Metformin poisoning treated with high dose insulin dextrose therapy: a case series.

PURPOSE: We describe the compassionate use of high dose insulin dextrose (HID) for life threatening metformin associated lactic acidosis (MALA) in four patients admitted to intensive care. METHODS: Patients presenting with refractory lactic acidosis believed to be secondary to metformin poisoning were included.High dose insulin dextrose at 0.5units/kg/hour was infused in 50% dextrose. Frequent blood gas analysis allowed titration of therapy. All patients also received continuous veno-venous haemofiltration. RESULTS: All four patients recovered to normal or near normal lactate and pH between 10 and 24 hours of therapy. Two patients had significant separation in time between initiation of HID and haemofiltration to suggest an independent effect of HID on improving pH and lactate.All patients had at least one episode of hypoglycaemia below 4.0 mmol/L with the lowest glucose in any patient during therapy being 3.0 mmol/L. All episodes were corrected with a dextrose infusion without sequelae. CONCLUSIONS: Our study demonstrates that HID therapy appears to be safe in patients with suspected metformin poisoning. It also appears to work to drive down lactate, improve pH and patients' clinical condition. Further evidence is required to assess the effectiveness of HID therapy in the context of MALA.

Activity and outcomes of a cardio-oncology service in the United Kingdom-a five-year experience.

AIMS: Cardio-oncology clinics optimise the cardiovascular status of cancer patients but there is a limited description of their structure, case mix, activity and results. The purpose of this paper is to describe the activity and outcomes of a cardio-oncology service, particularly with respect to supporting optimal cancer treatment and survival. METHODS AND RESULTS: We prospectively studied patients referred to our service from February 2011 to February 2016. New York Heart Association (NYHA) class and parameters of cardiac function were measured at baseline and after optimisation by our service. Up-titration of cardiac treatment, continuation of cancer therapy and mortality were used as outcome measures. Of the 535 patients (55.8% females) referred, rates of cardiotoxicity for anthracyclines, anti-HER2 agents and tyrosine kinase inhibitors were 75.8%, 69.8% and 62.1%, respectively. Patients with left ventricular systolic dysfunction (LVSD) (n =128) were younger, had higher rates of hypertension and previous exposure to chemotherapy/radiotherapy (P < 0.001). At a median follow-up of 360 days, 93.8% of the patients with LVSD showed improvement in left ventricular ejection fraction (45% pre vs. 53% post; P < 0.001) and NYHA class (NYHA III-IV in 22% pre vs. 10% post; P = 0.01). All patients with normal left ventricular ejection fraction and biochemical or functional myocardial toxicity and 88% of patients with LVSD were deemed fit for continuation of cancer therapy after cardiovascular optimisation. CONCLUSIONS: Through the establishment of a cardio-oncology service, it is feasible to achieve high rates of cardiac optimisation and cancer treatment continuation.

Toma de decisiones por el equipo cardiaco: ¿democracia o dictadura? / Heart team decision-making: democracy or dictatorship?

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Beneficio de la implementación de un sistema de atención en red sobre las mujeres con infarto agudo de miocardio con elevación del segmento ST / Benefit of the implementation of a ST-segment elevation myocardial infarction network on women

Objetivo: El sistema de atención en red por infarto con elevación del segmento ST «Codi Infart¼ se implementó en Cataluña (España) en junio de 2009. El objetivo del estudio fue evaluar el beneficio de la instauración del Codi Infart para las mujeres atendidas en nuestra institución. Método: Las mujeres referidas para angioplastia primaria se dividieron en 2 grupos de acuerdo con el Codi Infart: grupo no-Codi Infart (enero de 2003 a mayo de 2009) y grupo Codi Infart (junio de 2009 a diciembre de 2012); y se compararon lugar de procedencia, periodos, tratamientos recibidos y tasa de eventos cardiovasculares mayores definida como muerte por todas las causas, reinfarto o accidente cerebrovascular durante el ingreso, a 30 y 180 días. Resultados: De una población total de 2,426 pacientes, 501 (20.7%) eran mujeres. De ellas, 186 mujeres (2,09 casos/mes) pertenecían al grupo no-Codi Infart y 315 mujeres (10,16 casos/mes) al grupo Codi Infart. El porcentaje de mujeres atendidas aumentó desde la introducción del Codi Infart(22.2% vs. 18.5%, p = 0.028). Además, inicialmente el grupo Codi Infart presentó mayor porcentaje de mujeres atendidas fuera de nuestra institución (84.1% vs. 16.7%, p < 0.001), y menores tiempos totales de isquemia (220 [155-380] vs. 272 [196-456], p = 0.003), pero no se detectaron diferencias en eventos cardiovasculares mayores a 180 días (14.2% vs. 15.6%, p = 0.692). Conclusiones: La instauración del Codi Infart permitió aumentar de manera notable la tasa y el porcentaje de mujeres con infarto de miocardio con elevación del segmento ST tratadas mediante angioplastia primaria y reducir los tiempos totales de isquemia.

