Patients with acute coronary syndrome (ACS) often have raised blood glucose concentrations when admitted to hospital; a marker for poorer prognosis. Interventions to rapidly normalise blood glucose inconsistently are applied and with uncertain utility. Here we review the association of hyperglycaemia with outcome, present evidence that this hyperglycaemia reflects more than a pre-existing diabetic state and discuss mechanisms by which glucose may adversely affect the course of acute myocardial infarction (AMI). Finally, we seek evidence that intensive insulin treatment improves outcome.

The close anatomical relations of the heart and oesophagus, and the similarity of symptoms attributable to disorders of either organ, often lead to diagnostic difficulty in patients with chest pain. A definitive diagnosis of non-cardiac chest pain attributable to oesophageal reflux or spasm is hampered, both by the need for prolonged ambulatory monitoring of pH, manometry, and endoscopy, and by the common occurrence of asymptomatic reflux and spasm, and the corresponding difficulty in linking an episode of reflux or spasm with an episode of pain. Moreover, some patients with non-cardiac chest pain and normal tests of oesophageal structure and function have centrally mediated hypersensitivity, both within and without the oesophagus. Rather than proceed with investigations, in the absence of symptoms to suggest structural disease of the oesophagus, it would be reasonable to attempt symptomatic treatment with a proton pump inhibitor or an antidepressant.

Drug-drug interactions with corticosteroids, causing Cushing's syndrome with secondary adrenal suppression, are well known in HIV patients. Corticosteroids are widely prescribed in the HIV-positive population. However, digoxin is rarely used in HIV patients; hence, digoxin toxicity due to drug-drug interaction is not widely recognised. Nevertheless, this practice might change in the future as HIV cohorts of patients are ageing, due to the successful treatment of HIV infection with combination antiretroviral therapy. We report a case of digoxin toxicity in an HIV-positive 51-year-old man, due to a combination of drug-drug interaction and renal impairment. The first case report of digoxin toxicity due to drug-drug interaction with ritonavir in an HIV-positive woman was published in 2003. To the best of our knowledge, no similar case report has since been published in the literature. This case alerts the profession to the importance of drug-drug interaction and highlights the clinical features of digoxin toxicity.

Objective. Breast cancer treatment can negatively impact cardiac function in some breast cancer patients. Current methods (MUGA, echocardiography) used in clinical practice to detect abnormal cardiac changes as a result of treatment suffer from important limitations. Use of alternative techniques that would offer safe, inexpensive and non-invasive cardiac function assessment in this population would be highly advantageous. The aim of this study was to examine the agreement between impedance cardiography (ICG) and cardiac magnetic resonance imaging (CMR) in quantifying stroke volume (SV), cardiac output (CO) and end-diastolic volume (EDV) in this population. Approach. Sixteen breast cancer patients underwent ICG and CMR assessments at three time-points (before treatment, immediately after chemotherapy, and four months after chemotherapy). Bland–Altman analysis was used to quantify the accuracy and precision of ICG (relative to CMR) in estimating absolute values of SV, CO and EDV. Four methods (concordance rate, polar concordance rate, clinical concordance rate and trend interchangeability rate) were also used to assess ICG performance in tracking changes in these variables. Main results. Bland–Altman analysis showed that the accuracy of ICG relative to CMR was −3.1 ml (SV), 0.2 l·min−1 (CO) and −26.0 ml (EDV) and precision was 13.2 ml (SV), 1.1 l·min−1 (CO) and 20.1 ml (EDV), respectively. Trending ability assessment showed that (1) the concordance rate was 87% (SV), 73% (CO) and 73% (EDV), (2) the polar concordance rate was 67% (SV), 53% (CO) and 33% (EDV), (3) the clinical concordance rate was 33% (SV), 40% (CO) and 20% (EDV) and (4) the trend interchangeability rate was 29% (SV), 43% (CO) and 17% (EDV), respectively. Significance. Our findings show that, although ICG showed good accuracy for absolute SV and CO measurements and for CO and EDV changes, precision was poor for all variables in terms of both absolute measurements and trend tracking performance. This suggests that ICG cannot be used interchangeably with CMR in breast cancer patients.