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The Coagulation and Fibrinolytic Systems, Diabetes, and the Heart: Therapeutic Implications for Patients with Type 2 Diabetes

David J. Schneider and Burton E. Sobel

University of Vermont, Burlington, Vermont

An understanding of the propensity for patients with diabetes to sustain acute coronary syndromes is potentiated by consideration of the roles of thrombosis, platelet activation, and fibrinolysis in their genesis and derangements in all three systems associated with diabetes. In this selective review, we shall highlight several recent observations and concepts pertinent to clinical practice and particularly to medical management of patients with diabetes. We hope the information presented will be useful in selecting and implementing specific therapeutic approaches likely to reduce the risk of acute coronary events in patients with type 2 diabetes.

I. THROMBOSIS, ATHEROSCLEROSIS, AND ACUTE CORONARY SYNDROMES

Thrombosis appears to be a major contributor to atherogenesis. Early in the evolution of atherosclerosis, microthrombi present on the luminal surface of vessels can potentiate progression of atherosclerosis by exposing the vessel wall to clot-associated mitogens. In later stages, mural thrombi are associated with gradual g growth of atherosclerotic plaques and explosive consequences of plaque rupture including coronary occlusion responsible for acute coronary syndromes.

The classical view that acute coronary syndromes are attributable to highgrade occlusive, stenotic coronary lesions comprising final steps in a continuum

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