Impaired glucose regulation, elevated glycated haemoglobin and cardiac ischaemic events in vascular surgery patients.

AIMS: Cardiac morbidity and mortality is high in patients undergoing high-risk surgery. This study investigated whether impaired glucose regulation and elevated glycated haemoglobin (HbA(1c)) levels are associated with increased cardiac ischaemic events in vascular surgery patients. METHODS: Baseline glucose and HbA(1c) were measured in 401 vascular surgery patients. Glucose < 5.6 mmol/l was defined as normal. Fasting glucose 5.6-7.0 mmol/l or random glucose 5.6-11.1 mmol/l was defined as impaired glucose regulation. Fasting glucose > or = 7.0 or random glucose > or = 11.1 mmol/l was defined as diabetes. Perioperative ischaemia was identified by 72-h Holter monitoring. Troponin T was measured on days 1, 3 and 7 and before discharge. Cardiac death or Q-wave myocardial infarction was noted at 30-day and longer-term follow-up (mean 2.5 years). RESULTS: Mean (+/- sd) level for glucose was 6.3 +/- 2.3 mmol/l and for HbA(1c) 6.2 +/- 1.3%. Ischaemia, troponin release, 30-day and long-term cardiac events occurred in 27, 22, 6 and 17%, respectively. Using subjects with normal glucose levels as the reference category, multivariate analysis revealed that patients with impaired glucose regulation and diabetes were at 2.2- and 2.6-fold increased risk of ischaemia, 3.8- and 3.9-fold for troponin release, 4.3- and 4.8-fold for 30-day cardiac events and 1.9- and 3.1-fold for long-term cardiac events. Patients with HbA(1c) > 7.0% (n = 63, 16%) were at 2.8-fold, 2.1-fold, 5.3-fold and 5.6-fold increased risk for ischaemia, troponin release, 30-day and long-term cardiac events, respectively. CONCLUSIONS: Impaired glucose regulation and elevated HbA(1c) are risk factors for cardiac ischaemic events in vascular surgery patients.

Prognostic significance of declining ankle-brachial index values in patients with suspected or known peripheral arterial disease.

BACKGROUND: Peripheral arterial disease (PAD) is a risk factor for cardiovascular events. This study assessed the prognostic significance of repeated ankle-brachial index (ABI) measurements at rest and after exercise in patients with PAD receiving conservative treatment. METHODS: In a cohort study of 606 patients (mean age 62+/-12 years, 68% male), ABI at rest and after exercise was measured at baseline and after 1 year. Patients with reductions in ABI were divided into three equally-sized groups (minor, intermediate and major reductions) and were compared to patients without reductions. During a mean follow-up of 5+/-3 years, all-cause mortality, cardiac events, stroke and progression to kidney failure were noted. RESULTS: Death was recorded in 83 patients (14%) of which 49% were due to cardiac causes. Non-fatal myocardial infarction occurred in 38 patients (6%), stroke in 46 (8%) and progression to kidney failure in 35 (6%). By multivariate analysis, patients with major declines in resting (>20%) and post-exercise (>30%) ABI were at increased risk of all-cause mortality (HR: 3.3, 95% CI: 1.5-7.2, HR: 3.0, 95% CI: 1.4-6.4, respectively), cardiac events (HR: 3.1, 95% CI: 1.3-7.2, HR: 2.4, 95% CI: 1.1-5.6, respectively), stroke (HR: 4.2, 95% CI: 1.6-10.4, HR: 3.9, 95% CI: 1.4-10.2, respectively) and kidney failure (HR: 2.7, 95% CI: 1.1-7.5, HR: 6.9, 95% CI: 1.5-31.5, respectively), compared to patients with no declines in ABI. CONCLUSIONS: This study shows that major 1-year declines in resting and post-exercise ABI are associated with all-cause mortality, cardiac events, stroke and kidney failure in patients with PAD.

Abdominal aortic aneurysm screening using non-imaging hand-held ultrasound volume scanner--a pilot study.

BACKGROUND: Screening for abdominal aortic aneurysms (AAA) is cost-effective and timely repair improves outcome. Using standard ultrasound (US) an AAA can be accurately diagnosed or ruled-out. However, this requires training and bulk equipment. AIM: To evaluate the diagnostic potential of a new hand-held ultrasound bladder volume indicator (BVI) in the setting of AAA screening. METHODS: In total, 94 patients (66 +/- 14 years, 67 men) referred for atherosclerotic disease were screened for the presence of AAA (diameter > 30 mm using US). All patients underwent both examinations, with US and BVI. Using the BVI, aortic volume was measured at 6 pre-defined points. Maximal diameters (US) and volumes (BVI) were used for analyses. RESULTS: In 54 (57%) patients an AAA was diagnosed using US. The aortic diameter by US correlated closely with aortic volume by BVI (r = 0.87, p < 0.0001). Using a cut-off value of > or = 50 ml for the presence of AAA by BVI, sensitivity, specificity, positive and negative predictive value of BVI in detection of AAA were 94%, 82%, 88% and 92%, respectively. The agreement between the two methods was 89%, kappa 0.78. CONCLUSION: The bladder volume indicator is a promising tool in screening patients for AAA.

Increased distance between mitral valve coaptation point and mitral annular plane: significance and correlations in patients with heart failure.

OBJECTIVE: To measure the distance between the mitral leaflet coaptation point and the mitral annulus (CPMA) and assess the relation of this index to structural and functional characteristics of the failing left ventricle. DESIGN: Echocardiographic indices and CPMA were measured at baseline and again during dobutamine infusion and leg lifting. Left ventricular diastolic and systolic dimensions, left ventricular ejection fraction (LVEF) by Simpson's rule, mitral annulus dimension, and E point septal separation were correlated with CPMA. SETTING: Tertiary referral centre. PATIENTS: The total study population of 129 patients included 94 with LVEF < 35% and 35 with LVEF 35%-45%; 76 had coronary artery disease and 53 had dilated cardiomyopathy. INTERVENTIONS: A dobutamine infusion was given in 18 patients and preload increase by leg lifting in 28. MAIN OUTCOME MEASURES: Correlations between CPMA and contractility indices at baseline and during interventions. RESULTS: CPMA was correlated with left ventricular diastolic dimension (r = 0.52), left ventricular systolic dimension (r = 0.53), LVEF (r = -0.44), fractional shortening (r = -0.42), E point septal separation (r = 0.48), and mitral annulus dimension (r = 0.44) (all p < 0.001). Dobutamine decreased CPMA from (mean (SD)) 12.04 (3.64) mm to 8.92 (2.56) mm and increased LVEF from 27 (6.2)% at baseline to 33.4 (6.9)% at 10 microg/kg/min (both p < 0.001). These changes were strongly related (r = 0.68, p < 0.007). After leg lifting, CPMA decreased from 13 (4) mm at baseline to 10 (3) mm (p < 0.001), and LVEF increased from 32 (11)% at baseline to 39 (11)% (p < 0.001). Fractional shortening and left ventricular diastolic dimension also increased (p < 0.001) and mitral annulus dimension and E point septal separation decreased (p < 0.002), but left ventricular systolic dimension did not change. CONCLUSIONS: The mechanism displacing the mitral coaptation point towards the left ventricular apex is multifactorial. The correlations between CPMA difference (before versus after interventions) and ejection fraction difference (before versus after interventions) shows that this index depends mainly on left ventricular function.