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Background: The DANish StUdy of impaired glucose metabolism in the settings of cardiac rehabilitation (DANSUK) examined the effect of an intensified multifactorial intervention on risk factor profile in 104 patients with type 2 diabetes mellitus (T2DM) or impaired glucose tolerance (IGT) attending hospital-based outpatient comprehensive cardiac rehabilitation (CCR) compared to usual care (UC)., Methods: Patients with ischemic heart disease (67%), congestive heart failure (7%), or at least 3 risk factors for ischemic heart disease (26%) discharged from 1 coronary care unit were referred to CCR. Of 473 eligible individuals, 201 agreed to participate in the study, and 52% had T2DM or IGT. Patients randomized to CCR received a stepwise implementation of behavioral modification and pharmacotherapy., Results: After 1 year, patients with T2DM in the CCR group experienced a mean change in HbA1c of -0.65% +/- 0.9% compared with a mean change of -0.08% +/- 0.7% in the UC group (P < .05). Mean change in systolic and diastolic blood pressures was -8 +/- 15 and -5 +/- 9 mm Hg in the CCR group compared with a mean change of -0.8 +/- 15 and -0.2 +/- 7 mm Hg in the UC group (P < .05). Patients with IGT attending CCR obtained a significantly higher exercise capacity compared with patients in the UC group (P < .05)., Conclusions: In a group of patients with impaired glucose metabolism attending CCR, an intensified multifactorial intervention with an integrated diabetes module was more efficient in improving risk factor control than UC. Besides the improvement in the exercise capacity of patients with IGT, in patients with T2DM, both HbA1c and blood pressure were lowered to a level that has been shown to reduce both cardiac and diabetic complications. These findings have important implications for patients with impaired glucose metabolism in the future settings of CCR.

Background: Lifestyle and pharmacological interventions can delay the progression of impaired glucose tolerance (IGT) to type 2 diabetes (T2DM), and there is growing evidence that earlier detection of T2DM and intensified risk factor management may result in improved cardiovascular morbidity and mortality. We studied the prevalence of impaired glucose metabolism (T2DM, IGT and impaired fasting glucose; IFG) in patients referred to cardiac rehabilitation, and further studied whether we could identify groups in which an oral glucose tolerance test (OGTT) need not be performed., Methods: As part of a cardiac rehabilitation trial, 201 patients participated. Patients without a diagnosis of T2DM (N=159) underwent an OGTT 3 months after inclusion., Results: Forty-two patients (21%) had known T2DM at enrolment. Based on the OGTT, 26 patients (13%) had unrecognized T2DM, 36 (18%) had IGT and 19 (9%) were diagnosed with isolated IFG according to the World Health Organization definition. Using fasting plasma glucose alone, 19% of the patients with unrecognized T2DM and two-thirds of patients with IGT would be misclassified. Using IFG as a means to detect IGT showed a sensitivity of only 33% and a positive predictive value of 39%., Conclusion: More than 60% of the patients (123/201) referred to cardiac rehabilitation had impaired glucose metabolism and 18% of the screened patients (29/159) would be misclassified if an OGTT was omitted. IFG and IGT did not identify the same patients or the same cardiovascular risk profile. An OGTT test should therefore be considered a constituent part of routine care management in cardiac rehabilitation settings.

Patients with diabetes constitute a large group among patients with ischaemic heart disease, and their risk of repeated cardiovascular events is large. Due to this, there is increasing focus on intervention against the increased risk of cardiac morbidity and mortality in patients with diabetes. Subgroup analyses of patients with diabetes from studies on patients with ischaemic heart disease show that intervention with thrombolysis, aspirin, beta blockers, ACE inhibitors and statins have similar relative benefit among patients with diabetes, but because of the greater risk in these patients, the absolute benefit is increased. In spite of this, intervention is less common among patients with diabetes, a fact that should be corrected. Direct intervention targeted at the metabolic disorder in ischaemic heart disease has only been investigated in the DIGAMI study, where glucose/insulin treatment followed by long term treatment with insulin was compared to conventional treatment. The mortality was lower in the insulin treated group after one to four years of follow up, a promising result which is currently being investigated in the DIGAMI-2 study.

In patients with diabetes mellitus, heart disease is more common that in the background populations and has a more serious prognosis. The reasons are only partially understood. Whether patients with diabetes mellitus have a more diffuse and pronounced coronary atherosclerosis has been the subject of many investigations with diverging results. However, the larger studies suggest that coronary atherosclerosis is more pronounced and diffuse in diabetics compared with non-diabetic patients. The pathoanatomic picture of the atherosclerotic process seems to be identical in patients with and without diabetes mellitus. A number of structural abnormalities in the intramural vessels and interstitial tissue of the heart have been demonstrated in diabetics. However, similar abnormalities have also been reported in non-diabetic patients. With respect to where "diabetic cardiomyopathy" is a specific entity, the existing data are not confirmative. Whether diabetes mellitus per se induces functional changes in the coronary vascular system leading to myocardial ischaemia and dysfunction is a subject for future investigations.

