Journals Watch - MI, hypertension and diabetes

Too busy to read all the latest journals? Let Dr Simon Hunter bring you up to date with the research.

In MI patients treated with PCI, raised plasma glucose on admission led to worse outcomes (Photograph: SPL)
In MI patients treated with PCI, raised plasma glucose on admission led to worse outcomes (Photograph: SPL)

Glucose levels in MI
Am Heart J 2010; 160; 412-9

The treatment of acute MI has advanced in recent years with early coronary angiography and percutaneous coronary intervention (PCI) being the standard, combined with the infrastructure to get patients to the right treatment centre quickly.

It is known that a raised plasma glucose level on admission leads to a worse prognosis when patients receive fibrinolytic therapy, so this study examined whether the same is the case with patients who received PCI.

The authors followed 1,185 MI patients over 63 months. Of these patients, 261 died. The results showed that a raised admission plasma glucose was associated with a worse prognosis, with each mmol/l increase in glucose leading to a 7 per cent increase in mortality, irrespective of diabetes status.

A patient with a glucose level greater than 11 mmol/l had a twofold increase in mortality compared with a patient with low glucose. The authors suggested that this is due to increased oxidative stress and increased coagulability.

GPs in A&E
Br J Gen Pract 2010; 60: 729-34

This study looked at the effectiveness of having a GP in a busy Amsterdam A&E department where a nurse triaged patients to either normal A&E care or to be seen by a GP.

Of the eligible patients, 73 per cent agreed to take part in the study. There was a control period where patients received the usual method of care, then they started the new method where 84 per cent of patients were sent to see the GP and 16 per cent to the A&E doctor.

Compared with before the intervention started, patient satisfaction was increased. There was a reduction in diagnostic tests by 13 per cent, with X-rays decreasing from 43 per cent to 30 per cent, and fewer therapeutic treatments.

The number of patients referred to their own GP for after care increased by 17 per cent and outpatient referrals fell by the same amount.

The accuracy of diagnosis was similar in each group, while the time the patient spent in the department fell.

Beta-blocker use in MI
Am Heart J 2010; 160; 435-42

It has been known for many years that beta-blockers improve survival post-MI but studies have shown they are being under prescribed.

This US study specifically looked at the dosages of beta-blockers that patients were receiving. They found that 93 per cent were taking a beta-blocker on discharge from hospital, but the dosages were lower than recommended.

Approximately 20 per cent received less than 25 per cent of the recommended dose, 36 per cent received 25 per cent of the recommended dose and 26 per cent received 26-50 per cent.

Consistent predictors of low beta-blocker doses were absence of hypertension, PCI, older age and no ACE inhibitor. As QOF measures usage and not dosage, the picture is likely to be the same in the UK.

Hypertension in the elderly
Am J Med 2010; 123: 719-26

The population of elderly patients with hypertension and CHD is increasing. However, most studies of treatment options use data from younger patients. In this study, patients over 80 years were studied.

The authors re-examined the data from the INVEST (international verapamil SR-trandolapril study) trial, focusing on the patients who were over 80 years old. They found these patients had higher systolic BP, lower diastolic BP and wider pulse pressures than younger patients.

Antihypertensive treatment was as successful in this age group as other age groups in decreasing systolic BP, diastolic BP and pulse pressures.

However, there was a J-shaped curve with adverse outcomes when treating these patients when decreasing BP. This occurs at around 140mm Hg systolic and 70mmHg diastolic BP. The effect was much more marked for systolic BP in this age group.

Patient language used to describe angina symptoms
Br J Gen Pract 2010; 60: 735-41

GPs often diagnose angina using Diamond and Forrester's classification of chest pain, which includes the site, character and duration of the pain as well as provoking and relieving factors. As chest pain is common and angina is rare in general practice, this is a useful guide. But patients do not always give an accurate description of their symptoms.This study questioned patients with proven angina, asking them to describe their symptoms.

Some described their symptoms in the classical form, while up to 30 per cent offered more complex descriptions that lay outside Diamond and Forrester's cannon of symptoms. For example, patients described pain as 'sharp'. There was also a degree of underplaying the symptoms, especially in those who had had a previous MI.

While the typical symptoms are a good framework, GPs should be aware of variations in language used to describe symptoms.

Peer support in diabetes
Ann Intern Med 2010; 153: 507-15

Most patients with diabetes are seen for clinic visits once or twice a year, but would benefit from self-management help between clinic visits.

This study compared two models: nurse-led care and reciprocal peer support - where patients were given a three- hour session in which an action plan was agreed, training in peer communication skills was given and they were matched with a peer of a similar age and encouraged to telephone each other once a week. They were also offered optional group sessions.

The outcome measured was a change in HbA1c levels at six months. In the nurse-led group, the mean HbA1c increased by 0.29 per cent (from 7.93 per cent to 8.22 per cent) whereas in the peer group the mean HbA1c decreased by 0.29 per cent.

This created a difference of 0.58 per cent between the two groups. The effect was more marked in patients with an HbA1c above 8 per cent, where the mean decrease was 0.88 per cent.

  • Dr Hunter is a GP in Bishops Waltham, Hampshire, and a member of our team who regularly review the journals.

Reflect on this article and add notes to your CPD Organiser on MIMS Learning

CPD IMPACT: Earn More Credits

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Audit patient attendance at A&E to see if there are any patients are using the service inappropriately.
  • Consider creating a protocol of checking the beta-blocker dose of patients discharged from hospital post-MI.
  • Perform a significant event audit on patients with atypical chest pain, which was subsequently diagnosed as angina, to ascertain if there were any signs or symptoms that were missed.

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