What is the recommended management for a patient with type 2 diabetes after undergoing a Drug-Eluting Stent (DES) Percutaneous Coronary Intervention (PCI)?

Management of Type 2 Diabetes After Drug-Eluting Stent PCI

For patients with type 2 diabetes who have undergone drug-eluting stent (DES) percutaneous coronary intervention (PCI), a comprehensive management approach should include dual antiplatelet therapy (DAPT) for at least 12 months, SGLT2 inhibitors, GLP-1 receptor agonists, optimal glycemic control, and aggressive cardiovascular risk factor management.

Antiplatelet Therapy

Dual Antiplatelet Therapy (DAPT)

• After DES implantation for patients with type 2 diabetes:
  • Continue aspirin 81 mg daily indefinitely 1
  • P2Y12 inhibitor (clopidogrel 75 mg daily, prasugrel 10 mg daily, or ticagrelor 90 mg twice daily) should be given for at least 12 months 1
  • Patients should be counseled on the importance of DAPT compliance and not to discontinue therapy without discussing with their cardiologist 1

Considerations for DAPT Duration

• For patients at high bleeding risk, shorter DAPT duration (3 months) may be considered as it shows similar MACE outcomes with lower bleeding risk compared to 12 months 2
• For very high-risk diabetic patients without bleeding complications, DAPT may be extended beyond 12 months 1
• Concomitant proton pump inhibitor is recommended for patients at high risk of gastrointestinal bleeding 1

Glucose-Lowering Medications

First-Line Agents with Cardiovascular Benefits

1. SGLT2 inhibitors:

   • Empagliflozin, canagliflozin, or dapagliflozin are recommended for patients with T2DM and cardiovascular disease 1
   • Empagliflozin specifically is recommended to reduce the risk of death in T2DM patients with CVD 1
   • Empagliflozin has shown beneficial cardiometabolic effects when started before and continued after elective PCI 3
   • SGLT2 inhibitors reduce the risk of heart failure hospitalization 1

2. GLP-1 receptor agonists:

   • Liraglutide, semaglutide, or dulaglutide are recommended for patients with T2DM and CVD 1
   • Liraglutide specifically is recommended to reduce the risk of death 1

Medications to Avoid or Use with Caution

• Thiazolidinediones (pioglitazone, rosiglitazone) are not recommended in patients with heart failure 1
• Saxagliptin is not recommended in patients with T2DM at high risk of heart failure 1
• Metformin:
  • Should be checked with renal function after angiography 1
  • Consider stopping metformin when renal function deteriorates 1
  • In patients with renal failure, metformin should be stopped before the procedure 1

Lipid Management

• Statin therapy is recommended for all patients with diabetes and CAD 1
• For patients at very high CV risk with persistent high LDL-C despite maximum tolerated statin dose with ezetimibe, a PCSK9 inhibitor is recommended 1
• LDL-C targets:
  • For patients with T2DM at very high CV risk: <1.4 mmol/L (<55 mg/dL) and LDL-C reduction of at least 50% 1
  • For patients with T2DM at high CV risk: <1.8 mmol/L (<70 mg/dL) and LDL-C reduction of at least 50% 1

Blood Pressure Management

• Target blood pressure should be individualized:
  • SBP to 130 mmHg and, if well tolerated, <130 mmHg, but not <120 mmHg 1
  • DBP to <80 mmHg but not <70 mmHg 1
• Preferred medications:
  • RAAS blockers (ACE inhibitors or ARBs) are recommended rather than beta-blockers/diuretics 1
  • Consider combination of a RAAS blocker with a calcium channel blocker or thiazide/thiazide-like diuretic 1

Lifestyle Modifications

• Smoking cessation should be strongly encouraged 1
• Regular physical activity and cardiac rehabilitation programs are recommended 1
• Weight management with target of optimal BMI 1
• Diet following Mediterranean, DASH, or AHA recommendations 1

Monitoring and Follow-up

• Self-monitoring of blood glucose should be considered to facilitate optimal glycemic control 1
• Avoid hypoglycemia, which can trigger arrhythmias 1
• Regular monitoring of HbA1c with target individualized based on patient factors
• Home BP self-monitoring should be considered 1
• Follow-up appointment within 2-6 weeks for low-risk patients and 1-2 weeks for higher-risk patients 1

Special Considerations

• Insulin-treated diabetic patients have higher rates of adverse cardiovascular outcomes after PCI compared to non-insulin-treated patients 4
• Modern DES technology has significantly improved outcomes in diabetic patients, but challenges remain with higher rates of restenosis and stent thrombosis compared to non-diabetic patients 5

By implementing this comprehensive management approach, patients with type 2 diabetes who have undergone DES PCI can achieve optimal outcomes with reduced risk of cardiovascular events and mortality.