Platelet Function

Platelet activation plays a pivotal role in the initiation and progression of atherothrombosis. Aspirin:
Aspirin inhibits thromboxane (TX) A2 -dependent platelet activation and aggregation through irreversible inactivation of platelet cyclo-oxygenase 1 (COX-1) activity. once-daily administration of low-dose aspirin may be associated with incomplete inhibition of platelet COX-1 activity and TXA -dependent platelet function. Primary prevention:aspirin probably produces a modest reduction in the risk of cardiovascular events Secondary prevention: They analysed individual data on serious vascular (non-fatal MI, nonfatal stroke or vascular death) from approximately 4500 patients with DM in the randomized trials and found that treatment with antiplatelet drugs produced a proportional reduction of about one quarter. Risk-benefit ratio of Aspirin: aspirin was associated with a 55% increase in the risk of extracranial (mainly gastrointestinal) bleeding, both in people without- (the majority) andwith DM. favour aspirin use in adults with DM when the 10-year risk of cardiovascular events is <10%.
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Platelet Function
P2Y12 receptor blockers: Clopidogrel, an irreversible blocker of the adenosine diphosphate (ADP) receptor P2Y12, provides a valid alternative for patients who are aspirin-intolerant or have symptomatic peripheral vascular disease, because it has broad indications for long-term secondary prevention similar to aspirin. In a DM substudy, a similar reduction in recurrent ischaemic events was seen, but in the DM cohort this was not accompanied by an increase in bleeding. Ticagrelor (180 mg loading dose, followed by 90 mg twice daily), was also more effective than clopidogrel (300600 mg loading dose, followed by 75 mg daily) in reducing death from CV causes and total mortality at 12 months in a general post-ACS cohort,281 and decreased ischaemic events in DM patients without causing increased bleeding.282

Platelet Function

Multifactorial approach
Patients with glucose perturbations are in need of early risk assessment to identify co-morbidities and factors that increase cardiovascular risk. This includes evaluation of:
risk factors (e.g. lifestyle habits including smoking, hypertension and dyslipidaemia); microvascular and macrovascular disease and autonomic dysfunction; co-morbidities (e.g. heart failure and arrhythmias); inducible ischaemia bymeans of exercise testing, stress echocardiography, or myocardial scintigraphy; myocardial viability and LV function bymeans of echoDoppler and/or magnetic resonance imaging.

Multifactorial approach

Multifactorial approach

Management of stable and unstable coronary artery disease in patients with diabetes
DM is associated with a poorer prognosis in patients with acute and stable CAD Optimal medical treatment for patients with chronic coronary artery disease and diabetes
Beta-adrenergic blockers Blockers of the renin-angiotensin-aldosterone system (ACE-I or ARB) Lipid-lowering drug Nitrates and calcium channel blockers Ivabradine: heart-rate lowering, anti-anginal drug inhibits primarymodulator of spontaneous diastolic depolarization in the sinus node. Indicated in chronic stable angina in CAD patients with a contraindication or intolerance to beta-blocker. Antiplatelet and antithrombotic drugs Glucose control in acute coronary syndromes

Management of stable and unstable coronary artery disease in patients with diabetes

Revascularization
Revascularization in these patients is challenged by a more diffuse atherosclerotic involvement of epicardial vessels, a higher propensity to develop re-stenosis after PCI and saphenous graft occlusion after coronary artery bypass graft surgery (CABG) and unremitting atherosclerotic progression causing new stenosis.

Revascularization

Revascularization

Revascularization

Heart Failure and DM

Arrythmias

Peripheral Arterial Disease

Peripheral Arterial Disease

Peripheral Arterial Disease

Carotid artery disease

Reccomendation in PAD

Management of Microvascular disese

Recommendation in patient-centered care