Gastric feed intolerance is not increased in critically ill patients with type II diabetes mellitus

Objective To examine the occurrence of feed intolerance in critically ill patients with previously diagnosed type II diabetes mellitus (DM) who received prolonged gastric feeding. Design and setting Retrospective study in a level 3 mixed ICU. Patients All mechanically ventilated, enterally fed patients (n = 649), with (n = 118) and without type II DM (n = 531) admitted between January 2003 and July 2005. Interventions Patients with at least 72 h of gastric feeding were identified by review of case notes and ICU charts. The proportion that developed feed intolerance was determined. All patient received insulin therapy. Results The proportion of patients requiring gastric feeding for at least 72 h was similar between patients with and without DM (42%, 50/118, vs. 42%, 222/531). Data from patients with DM were also compared with a group of 50 patients matched for age, sex and APACHE II score, selected from the total non-diabetic group. The occurrence of feed intolerance (DM 52% vs. matched non-DM 50% vs. unselected non-diabetic 58%) and the time taken to develop feed intolerance (DM 62.6 ± 43.8 h vs. matched non-DM 45.3 ± 54.6 vs. unselected non-diabetic 50.6 ± 59.5) were similar amongst the three groups. Feed intolerance was associated with a greater use of morphine/midazolam and vasopressor support, a lower feeding rate and a longer ICU length of stay. Conclusions In critically ill patients who require prolonged enteral nutrition, a prior history of DM type II does not appear to be a further risk factor for feed intolerance. This research was supported by the National Health and Medical Research Council of Australia An erratum to this article can be found at     

Outcomes of patients with prior coronary artery bypass graft who present with acute coronary syndrome

Generally, patients with prior coronary artery bypass graft (CABG) are often under-represented in acute coronary syndrome (ACS) clinical trials. Nevertheless, there is growing global attention concerning their short- and long-term prognosis. Some reports suggest prior CABG as an independent risk factor for increased mortality, while others report an equal or a more favorable prognosis despite their adverse baseline clinical characteristics. The reasons for this ‘risk-mortality paradox’ need to be further evaluated. More recent reports showed a significant reduction in in-hospital morbidity and mortality over a 20-year period of follow up that may be attributed to the improvement in surgical CABG techniques and increased use of evidence-based therapies over the past two decades. In the current review we discuss the available literature regarding outcomes of prior CABG patients who are presenting with ACS.     

血清肌钙蛋白I轻度升高在初诊为非ST段抬高型急性冠状动脉综合征患者中的临床意义

目的：探讨血清肌钙蛋白 I（cTnI）轻度升高在初诊为非 ST 段抬高型急性冠状动脉综合征（NSTE-ACS）的患者诊治中的临床意义。方法选取2012年7月至2013年7月于天津医科大学第二医院心脏内科初诊为NSTE-ACS,血清cTnI水平在0.02～1 ng/ml的患者80例,为cTnI轻度升高组;血清cTnI正常的患者60例,为cTnI正常组。所有患者在院期间均行冠状动脉造影术。据冠状动脉造影结果计算Gensini积分评价冠状动脉病变严重程度,分析其与cTnI水平的关系。结果（1）与cTnI正常组相比,cTnI轻度升高组患者肌酸激酶、肌酸激酶同工酶水平更高,病变支数更多,最大病变程度更严重（P＜0.05）;（2）以全部观察对象作为整体,Gensini 积分、病变支数均与cTnI 水平呈正相关（r＝0.365,r＆#39;＝0.343,P＜0.01）;（3）cTnI 轻度升高组患者超声心动图显示室壁节段性运动异常及瓣膜钙化的比例显著高于正常组（P＜0.05）;（4）cTnI轻度升高组的谷草转氨酶及尿素氮均显著高于cTnI正常组（P＜0.05）,而白蛋白和二氧化碳结合力均显著低于cTnI正常组（P＜0.05）。结论对于初诊NSTE-ACS患者,cTnI轻度升高有重要的临床意义,提示冠状动脉病变范围较大、程度较重,且同时合并更复杂的临床情况。     

不同性别高龄急性冠脉综合征患者介入治疗的预后分析

目的探讨性别差异对高龄急性冠脉综合征患者经皮冠状动脉介入治疗预后的影响。方法回顾性分析80例85岁以上急性冠脉综合征患者,观察性别差异对住院期间和长期预后的影响。结果女性组高血压病、单支病变及DES植入比例略高;而既往心肌梗死史、既往冠脉介入治疗史、血脂异常、三支病变比例低于男性组。住院期间主要心血管不良事件(MACE)发生率要高于男性组(10.8%vs 7.0%;P>0.05)。随访1年时MACE发生率两组相似(5.7%vs 4.9%;P=0.10)。尽管80%患者仅植入1个支架,但1年生存率较高。结论高龄女性ACS接受PCI住院期间MACE发生率要高于男性,不完全血运重建策略仍可使这一特殊人群长期获益。     