This study was designed to compare once-daily administration of 5-10 mg amlodipine with two daily doses of 40 mg sustained-release isosorbide dinitrate in 59 patients with stable angina using a randomized, double-blind, crossover study design. Anginal episodes, nitroglycerin consumption, and possible adverse events were recorded in a diary. A maximal symptom-limited bicycle exercise test and 48-hour ambulatory ECG monitoring were performed at baseline and at the end of each 5-week period of therapy. Exercise time, time to angina, time to ST depression, and maximal ST depression were measured during exercise. During ambulatory monitoring, the number of ischemic episodes and the duration per hour of ST depression were assessed. Amlodipine significantly reduced anginal episodes (P < 0.001) when compared with isosorbide dinitrate. Furthermore, amlodipine prolonged time to ST depression (P < 0.001) and time to angina (P < 0.05) when compared with isosorbide dinitrate. The number and duration of ischemic episodes during ambulatory monitoring were significantly reduced with amlodipine when compared with baseline values (P < 0.05), whereas no differences were found between isosorbide dinitrate and baseline. Adverse events were reported more frequently with isosorbide dinitrate than with amlodipine (P < 0.02). Amlodipine appears to be more effective and tolerable than sustained-release isosorbide dinitrate as monotherapy for chronic stable angina.

Diabetes and systemic hypertension had no influence on left ventricular free wall rupture complicating acute myocardial infarction. Age <65 years and a history of coronary artery disease offers some protection from protection.

The aim of the study was to evaluate the prognostic significance of clinical and echocardiographic data in patients referred for echocardiography in a retrospective analysis. Four hundred and fifty-six patients from a district hospital were studied. Survival after three years was 64%. Multivariate analysis identified five factors with independent prognostic information (relative risks of death are shown in brackets): left ventricular wall motion index (WMI) < or = 1.2 by echocardiography (2.5), status as in-patient (2.1), age > 65 years (1.7), clinical heart failure (1.9) and atrial fibrillation (1.5). When information on age, hospitalisation status, heart failure and heart rhythm had already been entered in the Cox model, echocardiographic results such as decreased WMI and dilated right ventricle still gave further prognostic information. We conclude that among conventional clinical and echocardiographic data WMI was the strongest predictor of long-term survival, and, despite prior knowledge of major clinical features, echocardiography provided further prognostic information.

We present the results of a clinical and radiographic follow-up study of patients undergoing elbow synovectomies. Twenty-five elbows in 24 patients with rheumatoid arthritis were followed for a median period of 52 months (range 10-108) after operation. Nineteen (74%) stated they had improvement of pain and function. Two patients reported increased pain. Improvement of motion was noted, but this was not statistically significant. Radiographic classification showed statistically significant progressive changes. Three complications were noted, all without permanent sequels. Moderate elbow destruction can provide a good indication for elbow synovectomy in the treatment of patients suffering from rheumatoid arthritis.

The prognostic significance of conventional clinical and echocardiographic data in patients referred to echocardiography was retrospectively analyzed. 456 patients (206 females and 250 males) were studied in the department of cardiology in a district hospital. Survival after 3 years was 64%. By multivariate analysis five factors contained independent, significant, prognostic information (hazard ratios for death are given in parentheses): left ventricular wall motion score index (WMI) < or = 1.2 by echocardiography (2.5), status as inpatient (2.1), age > 65 years (1.7), clinical heart failure (1.9) and atrial fibrillation (1.5). A stepwise multivariate analysis was performed by entering variables into a model initially forced to contain information on age, hospitalization status, treatment of heart failure and heart rhythm. In this analysis, a poor WMI (< or = 1.2) and a dilated right ventricle contained further independent prognostic information. In conclusion, among conventional clinical and echocardiographic data, WMI was the most powerful predictor of long-term survival, and despite knowledge of major clinical features echocardiography provided further prognostic information.

The value of thrombolytic therapy in myocardial infarction is well established, while any beneficial effect of adjunct therapy is more uncertain. In a double-blind, randomized, parallel-group study the effect of combined intravenous infusions of streptokinase and isosorbide dinitrate (ISDN) on enzyme-estimated infarct size was investigated. One hundred consecutive patients with strong clinical and electrocardiographic suspicion of myocardial infarction, admitted to the coronary care unit within 8 hours after the onset of symptoms, were given a streptokinase infusion of 1.5 million units for 1 hour and a titrated dose of ISDN or placebo for 48 hours. From isoenzyme B of creatine kinase (CK-B) values measured every 4 hours, the infarct size was calculated and the possible presence of reperfusion was evaluated. The infarct size in patients receiving ISDN infusion was reduced (p = 0.04, one-sided test) compared with placebo. By subdividing the patients according to whether or not reperfusion had occurred, the infarct size appeared to be similar following ISDN and placebo in patients with reperfusion (419 versus 369 U/L), whereas the infarct size in patients not reperfused was markedly reduced after treatment with ISDN (223 versus 1320 U/L, p = 0.003). In conclusion, the present study demonstrates that the infarct size may be reduced by other means than reperfusion and it supports the use of combined infusion of thrombolytic agents and nitrates in patients with suspected myocardial infarction.