Myocardial perfusion at rest in patients with Diabetes Mellitus Type 1 compared with healthy controls assessed with Multi Detector Computed Tomography

Undiagnosed coronary artery disease in long-term type 1 diabetes. The Dialong study

AIMS

We studied the total prevalence of obstructive coronary artery disease (CAD), undiagnosed CAD and absent CAD in persons with ≥45-year duration of type 1 diabetes (T1D) versus controls, and associations with mean HbA_1c, LDL-cholesterol and blood pressure over 2-3 decades.

METHODS

We included 76% (n = 103) of all persons with T1D diagnosed ≤1970 attending a diabetes center and 63 controls without diabetes. We collected 20-30 years of HbA_1c, LDL-cholesterol and blood pressure measurements. Participants without previously diagnosed coronary heart disease (CHD) underwent Computed Tomography Coronary Angiography (CTCA). Undiagnosed obstructive CAD was defined as any coronary stenosis >50% on CTCA, absent CAD as no detected plaque, and total obstructive CAD as either obstructive CAD on CTCA or previous CHD diagnosis.

RESULTS

The prevalence of undiagnosed, absent and obstructive CAD was 24% (21/88), 16% (14/88) and 35% (36/103) in T1D versus 10% (6/60), 50% (30/60) and 14% (9/63) in controls (all p < 0.05). Mean HbA_1c was associated with undiagnosed obstructive CAD (OR 2.30 95% C.I. 1.13-4.69), while mean LDL-cholesterol was inversely associated with absent CAD (0.12, 0.04-0.43).

CONCLUSIONS

The prevalence of undiagnosed obstructive CAD was high (24%) in this cohort of long-term survivors with T1D. Mean LDL-cholesterol and HbA_1c were associated with CAD.

Nocturnal antihypertensive treatment in patients with type 1 diabetes with autonomic neuropathy and non-dipping: a randomised, placebo-controlled, double-blind cross-over trial

OBJECTIVES

Cardiovascular autonomic neuropathy (CAN) and abnormal circadian blood pressure (BP) rhythm are independent cardiovascular risk factors in patients with diabetes and associations between CAN, non-dipping of nocturnal BP and coronary artery disease have been demonstrated. We aimed to test if bedtime dosing (BD) versus morning dosing (MD) of the ACE inhibitor enalapril would affect the 24-hour BP profile in patients with type 1 diabetes (T1D), CAN and non-dipping.

SETTING

Secondary healthcare unit in Copenhagen, Denmark.

PARTICIPANTS

24 normoalbuminuric patients with T1D with CAN and non-dipping were included, consisting of mixed gender and Caucasian origin. Mean±SD age, glycosylated haemoglobin and diabetes duration were 60±7 years, 7.9±0.7% (62±7 mmol/mol) and 36±11 years.

INTERVENTIONS

In this randomised, placebo-controlled, double-blind cross-over study, the patients were treated for 12 weeks with either MD (20 mg enalapril in the morning and placebo at bedtime) or BD (placebo in the morning and 20 mg enalapril at bedtime), followed by 12 weeks of switched treatment regimen.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome was altered dipping of nocturnal BP. Secondary outcomes included a measurable effect on other cardiovascular risk factors than BP, including left ventricular function (LVF).

RESULTS

Systolic BP dipping increased 2.4% (0.03-4.9%; p=0.048) with BD compared to MD of enalapril. There was no increase in mean arterial pressure dipping (2.2% (-0.1% to 4.5%; p=0.07)). No difference was found on measures of LVF (p≥0.15). No adverse events were registered during the study.

CONCLUSIONS

We demonstrated that patients with T1D with CAN and non-dipping can be treated with an ACE inhibitor at night as BD as opposed to MD increased BP dipping, thereby diminishing the abnormal BP profile. The potentially beneficial effect on long-term cardiovascular risk remains to be determined.

TRIAL REGISTRATION NUMBER

EudraCT2012-002136-90; Post-results.

Cognitive Rest

Cognitive rest has been suggested as a treatment for school athletes who have sustained a concussion, but the concept has rarely been defined. The purpose of this article is to provide a comprehensive definition of cognitive rest, based on an integrative literature review. The method of synthesis was guided by Avant and Walker’s concept analysis format. The importance of rest is discussed as a nursing intervention, and model cases are presented to clarify the concept. Three defining attributes of cognitive rest are established: freedom from physical or mental discomfort, abstinence from mental exertion, and mental and emotional balance. Empirical referents are given as well as a suggested protocol to enable school nurses to form cognitive rest and return-to-classroom protocols that can be adapted to individual school settings.