Objective: The ST-segment elevation myocardial infarction network "Codi Infart" was implemented in Catalonia (Spain) in June 2009. The objective of this study was to evaluate the impact of the implementation of the Codi Infart on women. Method: Women referred for primary percutaneous coronary intervention, were divided into two groups according to Codi Infart: Non-Codi Infart group (January 2003 to May 2009) and Codi Infart group (June 2009 to December 2012). Place of first medical contact, time intervals in diagnosis and treatment, treatments received and rate of major cardiovascular adverse events defined as all-cause death, reinfarction or stroke in-hospital, at 30 and 180 days were compared. Results: From a total population of 2,426 patients, 501 (20.7%) were women. One-hundred eighty-six women (2.09 cases/month) belonged to Non-Codi Infart group and 315 women (10.16 cases/month) to Codi Infart group. The percentage of women attended increased since the introduction of CI (22.2% vs. 18.5%, P = .028). In addition, the Codi Infart group had a higher percentage of women initially attended outside our institution (84.1% vs. 16.7%, P < .001), and lower total ischemia time (220 [155-380] vs. 272 [196-456], P = .003). However, no differences in 180-day major cardiovascular adverse events were detected (14.2% vs. 15.6%, P = .692). Conclusions: The implementation of the major cardiovascular adverse events allowed to increase the rate and the percentage of women with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention and reducing total ischemic time.

[Benefit of the implementation of a ST-segment elevation myocardial infarction network on women]. / Beneficio de la implementación de un sistema de atención en red sobre las mujeres con infarto agudo de miocardio con elevación del segmento ST.

OBJECTIVE: The ST-segment elevation myocardial infarction network "Codi Infart" was implemented in Catalonia (Spain) in June 2009. The objective of this study was to evaluate the impact of the implementation of the Codi Infart on women. METHOD: Women referred for primary percutaneous coronary intervention, were divided into two groups according to Codi Infart: Non-Codi Infart group (January 2003 to May 2009) and Codi Infart group (June 2009 to December 2012). Place of first medical contact, time intervals in diagnosis and treatment, treatments received and rate of major cardiovascular adverse events defined as all-cause death, reinfarction or stroke in-hospital, at 30 and 180 days were compared. RESULTS: From a total population of 2,426 patients, 501 (20.7%) were women. One-hundred eighty-six women (2.09 cases/month) belonged to Non-Codi Infart group and 315 women (10.16 cases/month) to Codi Infart group. The percentage of women attended increased since the introduction of CI (22.2% vs. 18.5%, P=.028). In addition, the Codi Infart group had a higher percentage of women initially attended outside our institution (84.1% vs. 16.7%, P<.001), and lower total ischemia time (220 [155-380] vs. 272 [196-456], P=.003). However, no differences in 180-day major cardiovascular adverse events were detected (14.2% vs. 15.6%, P=.692). CONCLUSIONS: The implementation of the major cardiovascular adverse events allowed to increase the rate and the percentage of women with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention and reducing total ischemic time.

Percutaneous transcatheter aortic valve implantation: present and future perspective.

Transcatheter aortic-valve implantation is becoming the standard of care for inoperable patients with severe aortic stenosis and a valid alternative for those at high surgical risk. Since the first percutaneous transcatheter aortic-valve implantation in humans in 2002, over 50,000 transcatheter aortic valves have been implanted in the last decade, with progressive improvement in the available devices. Overall, there are two main families of transcatheter prosthesis: self-expandable and nonself-expandable. The self-expandable devices, for which CoreValve(®) (Medtronic CV Luxembourg S.a.r.l., Luxembourg) represents the prototype, are characterized by a structure composed of shape memory materials, usually nitinol, which acquire its final shape once released. By contrast, the non-self-expandable prostheses, mainly represented by the Edwards(®) valve (Edwards Life Sciences, Inc., CA, USA), require balloon dilatation to reach its final shape. Although several publications have already provided positive data on both technologies, new clinical studies with improved systems are currently being conducted in order to provide more solid data and potentially expand the spectrum of patients who can benefit from this therapy. Thus, the aim of the present paper is to review the salient features of the two most used systems today (third-generation CoreValve and Edwards SAPIEN XT(®)) as well as to provide data on other emerging valves and future perspectives.

Transcatheter aortic valve implantation in patients with left main percutaneous coronary intervention.

Transcatheter aortic valve implantation (TAVI) is the treatment of choice for severe symptomatic aortic stenosis in inoperable patients, and an alternative treatment for those at high risk. The coexistence of coronary artery disease (CAD) adds morbidity and mortality to the procedure. Prior percutaneous coronary intervention (PCI) has been suggested as safe and related to a better prognosis. However, PCI in the left main coronary artery (LMCA) prior to TAVI has been poorly represented in clinical trials and scarcely reported. Herein are presented three cases of a successful sequential approach by LMCA stenting and TAVI, underlining the importance of clinical and anatomic assessment by a multidisciplinary team. Future studies will be necessary to provide more evidence for this indication.

