Detection of glucose abnormalities in patients with acute coronary heart disease: study of reliable tools in clinical practice.

AIM: To investigate the prevalence of glucose abnormalities in patients with acute coronary syndrome and to assess the reliability of certain clinical or analytical variables to predict a pathologic result of oral glucose tolerance test (OGTT) at 3 months from discharge. SUBJECTS AND METHODS: Prospective study of 102 patients admitted to the coronary care units. Patients were classified according to the American Diabetes Association criteria. Three months after discharge, an OGTT was performed to non-diabetic patients. RESULTS: Forty-six (45.1%) patients were identified as diabetic (5 previously undiagnosed) and 56 (54.9%) as non-diabetic. OGTT identified 22% of diabetes, 33% of impaired glucose tolerance, and 45% of normal glucose tolerance. Fasting glucose (r=0.55, p<0.001), glycated hemoglobin (HbA1c) (r=0.46, p<0.001), low HDL cholesterol (HDLc) levels (r=-0.34, p<0.02), waist-hip ratio (r=0.45, p<0.01), high systolic blood pressure (r=0.5, p<0.01), and presence of acute myocardial infarction (r=0.46, p<0.001) at admission resulted significant to predict a pathologic result of OGTT. CONCLUSIONS: Glucose abnormalities are frequent in acute coronary syndrome patients. Certain clinical and analytical markers at admission such as fasting glucose, HbA1c, HDL-c<40 mg/dl, waist-hip ratio, and systolic blood pressure, are useful to recognize patients with a higher predisposition to present a pathologic result in OGTT at 3 months from discharge.

Implementación de la estrategia basal plus en la práctica clínica / Basal plus strategy implementation in clinical practice

El tratamiento con insulina puede ser necesario en la diabetes tipo 2, dado que muchos pacientes, con el tiempo, no consiguen alcanzar o mantener los objetivos glucémicos para prevenir las complicaciones crónicas asociadas a la hiperglucemia sostenida. Inicialmente, la adición de insulina basal al tratamiento previo con agentes orales suele ser la pauta más habitual. Esta estrategia se basa en el control óptimo de la glucemia en ayunas. Sin embargo, un porcentaje significativo de pacientes no consiguen alcanzar o mantener el objetivo de HbA1c <=7%, debido a que presentan elevaciones excesivas de la glucemia posprandial. En consecuencia, el paso siguiente en la intensificación deltratamiento podría ser la adición de una dosis única de insulina prandial antes de la comida que provoca la mayor excursión posprandial (estrategia basal plus), manteniendo el tratamiento previo con insulina basal y agentes orales. Este régimen ha demostrado ser sencillo, eficaz y adecuado para un gran número de pacientes. Además, en caso necesario, facilita la introducción progresiva de inyecciones adicionales de insulina prandial hasta una estrategia bolo basal. En este artículo se resumen las recomendaciones de un grupo de trabajo multidisciplinar para una adecuada implementación de la estrategia basal plus en la práctica clínica habitual (AU)

Insulin treatment may be necessary in type 2 diabetes, because many patients are not able overthe time to achieve or maintain glycemic targets to prevent chronic complications associated to sustained hyperglycemia. Initially, addition of basal insulin to previous treatment with oral agentsis the most commonly used regimen. This strategy is based on optimal control of fasting plasma glucose. However, a significant proportion of patients does not achieve or maintain HbA1c target <=7%, because they show excessive postprandial glucose values. Therefore, the next step for intensification of treatment might be the addition of a single dose of prandial insulin before the main meal, which is associated with the greatest postprandial glucose excursion (basal plus strategy), maintaining previous treatment with basal insulin and oral agents. This regimen has demonstrated to be easy to use, effective and appropriate for many patients. Furthermore, if necessary, it makes easier progressive introduction of additional injections of prandial insulin until the basal bolus strategy. In this manuscript, recommendations from a multidisciplinary working group are summarized for an adequate implementation of the basal plus strategy in the routine clinical practice (AU)

Tratamiento farmacológico de la emergencia hipertensiva / Farmacological treatment of the hipertensive emergency

Se presenta la emergencia hipertensiva desde varios puntos de vista. Se define la entidad, se abordaron las diferentes formas de presentación así como las causas que la producen. Se expone el tratamiento de elección para cada complicación, con dosis, vía de administración y efectos adversos (AU)

[Course of cardiac autonomic neuropathy in diabetic patients++ depending on the degree of metabolic control]. / Evolución de la neuropatía autónoma cardíaca en diabéticos según el grado de control metabólico.

