Search

IntroductionObesity and diabetes mellitus (DM) frequently co-exist, yet their individual contributions to cardiovascular risk remain debated. We explored cardiovascular disease biomarkers, events and mortality in a large cohort stratified by body mass index (BMI) and DM.Methods451,355 UK Biobank participants were stratified by ethnicity-specific BMI categories (normal, overweight, obese) and DM status. We examined cardiovascular biomarkers including: carotid intima-media thickness (CIMT); arterial stiffness; left ventricular ejection fraction (LVEF) and cardiac contractility index (CCI). Poisson regression models estimated adjusted incidence rate ratios (IRR) for myocardial infarction, ischaemic stroke and cardiovascular death, with normal weight non-DM as comparator.Results5% of participants had DM (10% normal weight, 34% overweight and 55% obese; versus 34%, 43% and 23%, respectively, in non-DM). In the non-DM group, overweight/obesity was associated with higher CIMT, arterial stiffness and CCI, and lower LVEF (pConclusionsObesity and DM are additively associated with adverse cardiovascular biomarkers and mortality risk. Whilst adiposity metrics are more strongly correlated with cardiovascular biomarkers than diabetes-oriented metrics, both correlate weakly, suggesting other factors underpin the high cardiovascular risk of normal-weight diabetes.

BackgroundContinuous positive airway pressure (CPAP) and high-flow nasal oxygen (HFNO) have been used to manage hypoxaemic respiratory failure secondary to coronavirus disease 2019 (COVID-19) pneumonia. Limited data are available for patients treated with noninvasive respiratory support outside of the intensive care setting.MethodsIn this single-centre observational study we observed the characteristics, physiological observations, laboratory tests and outcomes of all consecutive patients with COVID-19 pneumonia between April 2020 and March 2021 treated with noninvasive respiratory support outside of the intensive care setting.ResultsWe report the outcomes of 140 patients (mean±sd age: 71.2±11.1, 65% male (n=91)) treated with CPAP/HFNO outside of the intensive care setting. Overall mortality was 59% and was higher in those deemed unsuitable for mechanical ventilation (72%). The mean age of survivors was significantly lower than those who died (66.1 versus 74.4 years, pversus 4, pConclusionsCPAP and HFNO delivered outside of the intensive care setting are viable treatment options for patients with hypoxaemic respiratory failure secondary to COVID-19 pneumonia, including those considered unsuitable for invasive mechanical ventilation. This provides an opportunity to safeguard intensive care capacity for COVID-19 patients requiring invasive mechanical ventilation.

Coronavirus disease 19 (COVID-19) poses the greatest public health threat in 100 years, with cases rising rapidly in many countries around the world. We report a case of a 78-year-old female who exhibited a biphasic course of COVID-19; showing initial clinical improvement followed by deterioration before making a full recovery. The patient was managed with prolonged continuous positive airway pressure (CPAP) and supportive care. In total, 24 days of treatment with CPAP was administered. We emphasize the role of CPAP in the management of severely hypoxemic patients who are inappropriate for mechanical ventilation and describe the role of adequate nutrition and hydration for such patients.

Thyroid dysfunction is common in patients with chronic heart failure (CHF), but there is conflicting evidence regarding its prognostic significance. We investigated the relation between thyroid function and prognosis in a large, well characterized cohort of ambulatory patients with CHF. Heart failure was defined as signs and symptoms of the disease and either left ventricular systolic dysfunction (LVSD) mild or worse (heart failure with reduced ejection fraction [HFrEF]), or no LVSD and raised amino-terminal pro-B-type natriuretic peptide (NT-proBNP) levels (>125 ng/L; heart failure with normal ejection fraction [HFnEF]). Euthyroid state was defined as a thyroid-stimulating hormone (TSH) level between 0.35 and 4.70 mIU/l, hypothyroidism as TSH >4.70 mIU/l, and hyperthyroidism as TSH

