The Evaluation of Lipid-Lowering Treatment in Patients with Acute Coronary Syndrome in a Hungarian Invasive Centre in 2015, 2017, and during the COVID-19 Pandemic-The Comparison of the Achieved LDL-Cholesterol Values Calculated with Friedewald and Martin-Hopkins Methods.

Background/Objectives: Patients with acute coronary syndrome (ACS) represent a vulnerable population. We aimed to investigate serum lipid levels of patients with ACS upon admission and during one year of the COVID-19 pandemic in a rural county hospital, and compared these findings with the data of patients with ACS in 2015 and 2017. The secondary aim of this paper was the comparison of the LDL-C values calculated with the Friedewald and Martin-Hopkins methods. Methods: A retrospective analysis of lipid-lowering data of patients treated with ACS in 2015, 2017 and in a COVID-19 year (1 April 2020-31 March 2021) was performed; the patient's numbers were 454, 513 and 531, respectively. Results: In the COVID-19 period one year after the index event, only 42% of the patients had lipid values available, while these ratios were 54% and 73% in 2017 and in 2015, respectively. Using the Friedewald formula, in the COVID-19 era the median of LDL cholesterol (LDL-F) was 1.64 (1.09-2.30) mmol/L at six months and 1.60 (1.19-2.27) mmol/L at one year, respectively. These values were 1.92 (1.33-2.27) mmol/L and 1.73 (1.36-2.43) mmol/L using the Martin-Hopkins method (LDL-MH). The LDL-F yielded significantly lower values (15% lower at six months, p = 0.044; and 8% lower at one year, p = 0.014). The LDL-F reached the previous target of 1.8 mmol/L during the COVID-19 pandemic 36% at one year vs. 48% in 2017, and 37% in 2015. The recent target LDL-C level of 1.4 mmol/L was achieved in 22% of cases in the COVID-19 pandemic, 16% in 2015 and 19% in 2017. Conclusions: A significantly lower proportion of patients with ACS had available lipid tests during the COVID-19 pandemic. Besides the lower number of available samples, the proportion of achieved 1.4 mmol/L LDL-C target lipids was stable. More rigorous outpatient care in the follow-up period may help to improve the quality of lipid lowering treatments and subsequent secondary cardiovascular prevention. If direct LDL-C determination is not available, we prefer the LDL calculation with the Martin-Hopkins method.

[Lipid-lowering therapy of patients suffering from acute coronary syndrome in a Hungarian county hospital in 2015]. / Akut coronariaszindróma miatt 2015-ben kezelt betegeink lipidcsökkento terápiája.

INTRODUCTION: The actual guidelines of cardiovascular prevention lay special emphasis on the lipid-lowering therapy of patients suffering from acute coronary syndrome (ACS). AIM: To evaluate the occurrence of high-intensity statin therapy, recommended by guidelines, at discharge in a Hungarian county hospital with hemodynamic laboratory in patients who underwent percutaneous intervention, furthermore the LDL-cholesterol (LDL-C) levels and goal attainment rate in the first year. METHOD: Retrospective data collection from the hospital database regarding the therapy at discharge and the lipid levels in the year following the intervention due to ACS in 2015. RESULTS: Due to ACS event, 454 patients had coronary intervention in 2015, at discharge more than 90% of them received high-intensity statin (more than 80% rosuvastatin, 40 mg) or corresponding combination therapy. In 154 cases we found half-year lipid results; the median of LDL-C was 1.9 mmol/L, the 1.8 mmol/L target value attainment rate was 48.7%. Results after one year were found in 292 cases (73% without the deceased and foreign patients); the LDL-C median proved to be 2.0 mmol/L, the target level attainment rate was 37.3%. There was no significant difference between the results of patients from the three different ACS forms and between those of men and women. CONCLUSIONS: The lipid lowering therapy of the revascularized patients who come back for medical visits is acceptable, but greater emphasis has to be laid on increasing the rate of controlled patients compared to the present two-thirds. Orv Hetil. 2018; 159(12): 478-484.

