2008 Clinical Practice Guidelines - Canadian Diabetes Association

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2008 CLINICAL PRACTICE GUIDELINES S118 14. Schrier RW, Estacio RO, Esler A, et al. Effects of aggressive blood pressure control in normotensive type 2 diabetic patients on albuminuria, retinopathy and strokes. Kidney Int. 2002;61:1086-1097. 15. Lewis EJ, Hunsicker LG, Bain RP, et al.The effect of angiotensinconverting-enzyme inhibition on diabetic nephropathy. The Collaborative Study Group. N Engl J Med. 1993;329:1456-1462. 16. Lewis EJ, Hunsicker LG, Clarke WR, et al; Collaborative Study Group. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med. 2001;345:851-860. 17. Brenner BM, Cooper ME, de Zeeuw D, et al; RENAAL Study Investigators. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med. 2001;345:861-869. 18. The ACE Inhibitors in Diabetic Nephropathy Trialist Group. Should all patients with type 1 diabetes mellitus and microalbuminuria receive angiotensin-converting enzyme inhibitors? A meta-analysis of individual patient data. Ann Intern Med. 2001;134:370-379. 19. Heart Outcomes Prevention Evaluation Study Investigators. Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Lancet. 2000;355:253-259. 20. Lindholm LH, Ibsen H, Dahlof B, et al; LIFE Study Group. Cardiovascular morbidity and mortality in patients with diabetes in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet. 2002;359:1004-1010. 21. UK Prospective Diabetes Study Group. Efficacy of atenolol and captopril in reducing risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 39. BMJ. 1998; 317:713-720. 22. Whelton PK, Barzilay J, Cushman WC, et al; ALLHAT Collaborative Research Group. Clinical outcomes in antihypertensive treatment of type 2 diabetes, impaired fasting glucose concentration, and normoglycemia:Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALL- HAT). Arch Intern Med. 2005;165:1401-1409. 23. Bakris GL, Gaxiola E, Messerli FH, et al; INVEST Investigators. Clinical outcomes in the diabetes cohort of the INternational VErapamil SR-Trandolapril study. Hypertension. 2004;44:637-642. 24. Patel A, ADVANCE Collaborative Group. Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus (the ADVANCE trial): a randomized controlled trial. Lancet. 2007;370:829-840. 25. Curb JD, Pressel SL, Cutler JA, et al. Effect of diuretic-based antihypertensive treatment on cardiovascular disease risk in older diabetic patients with isolated systolic hypertension. Systolic Hypertension in the Elderly Program Cooperative Research Group. JAMA. 1996;276:1886-1892. 26. Tuomilehto J, Rastenyte D, Birkenhager WH, et al. Effects of calcium-channel blockade in older patients with diabetes and systolic hypertension. Systolic Hypertension in Europe Trial Investigators. N Engl J Med. 1999;340:677-684. 27. ALLHAT Collaborative Research Group. Major cardiovascular events in hypertensive patients randomized to doxazosin vs chlorthalidone: the antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT). JAMA. 2000; 283:1967-1975.
Management of Acute Coronary Syndromes Canadian Diabetes Association Clinical Practice Guidelines Expert Committee The initial draft of this chapter was prepared by David Fitchett MD FRCPC KEY MESSAGES • Diabetes is an independent predictor of increased shortand long-term mortality, recurrent myocardial infarction (MI) and the development of heart failure in patients with acute MI (AMI). • Patients with an AMI and hyperglycemia should receive insulin-glucose infusion therapy to maintain blood glucose between 7.0 and 10.0 mmol/L for at least 24 hours, followed by multidose subcutaneous insulin for at least 3 months. • People with diabetes are less likely to receive recommended treatment such as revascularization, thrombolysis, beta blockers or acetylsalicylic acid (ASA) than people without diabetes. Efforts should be directed at promoting adherence to existing proven therapies in the high-risk patient with MI and diabetes. INTRODUCTION Acute myocardial infarction (AMI) is responsible for about 11% of deaths in Canada each year. This represents about half of all deaths attributable to coronary artery disease (1). Approximately 30% of hospital admissions for AMI are in patients with diabetes (2-6).The hospital admission rates for AMI, corrected for age and sex differences, are over 3-fold higher in patients with diabetes (7). Diabetes is an independent predictor of increased short- and long-term mortality, recurrent MI and the development of heart failure in patients with AMI (8-10). Predictors of 1-year mortality in the person with diabetes and AMI include blood glucose (BG) level at hospital admission, age, blood pressure (BP), prior MI, duration of diabetes, insulin therapy and urine albumin level (11,12). THERAPEUTIC STRATEGIES IN ACUTE CORONARY SYNDROMES Guidelines for the management of patients with acute coronary syndromes (ACS) have been developed by the American College of Cardiology/American Heart Association (13-15) and the European Society of Cardiology (16). In most situations, there are no clinical trials that specifically address management of the patient with diabetes and ACS. However, subgroup analyses in patients with diabetes and ACS show either a similar or enhanced benefit from treatment compared to the overall group for a) reperfusion with fibrinolysis (17) or primary angioplasty (18,19) for ST-segment elevation ACS; and b) high-risk non-ST-segment elevation ACS with an early invasive strategy (20), the use of dual antiplatelet therapy with acetylsalicylic acid (ASA) and clopidogrel (21), and glycoprotein IIb/IIIa inhibitors in patients with non-ST segment elevation ACS (22). ISSUES IN THE MANAGEMENT OF THE PATIENT WITH DIABETES AND ACS Thrombolysis and ocular hemorrhage There is concern that the risk of ocular hemorrhage is increased in the person with diabetes. In the Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO 1) trial, there was no intra-ocular hemorrhage in the more than 6000 patients with diabetes who received thrombolytic therapy (23). Intra-ocular hemorrhage is an extremely rare complication of diabetes; consequently, diabetic retinopathy should not be considered a contraindication to fibrinolysis in patients with ST-segment elevation MI (STEMI) and diabetes (23). Glycemic control Hyperglycemia in the early hours after presentation is associated with increased in-hospital and 6-month mortality, independent of the presence of diabetes (24-26), and admission BG is an independent predictor of survival after AMI (25). The Diabetes Mellitus Insulin Glucose Infusion in Acute Myocardial Infarction (DIGAMI 1) study (27-32) indicated that tight glycemic control with the use of intravenous insulin in the early hours after presentation, followed by multidose subcutaneous insulin treatment over the subsequent months, resulted in a 30% reduction in 1-year mortality.The DIGAMI 2 study (33) failed to achieve the study goals, both in the number of patients recruited and in glycemic control, but despite these limitations, it did demonstrate that outcomes were closely related to glycemic control, however achieved. Studies have shown that glucose-insulin-potassium infusion in patients with AMI do not improve outcomes. However, these protocols often resulted in increased BG levels, and therefore cannot be used as evidence for outcomes associated with glycemic control. In the Hyperglycemia: Intensive Insulin Infusion in Infarction (HI-5) study (34) of glucose and insulin in patients with AMI, patients with BG maintained
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2008 Clinical Practice Guidelines - Canadian Diabetes Association

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