Objective: \ud \ud This study aims to evaluate the relationship between a single measurement at baseline of body mass index (BMI), glycated hemoglobin (HbA1c) and subsequent clinical outcomes in patients with type 2 diabetes mellitus (T2DM).\ud Method:\ud \ud Patients with T2DM were recruited from an outpatient diabetes clinic in a single large teaching hospital in Kingston upon Hull, UK. At baseline, demographics and HbA1c were recorded. Patients were categorized by BMI: normal weight (18.5–24.9 kg/m2), overweight (25–29.9 kg/m2), and obese (>30 kg/m2). Multivariable Cox regression models that included demographic, risk factors, and comorbidities were separately constructed for all-cause, cardiovascular, cancer and sepsis-related mortality, using four groups of HbA1c (8%).\ud Results:\ud \ud In total, 6220 patients with T2DM (median age 62 years, 54% male) were followed for a median of 10.6 years. HbA1c levels >8.0% were associated with increased risk of all-cause mortality and cardiovascular death. However, this increased risk was not consistent across the weight categories and reached statistical significance only in overweight patients (BMI 25–29.9 kg/m2).\ud Conclusions:\ud \ud In a large cohort of patients with T2DM elevated HbA1c levels at baseline did not consistently predict increased risk of all-cause and cardiovascular mortality across the different BMI categories.

Background Patients admitted to hospital with heart failure will have had a chest X-ray (CXR), but little is known about their prognostic significance. We aimed to report the prevalence and prognostic value of the initial chest radiograph findings in patients admitted to hospital with heart failure (acute heart failure, AHF). Methods The erect CXRs of all patients admitted with AHF between October 2012 and November 2016 were reviewed for pulmonary venous congestion, Kerley B lines, pleural effusions and alveolar oedema. Film projection (whether anterior–posterior [AP] or posterior–anterior [PA]) and cardiothoracic ratio (CTR) were also recorded. Trial registration: ISRCTN96643197 Results Of 1145 patients enrolled, 975 [median (interquartile range) age 77 (68–83) years, 61% with moderate, or worse, left ventricular systolic dysfunction, and median NT-proBNP 5047 (2337–10,945) ng/l] had an adequate initial radiograph, of which 691 (71%) were AP. The median CTR was 0.57 (IQR 0.53–0.61) in PA films and 0.60 (0.55–0.64) in AP films. Pulmonary venous congestion was present in 756 (78%) of films, Kerley B lines in 688 (71%), pleural effusions in 649 (67%) and alveolar oedema in 622 (64%). A CXR score was constructed using the above features. Increasing score was associated with increasing age, urea, NT-proBNP, and decreasing systolic blood pressure, haemoglobin and albumin; and with all-cause mortality on multivariable analysis (hazard ratio 1.10, 95% confidence intervals 1.07–1.13, p Conclusions Radiographic evidence of congestion on a CXR is very common in patients with AHF and is associated with other clinical measures of worse prognosis. Graphic abstract

Cardiogoniometry (CGM) is method of 3-dimensional electrocardiographic assessment which has been shown to identify patients with angiographically defined, stable coronary artery disease (CAD). However, angiographic evidence of CAD, does not always correlate to physiologically significant disease. The aim of our study was to assess the ability of CGM to detect physiologically significant coronary stenosis defined by fractional flow reserve (FFR). In a tertiary cardiology centre, elective patients with single vessel CAD were enrolled into a prospective double blinded observational study. A baseline CGM recording was performed at rest. A second CGM recording was performed during the FFR procedure, at the time of adenosine induced maximal hyperaemia. A significant CGM result was defined as an automatically calculated ischaemia score

Background Low cardiorespiratory fitness, defined by reduced maximal oxygen consumption (VO2), is a predictor of mortality in patients without chronic disease. However, the relation between ventilatory efficiency (as measured by the slope of the relation between ventilation (VE) and carbon dioxide production (VCO2)) and all-cause mortality is unknown. Purpose To assess the relation between variables derived from cardiopulmonary exercise testing and long-term survival in normal subjects Method We recruited 145 healthy subjects, with no history of chronic disease (57% male, mean age 63±12) from primary care at random. All participants underwent cardiopulmonary exercise testing at baseline. Participants were followed for 15.5±3.5 years. The primary end-point was all-cause mortality. Cox-proportional hazard models were used to assess the relationship between measures of exercise performance and outcome. Hazard ratios (HR) are reported with 95% confidence intervals (CI). Results During follow up, 34 participants (23.4%) died. On univariable analysis, VE/VCO2 slope, peak VO2, respiratory exchange ratio at peak exercise, peak heart rate and 6-minute walk test distance were significant predictors of all-cause mortality (table 1). However, only VE/VCO2 slope (HR per unit increase: 1.13, 95% CI: 1.00–1.28, P=0.043) and peak heart rate (HR per 10 unit increase: 0.73, 95% CI: 0.57–0.93, P=0.010) were independent predictors of all-cause mortality on multivariable analysis. Table 1. Cox regression analysis (univariable and multivariable) for cardiopulmonary exercise testing measures and all-cause mortality HR Presentation Univariable analysis Multivariable analysis HR 95% CI p value HR 95% CI p value Peak VO2 (ml/kg/min) Per unit increase 0.90 0.86–0.95 Conclusions Raised VE/VCO2 slope is an independent predictor of all-cause mortality in healthy patients with no history of chronic disease.