[Diabetic dyslipidaemia and the atherosclerosis]. / Diabeteses dyslipidaemia és atherosclerosis.

The incidence and the public health importance of diabetes mellitus are growing continuously. Despite the improvement observed in recent years, the leading cause of morbidity and mortality of diabetics are cardiovascular diseases. The diagnosis of diabetes mellitus constitutes such a high risk as the known presence of vascular disease. Diabetic dyslipidaemia is characterised by high fasting and postprandial triglyceride levels, low HDL level, and slightly elevated LDL-cholesterol with domination of atherogenic small dense LDL. These are not independent components of the atherogenic dyslipidaemia, but are closely linked to each other. Beside the known harmful effects of low HDL and small dense LDL, recent findings confirmed the atherogenicity of the triglyceride-rich lipoproteins and their remnants. It has been shown that the key of this process is the overproduction and delayed clearance of triglyceride-rich lipoproteins in the liver. In this metabolism the lipoprotein lipase has a determining role; its function is accelerated by ApoA5 and attenuated by ApoC3. The null mutations of the ApoC3 results in a reduced risk of myocardial infarction, the loss-of-function mutation of ApoA5 was associated with a 60% elevation of triglyceride level and 2.2-times increased risk of myocardial infarction. In case of diabetes mellitus, insulin resistance, obesity, metabolic syndrome and chronic kidney disease the non-HDL-cholesterol is a better marker of the risk than the LDL-cholesterol. Its value can be calculated by subtraction of HDL-cholesterol from total cholesterol. Target values of non-HDL-cholesterol can be obtained by adding 0.8 mmol/L to the LDL-cholesterol targets (this means 3.3 mmol/L in high, and 2.6 mmol/L in very high risk patients). The drugs of first choice in the treatment of diabetic dyslipidaemia are statins. Nevertheless, it is known that even if statin therapy is optimal (treated to target), a considerable residual (lipid) risk remains. For its reduction treatment of low HDL-cholesterol and high triglyceride levels is obvious by the administration of fibrates. In addition to statin therapy, fenofibrate can be recommended.

Improvement in prehospital time in acute coronary syndrome between 1985 and 2013 in the south-eastern area of Hungary.

Acute coronary syndrome (ACS) is a life-threatening condition and the time-period from the onset of symptoms to the patients' arrival into the hospital has crucial importance. The authors investigated retrospectively the patients' decision time (time from the onset of the symptoms to seeking medical help) and the transport time to hospital arrival. In Hungary, it is unique of its kind that the present data can be compared to those obtained in the same area almost three decades ago.One-hundred forty-two patients (106 males and 36 females) were involved in the study, the mean age ± SD was 62.4 ± 11.3 years. The median decision time was 40 min; the median hospital arrival time was 2 h and 13 min. These were significantly shorter than in 1985-1986. These time parameters were influenced neither by gender, age, the number of inhabitants in the patients' city, the patients' education level, the occurrence of any former coronary event in the family and nor by the fact that the type of ACS was myocardial infarction with or without ST segment elevation.During the last two and half decades both the decision and the hospital arrival time decreased significantly (by 39 and 28 %, respectively) probably due to greater knowledge of general practitioners and the better organized ambulance service. Further improvement is needed; this can be expected by consistent education of the patients.

Oral anticoagulant therapy and bleeding events with vitamin K antagonists in patients with atrial fibrillation in a Hungarian county hospital.