Thirty-one diabetic subjects, 19 males and 12 females, with a mean age of 40.5 +/- 14.0 years, 17 of whom were insulin dependent (IDDM) and 14 non-insulin dependent (NIDDM) treated with insulin and diet, were followed for a period of six months. Patients were diagnosed of diabetic autonomic cardiopathy (without other neuropathy causes, nor use of drugs except for insulin) by the alteration of at least 2 of the 5 cardiovascular tests (tCV) performed. Patients underwent an educational diabetes program and self-control, and after 6 months of treatment they were divided into two groups according to the degree of metabolic control. In group 1, in which there was a good control with mean blood sugar levels of 108 +/- 12 mg/dl (5.9 +/- 0.6 mmol/l) and triglycerides of 101 +/- 21 (1.1 +/- 0.2 mmol/l), an improvement in tCV was observed: Valsalva coefficient of 1.16 +/- 0.13 and 1.22 +/- 0.13 (initial and final respectively) (p less than 0.001), with and improvement in 56% of cases; E/I (expiration/inspiration) ratio increased from 1.13 +/- 0.11 to 1.21 +/- 0.11, improving 53% of cases (p less than 0.001); 30/50 index (RR in 30/RR beat in beat 15 after orthostatism) (n.s.); difference in systolic arterial pressure after standing (p less than 0.001) and increase in diastolic arterial pressure with isometric muscular exercise (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

[Protein malnutrition in insulin-dependent or type I diabetes mellitus. Relationship with the degree of metabolic control]. / Malnutrición proteica en la diabetes mellitus insulinodependiente o tipo I. Relación con el grado de control metabólico.

Fifty-eight insulin-dependent diabetic (IDDM) patients with a disease duration of more than three years were evaluated and divided in three groups depending on the mean sugar blood levels in a three month follow-up. In the first group sugar blood level was lower than 7.7 mmol/l, in the second group it was between 7.7 and 11.1 mmol/l, and in the third group it was higher than 11.1 mmol/l. The nutritional status was evaluated. Protein malnutrition was found in 50% of the evaluated subjects, with a significant relation between the degree of metabolic control and the prevalence of protein malnutrition. In group I (sugar blood level less than 7.7 mmol/l) the prevalence of malnutrition was 31%, whereas in groups II and III (greater than 7.7 mmol/l) it was 54% and 61%, respectively. We discuss the importance to evaluate the nutritional status in diabetic patients, as protein malnutrition is a significant cause of general morbidity and mortality, which can be added to those attributable to diabetes itself.

[Course of peripheral diabetic neuropathy depending on the metabolic control after 6 months of follow-up]. / Evolución de la neuropatía diabética periférica según el control metabólico después de 6 meses de seguimiento.

We evaluated 40 diabetic patients (with a duration of the disease longer than 10 years) with diabetic neuropathy, to assess the effect of a good metabolic control maintained for six months on the nervous conduction velocity. The motor nervous conduction velocity (NCV) and the sensory latency and potentials were evaluated in the median and external popliteal nerves. In the groups of patients with a good metabolic control (mean basal glucose blood levels 109 +/- 12 mg/dl, or 6.04 +/- 0.66 mmol/l) there was a significant clinical improvement with improved test results; the NCV if the external popliteal nerve changed from 40.5 +/- 5.9 m/sec to 43.5 +/- 5.8 m/sec (p less than 0.05). An improvement of motor involvement and sensory potentials were found in 35 and 20%, respectively, of group I patients. The differences with those patients without a good metabolic control, in whom no study parameter improved, were significant. These studies apparently show a good metabolic control may reverse or at least improve diabetic neuropathy. However, wider studies are required to elucidate whether diabetic neuropathy is reversible or not.