Introduction Thyroid dysfunction is common in patients with chronic heart failure (CHF), but there is conflicting evidence regarding its prognostic significance. We investigated the relation between thyroid dysfunction and prognosis in a large, well characterised cohort of ambulatory patients with CHF. Methods Heart failure was defined as signs and symptoms of the disease and either left ventricular systolic dysfunction (LVSD) mild or worse (heart failure with reduced ejection fraction (HeFREF)), or no LVSD and raised amino-terminal pro-B-type natriuretic peptide (NT-proBNP) levels (>125 ng/L) (heart failure with normal ejection fraction (HeFNEF)). Euthyroid was defined as a TSH level between 0.35–4.70 mIU/l, hypothyroidism as >4.70 mIU/L, and hyperthyroidism as Results 2997 patients had HeFREF and 1995 patients had HeFNEF. 4491 (90.0%) patients were euthyroid, 312 (6.3%) were hypothyroid, and 189 (3.8%) were hyperthyroid (Table 1). In univariable analysis, both hypothyroid patients (hazard ratio (HR) 1.25, 95% confidence interval (CI) 1.08 to 1.45) and hyperthyroid patients (HR 1.21, 95% CI 1.01 to 1.46) had a greater risk of death compared to euthyroid patients (Figure 1). There was a U-shaped relation between TSH and outcome (Figure 2). Increasing TSH was a predictor of mortality in univariable analysis (HR 1.02, 95% CI 1.01 to 1.03), but the association disappeared in multivariable analysis (Table 2). The three strongest predictors of adverse outcome were age, increasing NT-proBNP, and higher NYHA class. Conclusion Although thyroid dysfunction is associated with worse survival in patients with CHF, it is not an independent predictor of mortality. Conflict of Interest None

Habitual coffee consumption is protective against coronary heart disease in women; however, it is not clear whether such cardioprotection is conferred on those who have already experienced an acute myocardial infarction (AMI). Our aim was to investigate whether coffee consumption affected mortality after AMI.We carried out a dose-response meta-analysis of prospective studies that examined the relationship between coffee intake and mortality after an AMI. Using a defined-search strategy, electronic databases (MEDLINE and Embase) were searched for papers published between 1946 and 2015. Two eligible studies investigating post-AMI mortality risk against coffee consumption were identified and assessed using set criteria. Combined, these studies recruited a total of 3271 patients and 604 died. The hazard ratios for the following experimental groups were defined: light coffee drinkers (1-2 cups/day) versus noncoffee drinkers, heavy coffee drinkers (2 cups/day) versus noncoffee drinkers and heavy coffee drinkers versus light coffee drinkers.A statistically significant inverse correlation was observed between coffee drinking and mortality; all three groups showed a significant reduction in risk ratio. Light coffee drinkers versus noncoffee drinkers were associated with a risk ratio of 0.79 [95% confidence interval (CI): 0.66-0.94, P=0.008]; heavy coffee drinkers versus noncoffee drinkers were associated with a risk ratio of 0.54 (95% CI: 0.45-0.65, P0.00001); and heavy coffee drinkers versus light coffee drinkers were associated with a risk ratio of 0.69 (95% CI: 0.58-0.83, P0.0001).Drinking coffee habitually following AMI was associated with a reduced risk of mortality.