High incidence of glucose intolerance in Asian-Indian subjects with acute coronary syndrome

OBJECTIVE: The risk of diabetes and coronary heart disease is high in Asian Indians. In this study, we aim to assess 1) the prevalence of hyperglycemia in incident acute coronary syndrome (ACS), 2) the effect of glycemia on the outcome, and 3) the association of plasma levels of insulin and proinsulin with ACS. RESEARCH DESIGN AND METHODS: A total of 146 nondiabetic subjects (121 men, 25 women) with ACS admitted to two hospitals in 1 year were enrolled. Random blood glucose at admission and a standard oral glucose tolerance test within 3 days were done. Glucose tolerance was categorized as normal glucose tolerance, impaired glucose tolerance (IGT) or impaired fasting glucose, and diabetes. Diabetes was arbitrarily classified further as undiagnosed (HbA1c [A1C] >6.0%) or possibly stress diabetes (A1C <6.0%). Subjects not on antidiabetic treatment were reassessed with a glucose tolerance test between 1 and 2 months. Fasting plasma specific insulin, proinsulin, their molar ratios, and insulin resistance (homeostasis model assessment) were estimated at baseline. RESULTS: Mean age of the cohort was 55 +/- 10.6 (SD) years. At baseline, 24 (16.4%) had normal glucose tolerance, 67 (45.9%) had IGT or impaired fasting glucose, and 55 (37%) had diabetes (35 [24%] were undiagnosed and 20 [13.7%] had stress diabetes). At follow-up, 53 of 92 responders (57.6%) continued to have IGT or diabetes. Mean baseline plasma insulin, proinsulin and its ratios, and insulin resistance were higher than normal in all subgroups. CONCLUSIONS: Nondiabetic Asian Indians showed a high prevalence of hyperglycemia following ACS. ACS was associated with insulin resistance and increased levels of specific insulin, proinsulin, and high proinsulin-to-insulin ratios.     

老年急性冠脉综合征合并糖尿病患者冠脉造影分析

目的探讨老年急性冠脉综合征合并糖尿病患者冠状动脉病变的特点。方法对69例老年急性冠脉综合征患者行冠脉造影检查,其中合并2型糖尿病组21例,未合并糖尿病组48例,分析两组患者临床资料及冠脉病变特点。结果两组性别、年龄、肥胖、吸烟、高血压、高脂血症等差异均无统计学意义(P>0.05);与非合并糖尿病组比较,合并糖尿病组冠状动脉以多支血管病变为主(85.7%),其中合并三支血管病变差异有统计学意义[14(66.7)vs 17(35.4),P=0.016];合并糖尿病组重度狭窄或完全闭塞达(66.7%),其中重度狭窄90%≤D<99%与非糖尿病组比较差异有统计学意义[11(52.4)vs 11(22.9),P=0.016]。结论老年急性冠脉综合征合并糖尿病患者冠状动脉以三支血管病变为主,重度狭窄为主。     

Tackling the thrombotic burden in patients with acute coronary syndrome and diabetes mellitus

Patients with diabetes mellitus (DM) and coronary artery disease, particularly those presenting with acute coronary syndromes (ACS), have a higher risk of developing ischemic complications than their nondiabetic counterparts. Although ACS patients with DM benefit more than normoglycemic ACS patients from early coronary angiography and revascularization, they remain at a higher risk of complications following percutaneous coronary intervention and bypass surgery. The DM-associated prothrombotic state has been implicated in the pathogenesis of these complications and growing data supports the notion that potent platelet inhibition is of paramount importance in order to optimize outcomes of DM patients presenting with ACS. This article focuses on the evidence supporting the concept that augmented platelet reactivity and impaired responsiveness to oral antiplatelet agents are influential drivers of the increased propensity of DM patients with ACS to develop thrombotic complications. In particular, strategies to enhance platelet P2Y₁₂ receptor inhibition, a key factor to improve outcomes in this patient population, are reviewed.     

Tackling the thrombotic burden in patients with acute coronary syndrome and diabetes mellitus

Patients with diabetes mellitus (DM) and coronary artery disease, particularly those presenting with acute coronary syndromes (ACS), have a higher risk of developing ischemic complications than their nondiabetic counterparts. Although ACS patients with DM benefit more than normoglycemic ACS patients from early coronary angiography and revascularization, they remain at a higher risk of complications following percutaneous coronary intervention and bypass surgery. The DM-associated prothrombotic state has been implicated in the pathogenesis of these complications and growing data supports the notion that potent platelet inhibition is of paramount importance in order to optimize outcomes of DM patients presenting with ACS. This article focuses on the evidence supporting the concept that augmented platelet reactivity and impaired responsiveness to oral antiplatelet agents are influential drivers of the increased propensity of DM patients with ACS to develop thrombotic complications. In particular, strategies to enhance platelet P2Y(12) receptor inhibition, a key factor to improve outcomes in this patient population, are reviewed.     