BACKGROUND: Vitamin K antagonists, despite their tight therapeutic spectrum and the fear of bleeding complications, were long the most important drugs used in anticoagulant therapy. The aim of this study was to evaluate the quality of anticoagulant therapy and its relation with bleedings in everyday clinical practice. MATERIAL AND METHODS: We analyzed the data of 272 patients with non-valvular atrial fibrillation treated in our county hospital using retrospective data collection of the last 1008±384 days. The INR (International Normalized Ratio) values and the time in therapeutic range (TTR) were analyzed. We asked patients about bleeding complications and searched the medical records. RESULTS: The TTR proved to be 64% and there was no statistically significant difference between that of 252 (92.7%) patients taking acenocoumarol and 20 (7.3%) on warfarin. Analyzing various factors leading to TTR under 70%, we found that none of them have a significant impact. Significantly more bleeding events occurred in the first 3 months after the initiation of anticoagulant therapy and in patients with TTR under 70%, but the latter was not significant after adjustment for factors influencing bleeding (OR 1.607, CI 0.571-4.522, p=0.392). CONCLUSIONS: Although the present study's TTR values were similar to those found in the warfarin branch of various large-scale international trials and in real-life settings, further improvement of vitamin K antagonist therapy are necessary. As the possibilities for this are limited, we believe that the new type anticoagulant agents have a place in everyday clinical practice.

[A change of attitude in lipidology, achievement of target levels. What comes next?]. / Szemléletváltozás a lipidológiában, a célértékek elérése. Hogyan tovább?

One of the greatest challenges of cardiovascular prevention is to minimize the risk of cardiovascular events through the achievement of target lipid levels. Its importance is suggested by the comprehensive meta-analyses of large scale clinical trials and the therapeutic guidelines determining everyday clinical practice. The attainment of target levels is often emphasized, nevertheless, there is a gap between theory and practice. The authors compare the goal attainment rate based on Hungarian medical literature and their own data, and analyze the possibilities of further improvement. The CEL Program evaluated the achievement rate of target total cholesterol levels in more than 10 000 patients of general practitioners in 2004, 2005 and 2006, and the ratio increased from 12% to 30% within 3 years. According to the results of the Hungarian REALITY study the rate of patients achieving the target total cholesterol levels was 21% in 2004, and it increased to 27% during a 3-year period. To this very low improving rate also belongs the fact that in 2007, when only one fourth of patients were on target levels, 87% of general practitioners and 56% of specialists reconciled themselves to it and did not propose any modification in the therapy of patients not achieving the target levels. The surveys conducted at the department of internal medicine with cardiological profile of the county hospital in Gyula proved a considerable increase in the last 7 years in the administration of drugs improving the life expectancy of cardiovascular patients (aspirin, beta-blockers, ACE-inhibitors and statins) due to the widespread application of clinical guidelines and the special attention; nowadays the administration rate is above 90% in all four groups. Nevertheless, the rate of patients achieving the LDL-cholesterol goals was 37% in the high risk and 18% in the very high risk groups in December 2007 and January 2008. The fact that in the latter group only 21% of patients received combination therapy indicates that improving this ratio may be the next step. A greater emphasis should be placed on the achievement of target levels and regular revision of applied medical therapy, particularly in the high and very high risk patients as these groups can benefit the most from it.

Effects of ezetimibe on lipids and lipoproteins in patients with hypercholesterolemia and different apolipoprotein E genotypes.

