Primary care of patients with high cardiovascular risk
Endre Szigethy, Zoltán Jancsó, Csaba Móczár, István Ilyés, Eszter Kovács, László Róbert Kolozsvári & Imre Rurik Wiener klinische Wochenschrift The Central European Journal of Medicine ISSN 0043-5325 Volume 125 Combined 13-14 Wien Klin Wochenschr (2013) 125:371-380 DOI 10.1007/s00508-013-0379-2
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Author's personal copy original article Wien Klin Wochenschr (2013) 125:371–380 DOI 10.1007/s00508-013-0379-2
Wiener klinische Wochenschrift
The Central European Journal of Medicine
Primary care of patients with high cardiovascular risk Blood pressure, lipid and diabetic target levels and their achievement in Hungary Endre Szigethy · Zoltán Jancsó · Csaba Móczár · István Ilyés · Eszter Kovács · László Róbert Kolozsvári · Imre Rurik
Received: 12 July 2012 / Accepted: 12 May 2013 / Published online: 4 July 2013 © Springer-Verlag Wien 2013
Summary Cardiovascular diseases are responsible for the majority of premature deaths in Hungary as well. Most of them could be prevented with healthy lifestyle of patients and adequate drug prescription of primary care physicians. Earlier European surveys found wide differences between the practices and achievements of different countries in this field. The study was based on and designed according to the framework of previous European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) studies and aimed presenting Hungarian results and comparing with the achievements of other countries and previous Hungarian surveys. Among rural and urban settings, 679 patients under continuous care (236 diabetics, 218 with dyslipidaemia, and 225 with hypertension) were consecutively selected by 20 experienced general practitioners. The mean age of patients was 60.3 years (men) and 64.0 years (women). Among diabetics, less than 7 % of glycated hemoglobin (HbA1c) values were found in 42.5 % patients, while only 11.4 % patients had fasting plasma sugar less than 6.0 mmol/L. Of the patients treated for dyslipidaemia, the target level of triglyceride was reached by 40.6 %, recommended total cholesterol by 14.2 % and the HDL-
On behalf of the Tutorial Network of Family Physicians of North and East Hungary I. Rurik, PhD, MSc () · E. Szigethy, MSc · Z. Jancsó · I. Ilyés · E. Kovács · L. R. Kolozsvári Department of Family and Occupational Medicine, Faculty of Public Health, Medical and Health Science Center, University of Debrecen, Nagyerdei krt. 98, 4032 Debrecen, Hungary e-mail:
[email protected];
[email protected] C. Móczár Department of Family Medicine, Irinyi Health Center, Irinyi u. 22, 6000 Kecskemét, Hungary
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cholesterol by 71.8 %. The therapeutic control of total and HDL-cholesterol was better in men, although women had better triglyceride values. The achievement among patients with hypertension was 42.0 %. Significantly higher blood pressure was measured by patients who were treated with not recommended combinations of antihypertensive medication. A remarkable improvement could be observed in Hungary in the field of secondary prevention. It was greater among patients with hypertension and dyslipidaemia and smaller in diabetes care. Compared to the results of published European surveys, Hungary occupies a good position, but further improvement is still required. Keywords Cardiovascular prevention · Diabetes · Dys lipidaemia · EUROASPIRE · High-risk patients · Hungary · Hypertension · Primary care
Erstversorgung von Patienten mit hohem kardiovaskulärem Risiko – Blutdruck-, Lipid- und Diabetes-Zielwerte und ihre Einhaltung in Ungarn Zusammenfassung Auch in Ungarn sind kardiovaskuläre Erkrankungen für die meisten vorzeitigen Todesfälle verantwortlich. Den meisten davon könnte durch einen gesunden Lebensstil der Patienten und durch Verordnung entsprechender Medikamente durch erstversorgende Ärzte vorgebeugt werden. Frühere europäische Studien haben große Unterschiede bezüglich Durchführung und Erreichen der Zielwerte in den verschiedenen Ländern gefunden. Das Design unserer Studie basierte auf den Rahmenbedingungen früherer EUROASPIRE Studien. Das Ziel war die Präsentation der aktuellen Ergebnisse in Ungarn und der Vergleich mit früher erhobenen Ergebnissen in Ungarn sowie mit den in anderen Ländern erhobenen Daten.
