mellitus, Insulin Glucose Infusion in Acute Myocardial Infarction (DIGAMI) trial. Systems that are involved in maintaining the integrity and patency of the vasculature including endothelial and platelet function, coagulation, and fibrinolysis are impaired in diabetes, thereby shifting the balance to favour thrombus formation
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