Integración entre cardiología y atención primaria: impacto sobre la práctica clínica / Integration between cardiology and primary care: impact on clinical practice

Introducción y objetivos. Evaluar el impacto de un programa de integración entre cardiología y atención primaria en la práctica clínica, comparado con la atención convencional. La integración consiste en un cardiólogo hospitalario en cada centro de atención primaria, historia clínica común, guías clínicas consensuadas, sesiones de consultoría y otras herramientas de coordinación. Métodos. Estudio observacional de dos muestras transversales sobre prevalencias en periodos antes y después de la intervención: atención convencional y atención integrada. Se analiza: distribución de pacientes atendidos, impacto en indicadores de buena práctica clínica en los pacientes con cardiopatía isquémica, insuficiencia cardiaca y fibrilación auricular, satisfacción de atención primaria y uso de recursos. Resultados. Se incluyó a 3.194 pacientes (1.572 en atención convencional y 1.622 en integrada). La integración redistribuyó a los pacientes y aumentó el control del cardiólogo sobre enfermedades graves y el control desde primaria de los factores de riesgo y pacientes estables. En cardiopatía isquémica, mejoró el control de colesterolemia, presión arterial, optimización del tratamiento y documentación de la función ventricular. En insuficiencia cardiaca, aumentó el tratamiento con bloqueadores beta y la valoración funcional. En fibrilación auricular, mejoró el estudio con ecocardiografía e indicación de anticoagulación. El uso de recursos no aumentó. La satisfacción de los médicos de primaria se incrementó con la integración. Conclusiones. Tras la integración, mejoró el control y el tratamiento crónico de los pacientes con cardiopatía isquémica, insuficiencia cardiaca y fibrilación auricular, se redistribuyó a los pacientes crónicos entre atención primaria y cardiología, y aumentó la satisfacción de los médicos de familia, sin objetivarse incremento en el uso de recursos (AU)

Introduction and objectives. To assess the impact of a program integrating cardiology and primary care in clinical practice, compared with usual care. The integrated care consists of a hospital cardiologist in each primary care clinic, shared clinical history, joint practice guidelines, consultation sessions, and other coordinating tools. Methods. Observational, cross-sectional study of 2 series of chronic outpatients: conventional and integrated care. We analyzed patient distribution and the impact on good clinical practice indicators in patients with ischemic heart disease, heart failure and atrial fibrillation, along with primary care practitioner satisfaction and use of resources. Results. We included 3194 patients (1572 usual care, 1622 integrated care). Integrated care changed the patient distribution, allowing the cardiologist to focus on serious pathologies while cardiovascular risk factors and stable patients were monitored in primary care. In ischemic heart disease, improvement was observed in cholesterol management and blood pressure control; optimal medical treatment was more frequently prescribed and ventricular function evaluated more often. In heart failure, Beta-blockers treatment increased and functional class was assessed more often. In atrial fibrillation, an increase in anticoagulation prescription and echocardiography evaluation was observed. Satisfaction parameters improved with integrated care. The use of resources was not increased. Conclusions. Using our integration model, follow-up and chronic treatment of patients with ischemic heart disease, heart failure, and atrial fibrillation were improved. Monitoring of chronic patients was redistributed between primary care and cardiology, and family physicians¡¯ satisfaction levels improved. There was no increase in use of resources (AU)

[Integration between cardiology and primary care: impact on clinical practice]. / Integración entre cardiología y atención primaria: impacto sobre la práctica clínica.

INTRODUCTION AND OBJECTIVES: To assess the impact of a program integrating cardiology and primary care in clinical practice, compared with usual care. The integrated care consists of a hospital cardiologist in each primary care clinic, shared clinical history, joint practice guidelines, consultation sessions, and other coordinating tools. METHODS: Observational, cross-sectional study of 2 series of chronic outpatients: conventional and integrated care. We analyzed patient distribution and the impact on good clinical practice indicators in patients with ischemic heart disease, heart failure and atrial fibrillation, along with primary care practitioner satisfaction and use of resources. RESULTS: We included 3194 patients (1572 usual care, 1622 integrated care). Integrated care changed the patient distribution, allowing the cardiologist to focus on serious pathologies while cardiovascular risk factors and stable patients were monitored in primary care. In ischemic heart disease, improvement was observed in cholesterol management and blood pressure control; optimal medical treatment was more frequently prescribed and ventricular function evaluated more often. In heart failure, ß-blockers treatment increased and functional class was assessed more often. In atrial fibrillation, an increase in anticoagulation prescription and echocardiography evaluation was observed. Satisfaction parameters improved with integrated care. The use of resources was not increased. CONCLUSIONS: Using our integration model, follow-up and chronic treatment of patients with ischemic heart disease, heart failure, and atrial fibrillation were improved. Monitoring of chronic patients was redistributed between primary care and cardiology, and family physicians' satisfaction levels improved. There was no increase in use of resources. Full English text available from: www.revespcardiol.org.