Fibrinolysis in patients with acute coronary syndrome

The reperfusion therapy including both fibrinolytic therapy and primary percutaneous coronary intervention (PCI) has been established in patients with ST-segment elevation acute myocardial infarction (STEMI). Fibrinolysis has the advantage of universal availability and short time to administration. Because the benefit of fibrinolysis is directly related to the time from symptom onset to treatment as demonstrated in many studies, every effort must be made to minimize any delays between symptom onset and the initiation of a safe and effective reperfusion strategy in patients with STEMI. Although the benefit of fibrinolysis is limited by inadequate reperfusion or reocclusion of the infarct-related artery in a sizable portion of patients, fibrinolysis followed by planned PCI can be one of approaches in patients presenting within 2 or 3 hours from onset of STEMI.     

Hyperhomocysteinemia is a risk factor for coronary arteriosclerosis in Japanese patients with type 2 diabetes

OBJECTIVE: An increased plasma homocysteine level is an important risk factor for vascular disease, including coronary atherosclerosis, in the general population. However, the role of hyperhomocysteinemia in the development of coronary artery disease (CAD) in patients with type 2 diabetes is unknown. Therefore, we have endeavored to determine the relationship between plasma homocysteine levels and the presence of coronary arteriosclerosis in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: The study group consisted of 145 Japanese patients (95 men and 50 women) who underwent routine coronary angiography to assess chest pain or suspected CAD. Plasma total homocysteine level, lipid level, and parameters of fibrinolytic activity were measured. All patients were identified as diabetic or nondiabetic by the new American Diabetes Association (ADA) criteria. The diagnoses of all patients studied were confirmed by coronary angiography. The severity of coronary artery stenosis was quantified using CAD scoring on the basis of prior reports, and subjects were graded as nonstenotic, stenotic single-vessel, stenotic two-vessel, or stenotic three-vessel based on the number of stenotic coronary arteries. Patients were classified into two groups: those with stenotic vessels and those without stenotic vessels. RESULTS: The plasma homocysteine level was significantly higher in patients with than in patients without stenotic vessels (13.8 +/- 3.9 vs. 11.7 +/- 3.9 mumol/l, respectively; P = 0.0009). The number of stenotic coronary arteries, which was used to grade each case as nonstenotic, stenotic single-vessel, stenotic two-vessel, or stenotic three-vessel, was related only to the total homocysteine level in the diabetic (diabetes mellitus [DM]) group, but it was associated with lipoprotein(a) in the nondiabetic (non-diabetes mellitus [non-DM]) group. Spearman's rank correlation test demonstrated that the plasma homocysteine level was strongly correlated with CAD score, both in the entire study group and in the DM group (P = 0.003 for the entire group and P = 0.011 for the DM group). Hyperhomocysteinemia, which was defined as total homocysteine level > 14.0 mumol/l, was seen in 57 (39.3%) of the patients. The CAD score was highest in diabetic patients with hyperhomocysteinemia (P < 0.05). CONCLUSIONS: There seems to be a clear relationship between hyperhomocysteinemia and an increased risk of coronary arteriosclerosis in Japanese patients with type 2 diabetes.     

A prospective, randomized comparison of the metabolic effects of pioglitazone or rosiglitazone in patients with type 2 diabetes who were previously treated with troglitazone

OBJECTIVE: To characterize potential differences in glycemic control, plasma lipid level, and weight in a cohort of patients previously treated with troglitazone (TROG) who were switched to either pioglitazone or rosiglitazone. RESEARCH DESIGN AND METHODS: After a 2-week washout from TROG, 186 patients were randomly assigned to receive either pioglitazone (PIO) or rosiglitazone (ROSI). Weight, HbA(1c), and fasting lipid profile were documented before discontinuing TROG and at 4 months after starting either pioglitazone or rosiglitazone. Secondarily, the effect of concurrent medications on study outcomes was assessed. RESULTS: A total of 127 patients completed follow-up: 67 individuals in the PIO group (32 women, 35 men) and 60 individuals in the ROSI group (33 women, 27 men). There were no significant differences in gender mix, age, weight, fasting lipid profile, or HbA(1c) between the ROSI and PIO groups. After 4 months of randomized treatment, no change in HbA(1c) from baseline between or within groups was noted. Both groups experienced an equal and significant increase in weight from baseline of approximately 2.0 kg. Thiazolidinedione and HMG-CoA reductase inhibitor therapy had significant and independent effects on lipid profile (P < 0.005). Significant improvements in lipid profile were noted in the PIO group (P < 0.01), whereas none were detected with conversion to ROSI. Specifically, the PIO group experienced an average decrease in total cholesterol of approximately 20 mg/dl. CONCLUSIONS: Differing effects on lipid profile were apparent after random conversion from TROG to either PIO or ROSI, despite similar weight increase and glycemic control. The clinical significance of these differences remains to be determined, and further comparative research is warranted.     

