2014, Volume 21, Issue 4, pages 121–160

Hypoglycaemia is defined as a lower than normal level of blood glucose, and in patients on glucose-lowering therapy, defined as glucose levels less than 4 mmol/L. In the UK, it is usually classified as ‘mild’, if the episode is self-treated, or ‘severe’, if the individual requires third-party assistance. However, the American Diabetes Association definition of hypoglycaemia is different.¹ They classify hypoglycaemia into five categories. These are shown in table 1. 

Non-adherence to medication for chronic conditions, whether this involves tablets, inhalers, injections or other drug delivery systems, is a serious healthcare problem resulting in poor clinical outcomes and high costs. Here, we review the extent of the problem and the development of a novel evidence-based digital tool to support healthcare professionals (HCPs) in assessing and potentially improving the adherence of chronic patients. 

HCPs are increasingly focusing on developing interventions to address this problem. However, the development of effective adherence interventions is challenging; it involves finding the individual root causes of non-adherence, with the added difficulty of introducing and maintaining behavioural change, and offering tailored solutions that address the specific needs of a particular patient.

Identification of those at low risk of developing heart failure (HF) after acute coronary syndrome (ACS) would aid clinical management, but it is unclear whether N-terminal pro-brain natriuretic peptide (NT-proBNP) adds to the predictive accuracy of troponin. There were 229 subjects recruited into a prospective cohort study. Subjects were assessed for acute heart failure (AHF) prior to discharge and for readmission within 30 days of their ACS event (cohorts A+B). Cohort A (n=116) were further assessed for readmission within 12 months. Troponin I (TnI) and NT-proBNP levels were measured at ACS onset and at 6–12 hours. Readmissions were identified using electronic records. In total, 23.6% of subjects developed AHF during the index admission: 10.0% were readmitted within 30 days of admission; 17.2% within three months; 26.7% within six months and 36.2% within 12 months. At presentation, NT-proBNP, but not TnI, was significantly elevated among subjects who developed AHF compared with non-AHF subjects. Compared with non-readmitted subjects, readmission within 30 days was associated with significantly lower baseline NT-proBNP, and readmission after 30 days with higher baseline NT-proBNP. For all periods, TnI level was lower among readmitted compared with non-readmitted subjects. In conclusion, NT-proBNP has a potential role for rule out of those at low risk of AHF development and readmission. 

In a previous issue of the BJC, key issues regarding the use of high-sensitivity troponin and its use in clinical context were raised.¹ Despite the clear benefits with regards to earlier identification of ‘troponin-positive patients’, it is vital to highlight that troponin is specific for myocardial injury, but is not specific for the diagnosis of acute myocardial infarction (MI). Echocardiography is increasingly being used in cases where a ‘troponin-positive event’ is out of keeping with the history and examination for a type I MI. Competent use of this imaging modality can have drastic alterations in the management of patients and potentially prevent invasive cardiological procedures that may later provide more risk than benefit. This case report highlights the caution we must take when requesting troponin biomarkers and the use of echocardiography to aid in the management of the haemodynamically unstable patient.

This study aimed to assess mortality and cardiovascular (CV) outcomes of patients with newly diagnosed atrial fibrillation (AF) managed in the UK primary care setting. Electronic patient records in The Health Improvement Network were used to identify incident AF (n=9,418, 52.1% male, mean age 73.8 years [standard deviation 11.2]) and matched (gender, age and locality) controls (n=47,090) aged ≥40 years. Three main study outcomes were assessed within two years of follow-up: incident CV outcomes, CV mortality and all-cause mortality. AF cases had an increased risk of developing all investigated CV outcomes when compared with controls (systemic hypertension relative risk [RR]=1.9 [95% confidence interval 1.7–2.1]; peripheral thromboembolic events RR=2.0 [1.8–2.4]; congestive heart failure RR=13.1 [11.5–14.8]; valvular heart disease RR=7.0 [6.0–8.1]; ischaemic heart disease RR=4.3 [3.8–4.8]; stroke RR=3.7 [3.3–4.2]; myocardial infarction RR=3.1 [2.6–3.6]). AF patients were also twice (RR=2.0 [1.8–2.1]) as likely to die from all causes and almost three times (RR=2.7 [2.4–3.1]) more likely to die from CV reasons than controls. AF cases demonstrated consistently worse prognosis across all of the main outcomes assessed when compared with the control patients. 

Hypoglycaemia is defined as a lower than normal level of blood glucose, and in patients on glucose-lowering therapy, defined as glucose levels less than 4 mmol/L. In the UK, it is usually classified as ‘mild’, if the episode is self-treated, or ‘severe’, if the individual requires third-party assistance. However, the American Diabetes Association definition of hypoglycaemia is different.¹ They classify hypoglycaemia into five categories. These are shown in table 1. 

Earlier reports suggest differences in presentation between South Asians and white Europeans experiencing acute coronary syndromes. To compare the demographics and presentation of British South Asians, a long-term prospective survey of a consecutive series of British South Asians was conducted. South Asian patients were analysed as six distinct subgroups, with an overall comparison to a white European cohort.

South Asian patients were of similar mean age, and male predominance (66%), across all subgroups, but as a whole, were younger (62 ± 13 years) than white Europeans (69 ± 14 years), p<0.001. Diabetes was markedly more prevalent in South Asians (range 42–55%) compared with white Europeans (17%), p<0.001. South Asians, as a whole, reported a larger average area of discomfort (5.2 ± 3.5) than did white Europeans (4.4 ± 3.1), p<0.001. Posterior chest discomfort was reported by 38% of all South Asians (range 35–44%) and by 25% of white Europeans, p<0.001. The average intensity of discomfort was similar between white Europeans (6.4 ± 3.2) and South Asian cohorts (6.4 ± 3.0), p=0.80. Differences in ‘intensity of discomfort’ between South Asian subgroups did not reach significance. Silent cardiac events were more common in white Europeans (12.7%) than in South Asians (9.0%), p<0.001.

In conclusion, Asian patients were younger, more likely to be diabetic and tended to report discomfort over a greater area of their body, than did white Europeans. No differences were found between individual South Asian subgroups for pain distribution (extent), character or intensity. South Asian women tended to report a wider distribution of discomfort and intensity than did men across all subgroups.

We present an investigation into the use of electrocardiograms (ECGs) in an emergency setting.