Clinical articles

Cardiovascular disease is a major cause of death in patients with type 2 diabetes mellitus (T2DM) and multiple lipid abnormalities are common. Niacin effectively treats diabetic dyslipidaemia and reduces cardiovascular events in high-risk patients. We evaluated the lipid-altering efficacy and safety (especially, glycaemic control) of extended-release niacin/laropiprant (ERN/LRPT; a tablet containing 1 g ERN and 20 mg LRPT) in patients with T2DM. In this multi-centre, double-blind, placebo-controlled, 36-week study, patients (n=796) were randomised 4:3 to ERN/LRPT or placebo. After four weeks at 1 g/day, ERN/LRPT was doubled to 2 g/day (two tablets) for the remainder of the study. The vast majority of randomised patients (~90%) were dyslipidaemic based on medical history or baseline lipid levels; approximately 80% were taking statins and 99% were on an antihyperglycaemic regimen.

At week 12, ERN/LRPT produced significant (p≤0.001 for all) percentage changes from baseline in low-density lipoprotein cholesterol (LDL-C) (–17.9%), high-density lipoprotein cholesterol (HDL-C) (23.2%), LDL-C:HDL-C (–32.0%), triglycerides (–23.1%), apolipoprotein (Apo) B (–17.1%), Apo A-I (8.2%) and total cholesterol (TC):HDL-C (–22.9%) versus placebo. The clinical and laboratory adverse events that occurred more frequently in the ERN/LRPT group versus the placebo group were pruritus, rash, flushing, gastrointestinal upset and elevations in alanine aminotransferase, aspartate aminotransferase, fasting plasma glucose (FPG) and glycosylated haemoglobin (HbA_1c). From baseline to week 36, median FPG and HbA_1c increased with ERN/LRPT from 7.31 to 7.88 mmol/L and 6.9 to 7.3%, respectively, consistent with known niacin effects. More patients in the ERN/LRPT group required intensified antihyperglycaemic therapy (17.6% vs. 8.2%; p≤0.001). In this population of patients with T2DM, ERN/LRPT produced significant, durable improvements in lipids/lipoproteins and had a safety profile consistent with ERN/LRPT and ERN alone in other populations.

In this series of articles looking at contemporary ways to image atherosclerosis, we have covered the main techniques used in the UK as diagnostic tools and research modalities. For this final article, I have chosen to concentrate on new technologies that show promise for the future.

The outcome and complications of atrial fibrillation (AF) ablation in a UK patient cohort were investigated by offering symptomatic, drug-refractory patients ablation. Treatment goals were to disconnect all pulmonary veins electrically and improve symptoms using a state-of-the-art ablation method. Outcomes were defined as: ‘success’ (no symptoms or Holter AF); ‘partial success’ (substantially reduced AF symptoms); ‘clinical success’ (‘success’ and ‘partial success’); ‘failure’ (no symptom improvement).

Sulphonylureas are well established in the treatment of type 2 diabetes mellitus. They are effective in improving glycaemic control and preventing microvascular complications. Side effects that can restrict use include hypoglycaemia and weight gain. Although there is no clear evidence for reduction of cardiovascular disease from randomised-controlled trials, follow-up data from the United Kingdom Prospective Diabetes Study (UKPDS) shows reduced cardiovascular risk. Concerns about sulphonylureas causing inhibition of ischaemic preconditioning are relevant in primary angioplasty, but there is a lack of clear evidence, with a need for randomised-controlled trials to investigate this further.

Cardiac auscultation is a critical part of the clinical examination. In this review we discuss the conventional approach to teaching and using the skill of cardiac auscultation. We then consider how recent technological advances may improve the teaching and implementation of this essential clinical skill.

The number of patients with aortic stenosis (AS) in the UK is increasing. Patients with non-significant AS can be safely reviewed in technician-led clinics. The potential impact of this on healthcare services is unreported. The aim of this study was to describe the impact of establishing an AS surveillance clinic in a district general hospital setting and consider the potential impact of widespread implementation.

In recent years a large amount of research has focused on developing both invasive and non-invasive methods of assessing atherosclerosis. In this regard, magnetic resonance imaging (MRI) is safe, non-invasive, requires no ionising radiation, and is capable of giving high-resolution images of atherosclerotic plaque. As a result, MRI has been extensively applied to imaging of the vascular system – in particular, the carotid arteries – where it has been shown to have the ability to not only accurately quantify the extent of atherosclerotic plaque disease, but also to identify several compositional features suggestive of plaque vulnerability. Imaging of the relatively small coronary arteries has, until now, been limited by the problems of cardiac and respiratory motion, however, more recently, technological advancements have allowed more detailed plaque information to be acquired. This article will review the origins of MRI imaging of atherosclerotic disease, its current status, and its potential future applications.

A 66-year-old male presented with increasing dyspnoea. He was an ex-smoker and had been diagnosed with stage IV undifferentiated large cell carcinoma of the left lung two months previously. Clinical examination revealed signs consistent with cardiac tamponade. Cardiac tamponade, a life-threatening condition, is a continuum of haemodynamic compromise, initiated by a collection of fluid in the pericardial space causing an increase in intra-pericardial pressure and cardiac compression. Transthoracic echocardiography confirmed the presence of a large global pericardial effusion with echocardiographic signs of cardiac tamponade (figure 1A and 1B).

Cerebrogenic control of cardiac function is well recognised and acute neurological events, including epileptic seizures, may cause a disturbance of cardiac function even in the absence of significant cardiac structural or electrophysiological abnormalities. Sudden unexpected death in epilepsy (SUDEP) is a major cause of mortality in patients with epilepsy. Cardiac dysrhythmias are a potential cause of SUDEP.

Metformin is one of the oldest oral treatments to reduce hyperglycaemia in people with diabetes. Gastrointestinal side effects are common, and metformin should be used with caution in patients with renal impairment because of the slight risk of lactic acidosis. In the United Kingdom Prospective Diabetes Study (UKPDS) patients treated with metformin had a significant reduction in myocardial infarction and mortality that was not demonstrated in patients treated with sulphonylureas or insulin. The fact that metformin significantly reduces cardiovascular events plus reduces weight has meant that metformin is the drug of first choice in guidelines for the treatment of type 2 diabetes. There are no longer concerns about using metformin in patients with chronic heart failure, other than in patients with associated renal failure, or during episodes of acute left ventricular failure when metformin should be temporarily stopped.