BACKGROUND: The epsilon4 allele of the gene encoding apolipoprotein E (apoE) is associated with elevated serum levels of total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C), as well as an increased risk of coronary heart disease (CHD), greater disease severity, and higher CHD mortality. ApoE epsilon4 allele carriers have also shown reduced lipid and lipoprotein responses to lipid-modifying pharmacotherapy and lifestyle modifications. OBJECTIVE: To provide preliminary descriptive data on the effects of apoE genotype on lipid and lipoprotein responses to the cholesterol absorption inhibitor ezetimibe (Ezetrol/Zetia) in Hungarian subjects not at cholesterol goals at baseline. METHODS: This prospective open-label study compared the effects of the cholesterol absorption inhibitor ezetimibe 10 mg/day for up to 6 weeks added to existing therapies on the lipid profiles of 14 epsilon4 allele carriers and 14 age- and gender-matched APOE3/APOE3 homozygotes. RESULTS: Treatment with ezetimibe reduced TC, LDL-, and triglycerides, and increased high-density lipoprotein cholesterol (HDL-) significantly from baseline, and to similar extents, in both groups, lowering TC from baseline by 13.7% in APOE3/APOE3 homozygotes compared with 12.1% in epsilon4 allele carriers (p = 0.139); LDL-C by 22.8% (vs. 19.6%; p = 0.081); and triglycerides by 9.2% (vs. 9.1%; p = 0.120). Ezetimibe also increased HDL-C by 8.0% in subjects with the epsilon3/epsilon3 genotype compared with 8.9% in epsilon4 allele carriers (p = 0.263). CONCLUSIONS: Ezetimibe significantly improved lipid and lipoprotein profiles from baseline irrespective of apoE epsilon3/epsilon3 or epsilon4 genotype in Hungarian subjects not at cholesterol goals. Limitations of our study include its open-label nature and small sample population, as well as the facts that patients with the epsilon4 allele were not included and data were not collected on initial cholesterol levels, initial statin doses, cholesterol responses to statins, and the safety and tolerability of ezetimibe. Further randomized controlled studies in larger numbers of people followed for longer intervals are warranted to confirm these findings.

[Do we use digitalis properly in the management of elderly patients suffering from the signs of chronic heart failure?]. / Helyesen alkalmazzuk-e a digitáliszt idos, krónikus szivelégtelenség tüneteit mutató betegeinkben?

INTRODUCTION: The indications of digoxin therapy has been significantly narrowed and also the effective target therapeutic blood level has been decreased (0.9 micromol/L) compared to the previously desired one. OBJECTIVE: In this retrospective trial the data of 60 consecutive patients over 65 years (25 male, 35 female, mean age 77.3 +/- 5.0 y), hospitalized between 01. 01. 2002 and 31. 12. 2003 with a diagnosis of chronic heart failure and elevated (> 1.2 microg/I) serum level of digoxin, were analyzed. METHODS: Beside the analysis of the age, sex, serum level of digoxin and potassium, creatinine clearance value, symptoms and ECG-signs of digitalis intoxication, presence of atrial fibrillation, concomitant diseases and left ventricular ejection fraction value, the reasonability of digitalis treatment and therapy applied at the time of discharge (considering actual treatment guidelines) were also reviewed. RESULTS: At the admission mean serum level of digoxin was 2.1 +/- 0.9 microg/l. 20 patient's value (33.3%) was found above 2.2 microg/l. Symptoms characteristic for digitalis intoxication were observed in 28 patients. On the ECG performed at admission signs of digitalis effect/overdose were observed in 54 cases ("bigemin" ventricular extrasystoles, bradycardia, characteristic down-sloping ST-depressions). The mean left ventricular ejection fraction of the patients (51.5 +/- 12.7%) did not suggest to a significant left ventricular systolic dysfunction. For the elevated serum level of digoxin the impaired renal function (mean creatinine clearance 42.9 +/- 21.3 mL/min) was responsible in most cases. In patients with the highest serum level of digoxin (n = 20, 3.2 +/- 0.7 microg/L) the creatinine clearance was even lower, 30.4 +/- 13.7 mL/min. During hospital treatment the administration of digitalis was found to be unnecessary and thus terminated in 44 patients. At the discharge only 16 patients were receiving digitalis, 14 of them digoxin and 2 patients digitoxin. CONCLUSIONS: The authors emphasize, that in case of elderly patients the indication and control of digitalis therapy requires greater precaution and tight doctor-patient cooperation.

The evaluation of short and long-term administration of drugs improving life expectancy in patients with myocardial infarction in a Hungarian county hospital.

