This document discusses treatment guidelines for diabetic patients experiencing acute coronary syndrome (ACS). It recommends starting insulin therapy to control hyperglycemia during the first 48 hours as high blood glucose is linked to higher mortality. For long-term treatment after discharge, it recommends metformin as first-line due to its cardiovascular benefits without hypoglycemia risk. Novel drugs like SGLT2 inhibitors and GLP-1 receptor agonists are also good options due to proven reductions in major adverse cardiovascular events and heart failure in patients with established cardiovascular disease. The document provides guidelines on initiating and optimizing treatment with these newer drugs for diabetic patients with ACS or at high cardiovascular risk.

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

9. a

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 ofT2DM in patients with established atheroscleroticCVD
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 withGLP-1 RAs seem to be related to an
anti-atherosclerotic effect, whereasSGLT2 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
Drug native patients
1. 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
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

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