Prognostic value of plasma soluble P-selectin and von Willebrand factor as indices of platelet activation and endothelial damage/dysfunction in high-risk patients with hypertension: a sub-study of the Anglo-Scandinavian Cardiac Outcomes Trial.

BACKGROUND: Abnormal levels of prothrombotic markers have been described in hypertension, but no such marker has yet been shown to reliably predict cardiovascular outcomes in hypertension. We hypothesized that raised circulating levels of soluble P-selectin (sP-sel, an index of platelet activation) and/or von Willebrand factor (vWF, an index of endothelial damage/dysfunction) would predict vascular events in patients treated for cardiovascular risk. METHODS: We measured vWF and sP-sel levels by an ELISA in 234 hypertensive participants with no prior cardiovascular events who were participating in the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT). Plasma vWF and sP-sel levels were related to the subsequent cardiovascular events over a mean (SD) follow-up period of 59.6 (19) months. RESULTS: Plasma sP-sel was a significant predictor of myocardial infarction (P = 0.03), with the greatest risk amongst those with the highest sP-sel levels. sP-sel did not predict cerebrovascular events (P = 0.53) or composite cardiovascular events (P = 0.06). No significant relationships were found between vWF levels and outcomes. There was no relationship to the presence or absence of diabetes mellitus (DM) at baseline or subsequent development of DM during the follow-up period. CONCLUSIONS: Among 'high-risk' patients with hypertension, raised levels of sP-sel (platelet activation) were predictive of myocardial infarction. Levels of vWF (endothelial damage/dysfunction) were not associated with coronary events and neither marker predicted cerebrovascular or composite cardiovascular endpoints. Platelets (or P-selectin) might represent a target for novel therapies or an adjunctive aid to risk stratification in the setting of hypertension.

Preconception care of women attending adult general diabetes clinics--are we doing enough?

BACKGROUND: The presence of diabetes in pregnancy can result in substantial morbidity to both mother and baby if management is sub-optimal. AIMS: To assess the process of standards of preconception care (against the National Service Framework standards) of women attending the adult general diabetes clinics in a district general hospital. METHODS: Retrospective review of case notes of women aged 18-40 years attending the general diabetes clinics for annual review, over a period of 6 months. RESULTS: Seventy sets of notes were reviewed. The mean age of the patients was 32 years. Fifty-six patients had type-1 diabetes and 14 patients had type-2 diabetes. Mean duration of diabetes was 13 years. Eighty-six percent of the patients had blood pressure recordings documented. Mean blood pressure was 124/74 mmHg. Mean HbA1c was 9.1%. Documented evidence of home blood glucose monitoring was seen in 66% of the patients. Preconception counselling/contraception were discussed in 17 patients (25%). Twenty-nine patients (41%) were on potentially teratogenic medications. Alcohol and smoking history was not documented in 91% and 61% of the patients, respectively. CONCLUSIONS: This retrospective assessment highlights that reproductive issues in an at risk population of women with diabetes are not included in routine management of diabetes care in outpatient clinics.

Treating dyslipidaemia in the setting of diabetes mellitus and cardiovascular disease: a less commonly perceived therapeutic perspective in clinical practice.

Diabetes mellitus and cardiovascular disease are being managed more belligerently in recent times, with multifactorial cardiovascular risk reduction being the focus of therapeutic interventions. We review some of the caveats to be exercised in the treatment of these patients that are pertinent to clinicians in daily clinical practice.

An assessment of the coverage of a district-wide diabetic retinopathy screening service.

AIMS: To assess the coverage of the diabetes retinopathy screening service (DRSS) in North Staffordshire, to identify patient characteristies associated with non-attendance and to assess the proportion of patients with diabetic retinopathy who achieved glycaemic and blood pressure (BP) control targets. METHODS: Data for all patients who underwent annual retinal screening between 1 May 2000 and 30 April 2001 were obtained from the North Staffordshire Diabetes Register. Age, gender, ethnicity, socio-economic status, type and duration of diabetes were compared between patients who underwent eye screening and those who did not. Frequencies of patients who achieved glycaemic and BP targets in these groups of patients were compared to the remaining patients. RESULTS: 5646 of the 11682 (48%) patients on the diabetes register underwent retinal screening during the year. Patients with Type 2 diabetes, older patients, patients belonging to ethnic minorities and those wholly managed in primary care were less likely to attend for eye screening (P < 0.05 for all groups) with ethnic minority or primary care management demonstrating independent influence (P < 0.001). The percentage of patients with retinopathy achieving HbA1c and systolic BP targets was significantly lower than in their unaffected counterparts (chi2 = 63, P < 0.001 and chi2 = 71, P < 0.001 respectively). CONCLUSIONS: The efficacy of the DRSS in North Staffordshire is low and might be improved by targeting specific patient groups. Glycaemic control and systolic BP control needs to be improved in patients with diabetic retinopathy.

Type 2 diabetes mellitus: a cardiovascular perspective.

Diabetes mellitus is a disease, which is at the epitome of cardiovascular risk factors causing considerable morbidity and mortality. In addition to microvascular complications, there is two- to six-fold increased risk of macrovascular diseases, such as coronary artery disease, peripheral artery disease and stroke. While the mortality from coronary artery disease in patients without diabetes has declined over the past 20 years, the mortality in men with type 2 diabetes mellitus has not changed. Furthermore, the prevalence of diabetes in the UK has increased by 30% since 1991 and the same among the world population in 2010 is expected to be twice in 1990. This dramatic increase has serious implications from a cardiovascular perspective and thus the aggressive management of blood pressure, dyslipidaemia and blood glucose in diabetes is of vital importance. The aim of this review is to evaluate the current evidence and to discuss the implications of type 2 diabetes and its relevance to clinical practice in cardiology. We address this broad subject in discussing (i) the pathophysiology of cardiovascular disease in the setting of type 2 diabetes and (ii) the prevalence of cardiovascular risk, complications and prognostic implications in type 2 diabetes, with a discussion of current therapeutic interventions for the prevention or delay of these consequences where relevant.

Picture Quiz: Abdominal Pain in a patient receiving low molecular weight heparin.

A 63 year old lady with known ischaemic heart disease was admitted to hospital with cardiac sounding chest pain. Blood pressure was 161/80 on admission, and full examination was unremarkable. ECG showed ischaemic changes in the inferior leads, and a diagnosis of unstable angina was made. Troponin I was undetectable. She was treated with subcutaneous Enoxaparin 1.5mg/kg and an intravenous nitrate infusion. Her pain settled the following day, allowing the nitrate infusion to be weaned off, although the Enoxaparin treatment was continued, pending a cardiology opinion. On the third day after admission she collapsed on the ward with a blood pressure of 95/59mmHg; examination revealed lower abdominal tenderness with a mass in the right iliac fossa. Blood tests showed that her haemoglobin had dropped by 5 grams/decilitre,she underwent urgent abdominal ultrasound followed by CT.