Background and Objectives: The majority of patients included in trials of anti-platelet therapy are male. This systematic review and meta-analysis aimed to determine whether, in addition to aspirin, P2Y12 blockade is beneficial in both women and men with acute coronary syndromes. Methods: Electronic databases were searched and nine eligible randomised controlled studies were identified that had sex-specific clinical outcomes (n=107,126 patients). Risk Ratios (RR) and 95% Confidence Intervals (CI) were calculated for a composite of cardiovascular death, myocardial infarction or stroke (MACE), and a safety endpoint of major bleeding for each sex. Indirect comparison analysis was performed to statistically compare ticagrelor against prasugrel. Results: Compared to aspirin alone, clopidogrel reduced MACE in men (RR, 0.79; 95% CI, 0.68 to 0.92; p=0.003), but was not statistically significant in women (RR, 0.88; 95% CI, 0.75 to 1.02, p=0.08). Clopidogrel therapy significantly increased bleeding in women but not men. Compared to clopidogrel, prasugrel was beneficial in men (RR, 0.84; 95% CI, 0.73 to 0.97; p=0.02) but not statistically significant in women (RR, 0.94; 95% CI, 0.83 to 1.06; p=0.30); ticagrelor reduced MACE in both men (RR, 0.85; 95% CI, 0.77 to 0.94; p=0.001) and women (RR, 0.84; 95% CI, 0.73 to 0.97; p=0.02). Indirect comparison demonstrated no significant difference between ticagrelor and prasugrel in either sex. Compared to clopidogrel, ticagrelor and prasugrel increased bleeding risk in both women and men. Conclusion: In summary, in comparison to monotherapy with aspirin, P2Y12 inhibitors reduce MACE in women and men. Ticagrelor was shown to be superior to clopidogrel in both sexes. Prasugrel showed a statistically significant benefit only in men; however indirect comparison did not demonstrate superiority of ticagrelor over prasugrel in women.

Background Patients with diabetes are at increased risk of acute coronary syndromes (ACS) and their mortality and morbidity outcomes are significantly worse following ACS events, independent of other comorbidities. This systematic review sought to establish the optimum management strategy with focus on P2Y12 blockade in patients with diabetes with ACS. Methods MEDLINE (1946 to present) and EMBASE (1974 to present) databases, abstracts from major cardiology conferences and previously published systematic reviews were searched to June 2014. Relevant randomised control trials with clinical outcomes for P2Y12 inhibitors in adult patients with diabetes with ACS were scrutinised independently by 2 authors with applicable data was extracted for primary composite end point of cardiovascular death, myocardial infarction (MI) and stroke; enabling calculation of relative risks with 95% CI with subsequent direct and indirect comparison. Results Four studies studied clopidogrel in patients with diabetes, with two (3122 patients) having primary outcome data showing superiority of clopidogrel against placebo with RR0.84 (95% CI 0.72–0.99). Irrespective of management strategy, the newer agents prasugrel (2 studies) and ticagrelor (1 study) had a lower primary event rate compared with clopidogrel; RR 0.80 (95% CI 0.66 to 0.97) and RR 0.89 (95% CI 0.77 to 1.02), respectively. When ticagrelor was indirectly compared with prasugrel, there was a trend to an improved primary outcome with prasugrel (RR 1.11 (95% CI 0.94 to 1.31)) particularly in those managed with percutaneous coronary intervention (PCI) (RR 1.23 (95% CI 0.95 to 1.59)). Prasugrel demonstrated a statistical superiority with prevention of further MI with RR 1.48 (95% CI 1.11 to 1.97). This was not at the expense of increased major thrombolysis in MI (TIMI) bleeding rates RR 0.94 (95% CI 0.59 to 1.51). Conclusions This meta-analysis shows the addition of a P2Y12 inhibitor is superior to placebo, with a trend favouring the use of prasugrel in patients with diabetes with ACS, particularly those undergoing PCI.

