Impact of Diabetes Mellitus on the Clinical Course of Acute Myocardial Infarction: A Comprehensive Review

Resume. Diabetes mellitus is one of the most common comorbidities in patients hospitalized for acute myocardial infarction and significantly alters the clinical course of the disease, affecting initial presentation, in-hospital complications, and long-term survival. Despite advances in revascularization and pharmacological treatment, the mortality gap between patients with and without diabetes has persisted or even widened in some populations. This review summarizes current evidence on the impact of diabetes on the clinical course of acute myocardial infarction, including pathophysiological mechanisms, clinical presentation, in-hospital complications, revascularization outcomes, pharmacological considerations, and long-term prognosis. A literature search was conducted using PubMed, Scopus, and the Cochrane Library, prioritizing systematic reviews with meta-analyses, randomized controlled trials, and large observational cohort studies published between 2012 and 2026. Diabetes affects approximately 30 to 40 percent of patients hospitalized for acute coronary syndromes, and its prevalence in this population is increasing. Patients with diabetes have a higher burden of multivessel coronary artery disease, more extensive atherosclerosis, and more frequent comorbidities such as chronic kidney disease and heart failure. Acute myocardial infarction in patients with diabetes often presents atypically or silently, mainly due to autonomic neuropathy and altered pain perception. These patients also experience higher rates of in-hospital complications, including heart failure, cardiogenic shock, arrhythmias, and acute kidney injury. Long-term mortality remains substantially elevated, with glycemic control parameters, insulin treatment requirement, and chronic kidney disease emerging as independent predictors of adverse outcomes. Contemporary strategies such as sodium-glucose cotransporter 2 inhibitors and complete revascularization show promise, but dedicated randomized controlled trials in this population remain limited. In conclusion, diabetes fundamentally alters the clinical course of acute myocardial infarction through mechanisms beyond glycemic control alone. The persistent excess mortality reflects the inadequacy of current approaches focused mainly on conventional modifiable risk factors. A shift toward diabetes-specific risk stratification and targeted therapeutic interventions is needed. Clinicians should recognize the distinct clinical phenotype of acute myocardial infarction in patients with diabetes and apply intensified, individualized management strategies. Future research should focus on novel therapeutic targets and adequately powered randomized controlled trials of contemporary antidiabetic medications in this specific clinical context.