Drug intolerance in patients with idiopathic environmental intolerance syndrome

The increasing rate of the idiopathic environmental intolerance (IEI) has been observed for the last decade. The aim of this report was to analyse the allergic component of the disease in particular relation to drug intolerance. Six patients with diagnosed IEI showed a positive skin test reaction to several commonly used antibiotics, nonsteroidal anti-inflammatory drugs, myorelaxants, verapamil, etc. In three cases, the thorough diagnosis of sensitivity to anaesthetic agents enabled to perform necessary surgical treatment, in others - facilitated the proper treatment of headaches and hypertension. Symptoms related to allergy contributed to the deterioration of IEI. Thus, a consultation of IEI patients by an allergologist seems to be of a substantial importance.     

急性冠状动脉综合征合并糖尿病临床特点分析与护理

目的探讨急性冠脉综合征（ACS）合并糖尿病患者的危险因素及并发严重并发症时的临床特点,提出相应的护理措施。方法回顾2008年6月—2009年6月我院收治ACS患者126例,针对有无糖尿病史,分析临床特点。结果①36.5%的ACS患者伴有糖尿病;②ACS合并糖尿病患者中有空腹血糖、血胆固醇和血甘油三酯水平高于非合并糖尿病组（P〈0.05）;③ACS合并糖尿病患者住院期间严重并发症的发生率及病死率明显高于非合并糖尿病组（P〈0.05）。结论 ACS合并糖尿病的患者其临床表现不典型,致死性并发症多,预后不良。积极治疗高危因素,采取正确的防治措施,能减少并发症,降低病死率。     

Electrocardiographic diagnosis in patients with acute coronary syndrome

Electrocardiographic role in a diagnosis of ischemic heart disease has still important value. As important electrocardiographic findings of myocardial ischemia, there are ST elevation or depression, increase high T wave (hyperacute T wave), negative T wave and negative U wave, but it is particularly important to compare those findings and manifestation. Because the patient can always carry it, event ECG is advantageous in that they can record electrocardiography by themselves when they have some symptom. It is necessary to have attention to what abnormal findings of the electrocardiogram which it is easy to be overlooked such as increase T wave or negative U wave appear in early stage of phase of acute coronary syndrome. When the patient has some symptom that acute coronary syndrome is thought about, it is necessary to record electrocardiograms on several times and to do follow up even if there is no electorcardiographic abnormalities at first recording.     

Carbohydrate exchange in patients with acute coronary syndrome

Blood sugar measurement may be important for determining therapeutic tactics in patients in urgent pathological conditions. The role of hyperglycemia in the development of acute myocardial ischemia is under constant study, because the risk of death from myocardial infarction (MI) in patients with diabetes mellitus (DM) is twice higher than in those who do not suffer from DM. Having studied literature data, presented in the article, the authors report preliminary results of their work. Carbohydrate exchange disturbances are found almost in a half (49.1%) of patients with acute coronary syndrome (ACS). In patients with substantial and severe ACS manifestations that were considered to be those of acute myocardial infarction (MI) with ST interval elevation, as well as in patients with a repeated MI, carbohydrate exchange disorder was revealed in 65% and 77% of cases. In 30% of patients with a repeated MI, and in 14% of patients with MI with ST interval elevation, hyperglycemia was transient and disappeared on its own. Evaluation of this group of patients revealed type 2 DM in 44% of cases, which once more confirmed the information that DM patients were more liable to atherothrombosis. In half of the patients DM was newly revealed. This can be explained by the fact that a stressful situation urged revealing of the disease, which otherwise could be concealed. Data that suggest a higher hyperglycemia level in patients who finally could not be saved are of certain importance.     

Statin treatment in patients with acute coronary syndrome

In PROVE IT trial, intensive lipid-lowering therapy with statin (80 mg of atorvastatin daily) provides greater protection against cardiovascular events than does a standard regimen (40 mg of pravastatin daily) in patients with acute coronary syndrome (ACS), indicating that such patients benefit from early and continued lowering of LDL cholesterol to levels substantially below current target levels. However, differences between Japanese and Westerns as far as atherogenesis and response to statins are concerned, remain an unsolved problem that requires additional investigation. New guideline for the management of patients with ACS is needed for Japanese patients.