Management of Acute Coronary Syndromes in Patients with Diabetes.

Given the heightened risk for adverse cardiovascular outcomes in patients with diabetes mellitus, it is important that primary care clinicians be comfortable with the routine management of acute coronary syndromes (ACS) in this patient population. Notably, patients with diabetes are more likely to present atypically during an ACS. To improve health outcomes, patients with a history of diabetes and ACS should be evaluated for peripheral arterial disease and encouraged to pursue cardiac rehabilitation. Clinicians should also be cognizant of the high rate of polypharmacy in patients with diabetes and the potential glycemic and cardioprotective impact of medications they prescribe for these patients. For patients with diabetes presenting with an acute ACS, guidelines recommend an early invasive strategy as opposed to an initial conservative approach. Apart from ensuring effective glycemic control, guidelines largely recommend that patients with and without diabetes be treated similarly. Accordingly, dual antiplatelet therapy is the standard of care for ACS patients, irrespective of diabetes status. Although clopidogrel may be the most widely used of the P2Y12 inhibitors recommended for dual antiplatelet therapy, there is evidence of an impaired response in patients with diabetes. Newer oral P2Y12 inhibitors such as ticagrelor and prasugrel have demonstrated greater efficacy than clopidogrel in improving the cardiovascular outcomes of patients with ACS and diabetes.