Introduction Cardiogoniometry (CGM) is a novel method of 3-D electrocardiographic (ECG) assessment, which has previously been shown to have significant diagnostic accuracy at identifying patients with stable coronary artery disease (CAD) and acute coronary syndromes (ACS). However, there is considerable variation of reported diagnostic accuracy of CGM depending on the gold standard test used to compare it to. The aim of our review is to identify what is diagnostic accuracy of CGM at identifying stable CAD and ACS, and identify other novel clinical applications of the technology. Methods Using a pre-defined search strategy, electronic databases (MEDLINE and Embase) were searched for papers published between 1946–June 2015 and reference lists were pursued. For inclusion, papers had to be original research articles that investigated the clinical application of CGM. Sixteen publications were identified from our search; seven investigated the diagnostic accuracy of CGM to identify stable CAD; one investigated the diagnostic accuracy of CGM to identify ACS; one investigated CGM as a screening tool for cardiac allograft vasculopathy in heart transplant patients and seven investigated specific CGM parameters without commenting on diagnostic accuracy. If data was available and suitable for collation, it was pooled to calculate a comprehensive overview on markers of diagnostic accuracy, which included sensitivity and specificity. Results When looking at studies investigating the diagnostic accuracy of CGM to identify stable CAD the figures of diagnostic accuracy varied: Sensitivity (64–89%) and specificity (64%–82%), however CGM consistently outperformed 12-lead ECG in terms of sensitivity (29–76%) and was comparable in terms of specificity (18–95%). The collated data pooled for our analysis included 772 patients, of which 473 had stable CAD. Our analysis showed CGM has a sensitivity of 70% and specificity of 82% at identifying stable CAD, being significantly more accurate than 12-lead ECG. The one study identified investigating the diagnostic accuracy of CGM to identify ACS included patients with non-ST segment elevation ACS and used multiple comparators including 12-lead ECG. It showed that the sensitivity and specificity of CGM to identify non-ST segment elevation ACS was 69% and 54% respectively, having significantly higher sensitivity than 12-lead ECG. The diagnostic accuracy reported for CGM to detect cardiac allograft vasculopathy was 100% and 88% respectively for sensitivity and specificity. Conclusion CGM has superior diagnostic accuracy to 12-lead ECG at identifying patients with stable CAD and is significantly more sensitive than 12-lead ECG at identifying patients with non-ST segment elevation ACS. It may have an important role in screening patients with stable CAD and those with acute chest pain.

We read with great interest the results of the recently published meta-analysis by Lau et al. [(1)][1], along with its insightful accompanying editorial. First, we would like to thank the authors for highlighting the importance of the under-representation of women in clinical trials, an issue that

Introduction The HF-CGM study is a proof-of-principle study to investigate whether cardiogoniometry (CGM), a three-dimensional electrocardiographic method, can differentiate between pacing modes in patients with cardiac resynchronisation therapy (CRT). Methods At a tertiary cardiology centre, CGM recordings were performed using four pacing modes: no pacing; right ventricular (RV) pacing; left ventricular (LV) pacing and biventricular (BIV) pacing. Three orthogonal CGM planes orientated to the long axis (XY), the frontal plane (YZ) and the short axis (XZ) of the heart were constructed (see figure), and the direction of the QRS axis was calculated for each pacing mode in each plane. During BIV pacing, the direction of CGM QRS axis was compared between patients with optimal and non-optimal 12-lead ECG pacing variables. Optimally paced 12-lead ECG variables were defined as an R/S ratio greater than or equal to 1 in V1 and/or R/S ratio less than or equal to 1 in lead I. Results Eleven participants (aged 77.4±11.5; 63.6% male, LVEF 31±6%) were consecutively recruited. Only QRS axis measured in the XY plane could distinguish between LV and BIV pacing vs. no pacing (p=0.005 and p=0.001 respectively). Mean QRS axis and 95% confidence intervals (CI) for each pacing mode is shown in the table. Mean QRS axis in the XY plane with pacing off and during RV pacing was leftwards and basal; LV pacing was apical; and BIV pacing was rightwards and basal. There was a marked difference in the direction of QRS axis between patients with optimal vs. non-optimal paced QRS morphology in the XY plane (rightwards and basal vs inconsistent). Conclusions CGM recorded in the XY plane can accurately detect differences between ventricular pacing sites. Further studies are needed to determine whether CGM has clinical utility in optimising patients undergoing CRT.

Introduction Cardiogoniometry (CGM) is method of 3-dimensional electrocardiographic assessment which has been previously shown to identify patients with angiographically defined, stable coronary artery disease (CAD). However, angiographic evidence of CAD, does not always correlate to physiologically significant CAD. The aim of our study was to assess the ability of CGM to detect physiologically significant coronary stenosis defined by fractional flow reserve (FFR). Methods In a tertiary cardiology centre, patients with single vessel CAD were enrolled into a prospective double blinded observational study. A baseline CGM recording was performed at rest. A second CGM recording was then performed during the FFR procedure, at the time of maximal hyperaemia. A significant CGM result was defined as an automatically calculated ischaemia score Results Forty patients were included (aged 61.1±11.0; 60.0% male), of which sixteen (40%) were found to have significant CAD when assessed by FFR. Markers of diagnostic performance of CGM are shown in the table. Conclusion The diagnostic performance of CGM to detect physiologically significant stable CAD is poor at rest. Although, the diagnostic performance of CGM improves substantially during maximal hyperaemia, it does not reach sufficient levels of accuracy to be used routinely in clinical practice.

