Platelets and Antiplatelet Therapy in Patients with Diabetes Mellitus

Pathways and mediators of platelet activation. Several mediators lead to activation and subsequent aggregation of platelets. Binding of fibrinogen to the platelet surface receptor glycoprotein IIb/IIIa represents the final common pathway of platelet aggre
Author(s): 

Heidar Arjomand, MD, Bassam Roukoz, MD, Satish K. Surabhi, MD, *Marc Cohen, MD


Treatment with GP IIb/IIIa inhibitors has also been shown to be effective in the setting of acute ST-elevation MI.36,37 In the ADMIRAL (Abciximab before Direct Angioplasty and Stenting in Myocardial Infarction Regarding Acute and Long-Term Follow-up) trial, patients with acute MI assigned to stenting plus abciximab, as compared to stenting alone, had a lower incidence of death, reinfarction or urgent revascularization (7.4% versus 15.9%; p = 0.02) at 6-month follow-up.37 In the diabetic subgroup (53/300), treatment with stent plus abciximab, as compared to stent plus placebo, significantly reduced mortality (0% versus 16.7%; p = 0.02) and TVR (13.8% versus 37.5%; p = 0.046) at 6 months. However, it should be noted that the overall number of patients is small, which prohibits any conclusive statements.37
Other adjunctive therapy. Diabetes mellitus is associated with a markedly increased prevalence of cardiovascular disease. Moreover, cardiovascular case fatalities remain the leading cause of death in patients with diabetes. Therefore, in addition to treatment with antiplatelet agents, more vigorous control of hyperglycemia, hyperlipidemia, hypertension and other risk factors is of crucial importance in reducing the risk of cardiovascular disease in diabetic patients.17 Improved glycemic control attenuates the heightened platelet activity seen in patients with diabetes. There is also a significant reduction in microvascular diabetes complications with intensive glucose control.38 With regard to treatment of hyperlipidemia, diabetes is considered a CAD risk equivalent, and diabetic patients should be treated aggressively with lipid-lowering agents, and in particular statins, to achieve the targeted low-density lipoprotein of <= 100 mg/dl. Available data indicate that hypertension increases the risk of cardiovascular events in patients with diabetes. Moreover, hypertension among diabetic patients has been associated with other complications, including nephropathy, retinopathy and development of cerebrovascular disease. Therefore, every effort should be made to achieve the target blood pressure of 130/80 mmHg in this high-risk group of patients.38
Summary. Atherosclerotic heart disease is the major cause of mortality in diabetic patients. To a large extent, platelet inhibition with oral or intravenous agents has “normalized” the increased risk of diabetic patients with CAD. Aspirin is effective in the primary prevention of fatal and nonfatal MI in patients with diabetes, and in the absence of contraindications, should be given to all diabetic subjects at high risk for vascular disease. Clopidogrel has been proven superior to aspirin, especially in diabetic patients. Patients with diabetes and non-ST elevation ACS would benefit from combination antiplatelet therapy with aspirin and clopidogrel. There is a large body of evidence indicating the beneficial effects of GP IIb/IIIa inhibitors in reducing MI and death in diabetic patients with ACS or after PCI.


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