Treatment of cardiac risk factors in diabetic patients: How well do we follow the guidelines?

BACKGROUND: Diabetic patients are at increased risk for both macrovascular and microvascular disease compared with nondiabetic patients. METHODS: We conducted a prospective observational study to assess the control of multiple predetermined cardiovascular risk factors in 235 treated diabetic patients undergoing elective cardiac catheterization at our institution between December 20, 1997, and February 15, 2000. The following parameters were used to define optimal treatment in these patients: hemoglobin (Hgb) A1c <7%, low-density lipoprotein cholesterol (LDL-c) <100 mg/dL, high-density lipoprotein cholesterol (HDL-c) >/=45 mg/dL for men and >/=55 mg/dL for women, triglyceride (TG) level <200 mg/dL, blood pressure (BP) <130/85 mm Hg, body mass index (BMI) <25, daily aspirin therapy, and current nonsmoking status. The use of b-blockers and angiotensin-converting enzyme inhibitors was also evaluated. RESULTS: The average patient age was 64 +/- 11 years; 155 (65%) were male. One hundred ninety-one (81%) patients had documented coronary artery disease at cardiac catheterization. The mean Hgb A1c level for all diabetic patients was 8.2% +/- 1.6%. Overall, 49 (21%) had an Hgb A1c level <7%. The fasting cholesterol panel for all patients revealed a mean LDL-c level of 103 +/- 41 mg/dL, a mean HDL level of 39 +/- 11 mg/dL, and a mean TG level of 164 +/- 128 mg/dL. One hundred sixteen (52%) patients had an LDL-c <100 mg/dL. Only 32 of 147 (22%) male patients and 14 of 80 (18%) female patients achieved an HDL-c >/=45 mg/dL or >/=55 mg/dL, respectively. One hundred seventy-seven of 232 (76%) patients had a TG level <200 mg/dL. Only 23 of 233 (10%) diabetics were controlled to a BP of <130/85 mm Hg, and 25 (11%) achieved a BMI <25. Only one patient (0.4%) had optimal control of all modifiable risk factors. CONCLUSIONS: These data demonstrate the poor control of numerous cardiovascular risk factors in treated diabetics undergoing elective cardiac catheterization.

Effects of beta-adrenergic blocking therapy on left ventricular diastolic relaxation properties in patients with dilated cardiomyopathy.

BACKGROUND: The hemodynamic mechanism for the improvement in left ventricle (LV) end-diastolic pressure in cardiomyopathy patients treated with beta-adrenergic blocking agents is controversial. We hypothesized that the salutary effect of this kind of therapy on LV end-diastolic pressure would be indicative of an improvement in late, passive diastolic relaxation properties. METHODS AND RESULTS: We studied 14 cardiomyopathy patients in normal sinus rhythm with no arteriographic evidence of coronary artery disease and an LV ejection fraction of

Impact of vascular adaptation to chronic aortic regurgitation on left ventricular performance.

BACKGROUND: This investigation was designed to test the hypothesis that vascular adaptation occurs in patients with chronic aortic regurgitation to maintain left ventricular (LV) performance. METHODS AND RESULTS: Forty-five patients with chronic aortic regurgitation (mean age 50+/-14 years) were studied using a micromanometer LV catheter to obtain LV pressures and radionuclide ventriculography to obtain LV volumes during multiple loading conditions and right atrial pacing. These 45 patients were subgrouped according to their LV contractility (Ees) and ejection fraction values. Group I consisted of 24 patients with a normal Ees. Group IIa consisted of 10 patients with impaired Ees values (Ees <1.00 mm Hg/mL) but normal LV ejection fractions; Group IIb consisted of 11 patients with impaired contractility and reduced LV ejection fractions. The left ventricular-arterial coupling ratio, Ees/Ea, where Ea was calculated by dividing the LV end-systolic pressure by LV stroke volume, averaged 1.60+/-0.91 in Group I. It decreased to 0.91+/-0.27 in Group IIa (P<0.05 versus Group I), and it decreased further in Group IIb to 0.43+/-0.24 (P<0.001 versus Groups I and IIa). The LV ejection fractions were inversely related to the Ea values in both the normal and impaired contractility groups (r=-0.48, P<0.05 and r=-0.56, P<0.01, respectively), although the slopes of these relationships differed (P<0.05). The average LV work was maximal in Group IIa when the left ventricular-arterial coupling ratio was near 1.0 because of a significant decrease in total arterial elastance (P<0.01 versus Group I). In contrast, the decrease in the left ventricular-arterial coupling ratio in Group IIb was caused by an increase in total arterial elastance, effectively double loading the LV, contributing to a decrease in LV pump efficiency (P<0.01 versus Group IIa and P<0.001 versus Group I). CONCLUSIONS: Vascular adaptation may be heterogeneous in patients with chronic aortic regurgitation. In some, total arterial elastance decreases to maximize LV work and maintain LV performance, whereas in others, it increases, thereby double loading the LV, contributing to afterload excess and a deterioration in LV performance that is most prominent in those with impaired contractility.

Halothane-verapamil causes regional myocardial dysfunction in the dog.

Regional myocardial function was studied using sonomicrometry in six mongrel dogs, anaesthetized with halothane (1% inspired), as increasing doses of verapamil were given i.v. In addition to a gradual increase in end-diastolic length and a reduction in systolic shortening, an abnormal (paradoxical) contraction pattern appeared in the apical region. This occurred in the absence of coronary artery damage and at coronary perfusion pressures unlikely to result in ischaemia. Administration of verapamil in the presence of halothane results in regional dysfunction similar to that caused by the intracoronary administration of nifedipine.