Primary care of patients with high cardiovascular risk
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Zwanzig erfahrene Ärzte für Allgemeinmedizin, sowohl vom Land als auch von der Stadt, suchten konsekutiv 679 von ihnen kontinuierlich betreute Patienten (236 Diabetiker, 218 mit Dyslipidaemie und 225 mit Hypertonie) aus. Das mittlere Alter der Patienten lag bei den Männern bei 60,3 und bei den Frauen bei 64 Jahren. Bei den Diabetikern wurde bei 42,5 % ein HbA1c Wert von unter 7 % festgestellt, wobei der Nüchtern Blutzucker nur bei 11,4 % unter 6,0 mmol/l lag. Bei den wegen Dyslipidämie behandelten Patienten wurden die Zielwerte für die Triglyzeride von 40,6 %, für das Gesamtcholesterin von 14,2 %, und für das HDL Cholesterin von 71,8 % erreicht, wobei hier die Männer besser abschnitten. Dafür hatten die Frauen die besseren Triglyzeridwerte. Die Blutdruckzielwerte wurden von 42 % der wegen Hypertonie behandelten Patienten erreicht. Die Blutdruckwerte waren bei Patienten, die mit nicht empfohlenen Kombinationen von Antihypertensiva behandelt wurden, signifikant höher. Es konnte im Vergleich zu früher in Ungarn eine bemerkenswerte Besserung auf dem Gebiet der sekundären Prävention erreicht werden. Die Besserung war deutlicher ausgeprägt bei den Patienten mit Hypertonie und Dyslipidämie und weniger bei den Patienten mit Diabetes mellitus. Im Vergleich zu den in europäischen Studien publizierten Ergebnissen nimmt Ungarn eine gute Position ein, wobei jedoch eine weitere Besserung weiterhin anstrebenswert scheint. Schlüsselwörter Kardiovaskuläre Prävention · Diabetes mellitus · Dyslipidämie · Hypertonie · EUROASPIRE · Ungarn · Allgemeinmedizin
Introduction Cardiovascular diseases (CVDs) are among the major causes of death, hospital admissions, and disability in middle-aged and older patients in Europe. Beyond the process of ageing, the main reasons for atherosclerotic CVD are the unhealthy lifestyle and related modifiable physiological and biochemical factors. The main objectives of CVD prevention are to reduce the risk of first or recurrent atherosclerotic events, to improve the quality of life, and prolong survival [1–3]. In the Central and Eastern European countries, CVDs are the leading cause (representing 50–60 %) of total mortality [4]. Between 1993 and 2007, CVD-related mortality rate decreased by 53 % because of increased cardio-metabolic prescription in Hungary [5, 6]. The task of drug prescription has been delegated to primary care (family physicians/general practitioners) especially those, who are responsible for controlling the laboratory and other measurable parameters. Various medical societies provide physicians’ professional support with their task by issuing guidelines for them. The implementation of these guidelines depends on many factors such as the knowledge, enthusiasm and (financial) initiatives of family physicians and their
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adherence to the guidelines. Besides other characteristics of the health care system and society, the compliance of patients (which can be influenced by the practitioners as well) and the cultural and financial situation of patients also play an important role [7]. Guideline implementation in daily practice has been evaluated using many local and three cross sectional surveys called European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) starting in the mid-1990s. They were conducted under the auspices of the European Society of Cardiology Euro Heart Survey programme in 1995–1996, 1999–2000 and 2006–2007 in patients with Coronary heart disease (CHD) [8–10]. Comparison across the three surveys of coronary patients showed adverse lifestyle trends, a substantial increase in obesity in every country, and higher prevalence of smoking among younger patients. Despite the substantial increase in prescribing antihypertensive and lipid lowering drugs, blood pressure management remained unchanged, and almost half of the patients did not achieve the recommended lipid targets. EUROASPIRE III. survey was undertaken in defined geographical areas and general practices in Belgium, Bulgaria, Croatia, Finland, Germany, Italy, Latvia, Poland, Romania, Slovenia, Spain and the UK. The governing principle of sample taking was that any patient treated for hypertension, dyslipidaemia, or diabetes had an approximately equal chance to be included [8]. Similarly to other countries, recent evidence-based guidelines have modified the care of diabetic and hypertensive patients and lipid lowering therapy in Hungary as well [11, 12]. The First Hungarian Consensus Conference (expert panels of different societies) held in 2003 was followed by programs promoting the guidelines defined by this conference that has been organized every 2 years since then [13]. Previous Hungarian studies emphasized that the patients’ education played a key role in reaching the target levels. A large gap was found between the lipid target goals achieved by family physicians (19 %) and specialists (36 %). The therapy was later modified by only 15 % of the patients [14, 15]. In another study, only a quarter of the patients receiving lipid lowering treatment achieved the target levels [16]. There were lower (16 %) lipid levels and about 50 % of diabetic and hypertensive target achievements in the first government-financed Hungarian screening program [17]. In our previous evaluations in the Eastern and Northern part of the country, 47 % of blood pressure, 36 % of triglyceride, 34 % of glycated hemoglobin (HbA1c), and 21 % of total-cholesterol data ( 5 mmol/l) was detected in 78 % at the initial visit [22]. Special atten-
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tion and more intensive lipid lowering treatment was required if the patients had a high-risk for CHD [23, 24]. Hungary was not involved in the EUROASPIRE studies, therefore we aimed to collect and present data about the recent Hungarian primary care practice and compare them with the achievements of other countries.
Method and patients Selection of participants In all, 20 experienced general practitioners, members of the Tutorial Network of Family Physicians in North and East Hungary were involved in the study on a voluntary basis, between January and December 2011. Of these, 10 were based on rural circumstances while the others were based on urban circumstances.
Selection of patients Within each general practice, men and women between 18 and 80 years of age at the time of identification were involved to whom one or more of the following medications had been prescribed by a physician: (1) antihypertensive and/or (2) lipid lowering and/or (3) treatment for diabetes not less than 6 months and not longer than 3 years before the date of identification. The patients were consecutively selected and the first 15 people were involved from each diagnostic (prescription) group. Laboratory data and measurements were retrieved from (electronic) practice records according to prescribed drug therapies. Patients sampled by each of these drug treatments might have been using one or more of the other drug therapies.
• f asting plasma glucose (
