Lege Artis Medicinae

[Quality assessment in the management of acute coronary syndromes]

ZÖLLEI Éva, PAPRIKA Dóra, VINCZE Dóra, KOVÁCS Katalin, RUDAS László

AUGUST 20, 2002

Lege Artis Medicinae - 2002;12(08)

[INTRODUCTION AND METHODS - Quality monitoring activities are essential for improving the care of acute coronary patients. The aim of our study was to establish a registry and assess the adherence to widely used quality indicators. We investigated two groups of patients, those admitted to our Intensive Care Unit with the diagnosis of acute myocardial infarction (Group 1) and unstable angina (Group 2). RESULTS - Group 1. consisted of 173 patients, of whom 60% was eligible for thrombolysis. In 5 cases no acute reperfusion therapy was done. For reperfusion we used systemic thrombolysis in 74% and primary coronary angioplasty in 26%. The prehospital delay was 150 minutes, the ”door-to-needle” time and the ”door-toballoon” time were 30 minutes and 102 minutes, respectively. 95% of the patients received aspirin, 79% beta-blocker, 82% angiotensin converting enzyme inhibitor and 39% cholesterol lowering medications. Group 2. included 84 patients, most of them had high risk features according to the Braunwald classification and the American College of Cardiology, American Heart Association guideline. Coronary angiography was performed in 80 cases. Regarding revascularization, 43 patients underwent coronary bypass surgery, 30 percutan angioplasty with stent implantation in 18. In this group aspirin was given in 82, unfractionated heparin in 9, low molecular weight heparin in 49, glycoprotein IIb/IIIa inhibitor in 15 cases. 21 patients received intravenous nitroglycerin, 70 patients betablocker and 57 patients cholesterol lowering drugs. DISCUSSION - Quality management is extremely useful in assessing our practice, our shortcomings and developments.]

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[BACKGROUND - Little is known about the relationship between gestational diabetes and late diabetes complications. The relationship between these abnormalities was investigated in this study. PATIENTS, METHODS - Besides reclassification of their glucose tolerance, the prevalence and correlating factors of diabetic neuropathy were evaluated in 123 gestational diabetic (GDM) women controlled prior by our team during their pregnancies. 26 pregestational type 2 diabetic patients served as controls. Mean follow-up time was 7.2 years. Vibration perception threshold was measured to diagnose peripheral neuropathy, while cardiovascular autonomic neuropathy was evaluated using the battery of four cardiovascular reflex-tests. RESULTS - From 123 prior GDM women, 63 were characterized as having diabetes (52.9%), while 14 had impaired glucose tolerance (11.8%). Peripheral neuropathy was diagnosed in 23.6 %, parasympathetic neuropathy in 37.4 %, while sympathetic neuropathy was confirmed in 7.3 % of the patients evaluated during follow-up visit. Association between abnormal glucose tolerance and neuropathy was statistically significant only in the case of parasympathetic neuropathy (p=0.0001), and this relationship was independent from elevated BMI, microalbuminuria and the higher rate of hypertension observed in these women (p=0.006). Since the number of abnormal neuropathy tests were also higher than expected in women with normal glucose tolerance, we hypothetised a cross-sectional link between neuropathy and insulin resistance. An additional analysis comfirmed this association between insulin resistance and parasympathetic neuropathy independent of metabolic status of these patients (p=0.005). CONCLUSIONS - The importance of gestational diabetes, which is sometimes underestimated by many clinicians, was highlighted by our study since it projected a high frequency of parasympathetic cardiovascular neuropathy in these patients. This form of diabetes not only projects the development of late onset type 2 diabetes, but could also act as a predictor of late diabetes complications. According to our results diabetic parasympathetic neuropathy may be linked to type 2 diabetes/ insulin resistance syndrome, and could play a role in the excess cardiovascular mortality observed in these patients.]

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