There is a high prevalence of ischemic heart disease and a high incidence of myocardial infarction in the diabetic patient due to hypertension, dyslipidemia, hyperglycemia, insulin resistance, increased platelet aggregation and red cell coagulability, decreased fibrinolysis, and abnormalities of endothelial function. There is also an increase in the extent of the atherosclerosis and the number of coronary arteries involved with the atheromatous process in the diabetic patient. Though other symptoms may be present, chest pain associated with a diabetic myocardial infarction is often delayed, diminished, or absent in the diabetic patient, resulting in a delay in diagnosis and treatment. The morbidity and mortality of the diabetic patient with a myocardial infarct is increased due to multiple factors that include the presence of autonomic neuropathy, microvascular disease, and diabetic cardiomyopathy. With modern therapy, the prognosis after a myocardial infarction has improved for the diabetic patient. In treating a myocardial infarction in the diabetic patient, aggressive glycemic control may reduce myocardial damage, and oral hypoglycemics should be avoided. Aspirin, beta-blockers, and angioten-sin-converting enzyme (ACE) inhibitors should be used, and in the vast majority of cases thrombolytic therapy is indicated. Angioplasty or coronary artery bypass grafting may be needed to salvage myocardium, and the results of these interventions are equivalent to those of the nondiabetic person in the short-term, though the incidence of restenosis after angioplasty, even with stenting, is increased in the diabetic patient. Successful secondary prevention includes the use of aspirin, ACE inhibitors, and beta-blockers, the cessation of smoking, and control of body weight, hypertension, and dyslipidemia.
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