1. Reducing Adverse Outcomes after ACS in Patients with Diabetes Goals
Diabetes increases risk of CV events
Frequency of Diabetes in CAD patients
Need to identify patients with diabetes
Strategies to reduce adverse outcomes
Changing landscape with new therapies

2. Mortality following Myocardial Infarction in Patients with and without Diabetes
DM STEMI
62,000 Patients in TIMI trials
DM STEMI
Non DM STEMI
Non DM STEMI
Donohoe et al JAMA 2007;298:765

3. Impact of Diabetes on Outcomes after ACS AMI with CHF or LV Dysfunction
1 year outcomes
Diabetes
New Diabetes
No Diabetes
VALIANT
Aguilar et al Circulation 2004;110;1572

4. In-Hospital Management of ACS in the DM Patients and Long-Term Outcomes
Choice of revascularisation PCI vs CABG
Anti-platelet agent
Preferential use of ticagrelor / prasugrel
Use of DAPT in patients managed without PCI
Initiation / dose optimisation of
Statins, BP control, Use of ACEi /ARB, beta blocker
Glycemic management
Glucose control
Need for referral?
Choice of drug with CV benefit / known safety
Facilitate lifestyle change
Smoking cessation
Refer to Rehabilitation Clinic

5. Optimal Secondary Prevention on Patient with Type 2 Diabetes after ACS
Vascular Protection
Prevention of vascular events
Cardiac protection
Prevention of heart failure /
Sudden death
Risk factor management
Limit CAD progression
Anti-platelet therapy
Lipid lowering
ACE inhibition /ARB
Beta blockers
ACE I / ARB
Mineralo corticoid inhibition
Saccubitril / Valsartan
Ivabradine
ICD and or CRT
Smoking cessation
Lipid and BP control
Glycemia control
Rehabilitation and lifestyle

6. CV death
HR 0.62
(95% CI 0.49, 0.77)
p<0.0001
Cumulative incidence function. CI, confidence interval; HR, hazard ratio. Zinman et al. N Engl J Med 2015:373:

7. LEADER Liraglutide Cardiovascular Outcome Trial
CV death, MI, Stroke
Non-fatal MI HR 0.88 (95% CI )
Non-fatal Stroke HR 0.89 (95% CI )
Heart failure HR 0.87 (95% CI )
Patients with an event %
Patients with an event %
CV Mortality
Months
Months
LEADER Marso et al N Engl J Med 2016 June

8. Meta-analysis of Clinical Trials with Statin Treatment: Impact on Mortality in Diabetes
Events (%)
Cause of death
Treatment
Control
RR (CI)
Vascular causes:
CHD death
Diabetes
436 (4.6%)
495 (5.3%)
0.88 ( )
No diabetes
1112 (3.1%)
1465 (4.1%)
0.78 ( )
Any CHD death
1548 (3.4%)
1960 (4.4%)
0.81 ( )
Test for heterogeneity within subgroup: x21 = 2.8; p = 0.09
All causes:
Diabetes
1031 (11.0%)
1104 (11.9%)
0.91 ( )
A meta-analysis of statin therapy shows that similar benefits are seen for reduction of CHD death, vascular death and all-cause mortality for patients with and without diabetes. Non-CHD and non-vascular death are not significantly reduced in either group. However, there is no suggestion of any increase of non-CVD mortality.
Reference:
Kearney PM, Blackwell L, Collins R, et al. Efficacy of cholesterol-lowering therapy in 18,686 people with diabetes in 14 randomised trials of statins: a meta-analysis. Lancet 2008; 371(9607):
No diabetes
2801 (7.9%)
3250 (9.1%)
0.87 ( )
Any death
3832 (8.5%)
4354 (9.7%)
0.88 ( )
Test for heterogeneity within subgroup: x21 = 0.8; p = 0.04
RR (99% CI)
0.5
1.0
1.5
RR (95% CI)
Treatment better
Control better
Kearney PM, et al. Lancet 2008; 371(9607): 8

9. Major Pre-specified Subgroups
Simva†
EZ/Simva†
Male
34.9
33.3
Female
34.0
31.0
Age < 65 years
30.8
29.9
Age ≥ 65 years
39.9
36.4
No diabetes
30.2
Diabetes
45.5
40.0
Prior LLT
43.4
40.7
No prior LLT
30.0
28.6
LDL-C > 2.5mmol/l
31.2
29.6
LDL-C ≤ 2.5 mg/dl
38.4
36.0 *
†7-year event rates
0.7
1.0
1.3
Ezetimibe/Simva Better
Simva Better
*p-interaction = 0.023, otherwise > 0.05

10. Secondary Prevention in Patients with Diabetes and ACS
High risk group for CV events especially CHF and CV death
Need to identify patients with DM
Need to optimise all aspects of risk reduction including
Lifestyle management, BP, Statins, RAASi
New opportunities with additive and potentially large benefit
Glucose lowering agents with CV benefit
Further LDL lowering with PCSK9 inhibitor