Introduction Cardiogoniometry (CGM) is a method of 3-dimensional electrocardiographic assessment which provides detailed spatial and temporal information about cardiac electrical activity. The 12-lead electrocardiogram (ECG) is instrumental at localising ischaemia in patients with ST-elevation myocardial infarction, however ECG changes in non-ST elevation myocardial infarction (NSTEMI) are often non-specific for an ischaemic territory. The aim our our study was to evaluate the ability of CGM to identify the culprit lesion in patients with NSTEMI Methods At a tertiary cardiology centre, patients with a diagnosis of NSTEMI were consecutively recruited in a prospective, double blind, observational study. CGM and 12-lead ECG recordings were performed prior to coronary angiography and were interpreted by independent investigators, with the location of the culprit lesion indicated by each recording recorded. Based on coronary angiography, the site of the culprit lesion was then determined by the operating interventionist. Measures of diagnostic performance were than calculated for CGM and the 12-lead ECG for each lesion site: left anterior descending (LAD), left circumflex (LCx) and right coronary (RCA). Kappa statistic for agreement was calculated between CGM, 12-lead ECG and coronary angiography. Results Thirty patients (aged 67.5±10.8; 76.9% male) were recruited. Markers of diagnostic performance are shown in the table. Both CGM and the 12-lead ECG were able to provide ischaemia localising information in 57.7% of participants. Conclusion Although CGM is superior to the 12-lead ECG at accurately locating the culprit lesion site in patients with NSTEMI, it is only able to provide ischaemia localising information in a similar number of patients as the 12-lead ECG.

Introduction and aims Diabetic patients have increased platelet reactivity and are at an increased risk of Acute Coronary Syndromes (ACS). Furthermore, they are subject to relatively higher rates of mortality and morbidity independent of other co-morbidities. This systematic review sought to establish the optimum P2Y 12 receptor antagonist therapy for this high risk population. Methods We searched publications in databases (Medline (1946 to present) and Embase (1974 to present)) and abstracts from major cardiology conferences to 8 th June 2014; for randomised control trials with clinical outcomes for P2Y 12 inhibitors in adult diabetic patients with ACS. There were no date or language restrictions. Two authors independently evaluated the methodological quality of included studies and extracted the data. Meta-analysis was performed with statistical direct and indirect comparison. Studies were evaluated for the primary composite end point of cardiovascular death, non-fatal myocardial infarction and non-fatal stroke. In addition, the secondary outcome of bleeding was assessed. Results 1162 studies were reviewed and 17 articles (7 study populations) satisfied protocol inclusion/exclusion criteria. Four studies compared clopidogrel to placebo in diabetic patients of which two had the required primary outcome data (n = 3122 patients). Results showed superiority of clopidogrel with a relative risk (RR) 0.84 (95% confidence interval (CI) 0.72–0.99). Irrespective of management strategy (invasive or medical) the newer agents prasugrel (2 studies) and ticagrelor (1 study) had a lower primary event rate compared to clopidogrel; RR 0.80 (95% CI 0.66–0.97) and RR 0.89 (95% CI 0.77–1.02) respectively. Therefore predictably both prasugrel and ticagrelor were superior when indirectly compared to placebo (Figure 1). Ticagrelor was indirectly compared to prasugrel showing a trend to an improved primary outcome with prasugrel (RR 1.11 (95% CI 0.94–1.31)) particularly in those managed with percutaneous coronary intervention (RR 1.23 (95% CI 0.95–1.59)). Prasugrel demonstrated a statistical superiority with prevention of further myocardial infarction with RR 1.48 (95% CI 1.11–1.97). This was not at the expense of increased major TIMI bleeding rates RR 0.94 (95% CI 0.59–1.51) (Figure 2). Conclusions This meta-analysis shows that the addition of a P2Y 12 Inhibitor is superior to placebo, with a trend favouring the use of prasugrel in diabetic patients with ACS, particularly those undergoing PCI. This supports the 2014 NICE (National Institute for Health and Care Excellence) guidance that determined the cost effectiveness of prasugrel to be dominant in comparison to clopidogrel.