Clinical articles

Increased attention to good glycaemic control in diabetic patients has encouraged more intensive use of insulin. To help achieve a steady ‘basal’ insulin supply, a new long-acting insulin analogue glargine (Lantus®) has been introduced. This provides a flatter ‘peakless’ circulating concentration of insulin than protamine (isophane) and lente insulins, facilitating dose escalation with reduced risk of hypoglycaemia. Another long-acting insulin analogue detemir (Levemir®) is advanced in development. Intensive insulin therapy requires ‘top-ups’ to coincide with mealtimes. The recently introduced rapid-acting monomeric analogues, lispro and aspart, are particularly useful in this respect. The monomeric analogues are quickly absorbed and short acting: hence they reduce post-prandial glucose excursions (which have been ascribed especial cardiovascular risk) with less risk of hypoglycaemia than conventional short-acting insulin. Premixed rapid-intermediate acting mixtures of monomeric analogues with protamine are also available. Continuous subcutaneous insulin infusion is receiving increased use as the pump technology advances, mainly incorporating the monomeric insulin analogues. Inhaled insulins continue in development, and various oral insulin formulations have entered clinical trials.

Atrial fibrillation (AF) is the commonest sustained arrhythmia affecting elderly people. It will become increasingly prevalent in Western societies, given the growing proportion of elderly people in these populations.>br> AF may lead to a variety of embolic phenomena, notably stroke. Furthermore, AF may complicate other conditions, such as hypertension and heart failure. AF is associated with an increased risk of death.
The management of AF can be a difficult problem, particularly in symptomatic, elderly patients. Results from recent large, multicentre clinical trials in sustained AF have demonstrated that a rate control strategy with conventional drugs, is at least as effective, and possibly superior, to rhythm control by chemical or electrical cardioversion over a three-year period. Whether these results can be extrapolated to longer time periods than the trials’ durations (approximately 3.5 years) is not known. Results from clinical trials of a new oral anticoagulant, ximelagatran, indicate that this agent is as good an anticoagulant as warfarin in sustained AF. Other results are awaited from on-going trials on the tolerability and side-effect profile of this drug. The possibility of an alternative anticoagulant which does not share warfarin’s need for routine monitoring of its anticoagulant effect, nor share warfarin’s potential for adverse interactions with other drugs, is very attractive, particularly in elderly patients.
In the longer term, radiofrequency ablation techniques might provide a more widely available, curative therapy, for elderly patients with AF.

Increasing numbers of patients are receiving warfarin therapy, with atrial fibrillation being the main indication. If warfarin therapy is to be effective, however, good therapeutic control is important. Recent advances in models of management, including primary care clinics and patient self-management, has meant that patients have an increasing choice as to how and where they have their warfarin monitored. Comparison of performance between these different models of care has been historically difficult due to the use of different reporting techniques. This paper highlights the different methods of reporting therapeutic control, including adverse event reporting, and recommends that at least two measures from a set of recognised parameters should be used. This makes comparison of control between centres possible.

The timing and effectiveness of a new protocol for organising direct current cardioversion (DCCV) for patients with atrial fibrillation (AF) was compared with the existing system in a medium-sized district general hospital in the United Kingdom. The new protocol comprised a monthly dedicated DCCV list in the operating theatres, with an anaesthetist and an Operating Department Assistant providing anaesthesia, and cardiology medical staff performing the cardioversion. The last 35 consecutive patients undergoing DCCV for AF before the new protocol was introduced were compared with the first 35 patients having DCCV under the new protocol.
The time to perform 35 consecutive cardioversions was reduced from 32 months to 10 months. The new system resulted in no cancellations for administrative reasons and only one patient for a clinical reason. Sinus rhythm (SR) was restored in 60% cases under the new protocol (double the success rate before the new protocol) and 76% patients discharged in SR under the new protocol, remained in SR at clinic follow-up.
A simple change in the method of delivering a clinical service has resulted in an improvement in both the administration and clinical outcome for patients. Such changes, requiring co-operation between anaesthetic and cardiology departments, could be implemented widely for the benefit of many patients.

This article explores the strengths and weaknesses of current treatment pathways of atrial fibrillation as discussed at a multidisciplinary meeting of healthcare professionals organised by the Thrombosis Quorum. By discussing case studies using a Socratic method of dialogue to elicit better questioning of management practices, the meeting reached a consensus on various issues in the care of the patient with atrial fibrillation.

With an ageing population in the United Kingdom, atrial fibrillation has become an increasing cause of morbidity and mortality, and a burden on health resources. Drug therapies for the management of atrial fibrillation have a number of roles, including the restoration and maintenance of sinus rhythm and the prevention of thrombo-embolic complications. New anti-arrhythmic drugs are under development and alternatives to warfarin are being investigated. This article examines the current knowledge on the effectiveness of drug therapy in atrial fibrillation and discusses some aspects of the future of drug therapy for atrial fibrillation.

With an ageing population in the United Kingdom, atrial fibrillation has become an increasing cause of morbidity and mortality, and a burden on health resources. Drug therapies for the management of atrial fibrillation have a number of roles, including the restoration and maintenance of sinus rhythm and the prevention of thrombo-embolic complications. New anti-arrhythmic drugs are under development and alternatives to warfarin are being investigated. This article examines the current knowledge on the effectiveness of drug therapy in atrial fibrillation and discusses some aspects of the future of drug therapy for atrial fibrillation.

In addition to identifying those patients with coronary heart disease, the National Service Frame-work also requires general practitioners to identify all people with a diagnosis of occlusive arterial disease, including stroke and peripheral vascular disease, and offer appropriate interventions. Asymptomatic peripheral vascular disease is common; it is estimated almost one in five patients between the ages of 55 and 74 would be identified as at risk. Patients with asymptomatic disease have the same increased risk of cardiovascular events and death as in patients with symptomatic disease. The author discusses how to diagnose asymptomatic disease, the merits of a screening programme in primary care, and which patients general practitioners should target.

The current focus of our efforts in treating hypertension is to ‘treat to target’ using combination therapy. However, 24-hour control of blood pressure (BP) is of crucial importance in reducing cardiovascular risk. There is a circadian rhythm for such risk, with morning peaks in sudden cardiac death, myocardial infarction, unstable angina and ischaemic stroke. There is also a natural circadian rhythm in BP. Lack of a significant nocturnal dip worsens prognosis: patients tend to have increased left ventricular hypertrophy, cardiovascular mortality and cerebrovascular disease. Risk is related to the patient’s total BP load.
The implications are that truly long-acting once-daily antihypertensives are needed, with a trough/peak ratio > 50%. Patient compliance is very important. Ambulatory BP monitoring should be used in selected patients. Patients should be advised to take their antihypertensive medication on waking rather than waiting until after breakfast.

We describe a case of infective endocarditis, which presented with digoxin toxicity. This case is of interest since the patient only became pyrexial six days after admission when blood cultures grew Streptococcus viridans. We believe this is the first case of infective endocarditis presenting with digoxin toxicity.