OBJECTIVE: The patients after myocardial infarction could hope for a significant improvement in their life expectancy when complying with the principles of the secondary prevention. Today there is no doubt that the administration of ACE-inhibitors, beta-blockers, aspirin and statins decrease mortality in these patients. Although the clinicians are aware of the guidelines of Evidence Based Medicine, international and Hungarian surveys show that in their everyday application there is still much to improve. PATIENTS AND METHODS: The authors studied the therapy of 200 consecutive patients (115 men and 85 women) who suffered from acute myocardial infarction (either STAMI or NSTAMI) in 1999-2000 at the discharge from their internal medicine department with cardiological profile and 6 months later during outpatient check-up. Having these therapeutic data a special emphasise was given to the same group of drugs and their administration was investigated in patients suffering from acute coronary syndrome with elevated troponin-T levels in the year 2002. RESULTS: In the study of years 1999-2000 at the discharge 175 of 200 patients received ACE-inhibitor (87%), 121 (60%) beta-blocker, 180 (90%) antiplatelet and 102 (51%) statin therapy. At the time of the control performed 6 months later 85% of the patients were on ACE-inhibitor, 88% on beta-blocker, 77% on aspirin and 47% on statin therapy. In this high risk population during the 6 months control the LDL-cholesterol goal of 2.5 mmol/l was attained in the 17% of patients. In the survey performed in 2002 the use of beta-receptor blocker increased to 85%, antiplatelet drug and statin administration to 95% and 57%, respectively. CONCLUSIONS: Although the administration of drugs improving life expectancy in the authors' department is comparable with the published Hungarian and international data, effort to the widespread application of the ever growing principles of the Evidence Based Medicine and continuous self-control are essential.

[Treatment of atrial fibrillation in a Hungarian hospital department of cardiologic internal medicine at the turn of the millennium]. / Törekvés a pitvarfibrilláció ritmuskontroll-kezelésére kardiológiai profilú belgyógyászati osztályon az ezredfordulón.

INTRODUCTION: The atrial fibrillation is a severe and frequent disease, which influences greatly the patients' quality of life. Only a few Hungarian studies exist which discuss the physicians' own experiences in its treatment. AIM: The description of the experiences acquired in an internal medicine department with cardiological profile during the treatment based on the actual guidelines and the review of the results of one year follow-up. METHOD: Retrospective analysis of the data of patients treated with atrial fibrillation between 1 january 1999 and 31 december 2001 and a one year follow-up was performed. The age, gender, success in cardioversion, the antiarrhythmic therapy at the discharge and the modification in it during the first year were evaluated. RESULTS: During the 3 years long period 1115 patients with atrial fibrillation were admitted (53.9% female, 46.1% male, the mean age was 72.0 +/- 10.4 years), 391 of whom were discharged with sinus rhythm. In 193 cases (49%) a spontaneous cardioversion was observed. 120 electrical (31%) and 78 pharmacological (20%) cardioversions were performed. The electrical form was carried out in 42 cases with acute atrial fibrillation (in 36 of them successfully) and in 100 cases as an elective procedure, in 84 successfully. Pharmacological cardioversion was made in 39 acute cases with the administration of propafenone (in 29 ones successfully) and in 57 elective cases with quinidine + beta-blocker + magnesium (in 49 ones successfully). For the maintenance of sinus rhythm in the 38.8% of cases amiodarone, 24.0% propafenone, 19.9% sotalol, 10.7% beta-blocker, 0.8% quinidine, 0.5% prajmaline was administered, and 5.1% of the patients didn't receive any special treatment. During the one year follow-up from the 391 patients 261 remained on sinus rhythm, in 81 cases (21%) the return of the atrial fibrillation was diagnosed (in 57 of them a successful cardioversion was performed again), 11 patients (3%) died and 38 (9%) were lost for observation. At the time of the one year control 57.8% of patients treated with amiodarone, 61.7% of those treated with propafenone, 67.9% with sotalol and 35.7% with beta-blocker remained on sinus rhythm. The amiodarone was omitted in 17 cases because of its side effects. CONCLUSIONS: The treatment of the atrial fibrillation has to be performed individually taking into account the guidelines, the comorbidity, the time of the beginning of rhythm disorder, the patients' present other drugs and the former antiarrhythmic therapy. A continuous and consistent follow-up of these patients is crucial.