Prise en charge du patient hyperglycémique au cours et au décours d'un syndrome coronarien aigu - 2013

Type 2 diabetes is a major risk for cardiovascular morbidity and mortality (1,2). The increased risk for coronary artery disease is already present at mildly elevated levels of blood glucose still below the threshold for diabetes (3-5). The prevalence of diabetes or abnormal glucose metabolism is very high in patients presenting with an acute coronary syndrome (ACS). Indeed, among patients hospitalized for an ACS, 30% to 40% have diabetes, 25% to 36% show impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) and only 30% to 40% have normal glucose tolerance (6-9). In addition, the prognosis after an ACS is impaired in diabetic patients (9). Thus diabetes care during and in the immediate follow-up of an ACS is an important issue. So far, recommendations on diabetes treatment during an ACS are limited. There is clearly a lack of specific guidelines with regard to glucose management in ACS patients. There is no consensus statement on the use of non-insulin treatments during and in the immediate follow-up of an ACS. Furthermore, cardiologists have no clear recommendations on when to refer a patient to a diabetologist/diabetology team during and following an ACS. In addition, in patients presenting with an ACS, without previously known diabetes but with hyperglycaemia, there is a need for a clear diagnostic pathway for the diagnosis and the management of abnormal glucose metabolism (IFG/IGT) and diabetes.

For these reasons the Diabetes and Cardiovascular Disease study group of the SFD (Société Francophone du Diabète), in collaboration with the SFC (Société Française de Cardiologie), has decided to set up a consensus statement on the "Care of the hyperglycaemic/diabetic patient during and in the immediate follow-up of an acute coronary syndrome". The aim was to write a consensus statement with regard to the hyperglycaemic/diabetic patient at different times of an ACS (the Intensive Care Unit [ICU] period, the post-ICU period and the short-term follow-up after discharge including cardiac rehabilitation), embracing all of the different diagnostic and therapeutic issues and optimizing the collaboration between cardiologists and diabetologists. We have used for this consensus, the recommendation grades according to the French HAS;

• Level A: established scientific proof (based on high quality randomized comparative trials or meta-analysis of randomized control trials),
• level B: scientific hypothesis (based on low quality randomized comparative trials, well-run non randomized comparative studies or cohort studies)
• and level C: low level of proof (based on case-control studies) (10).