Patients in cardiac rehabilitation programme--where we were in 1999 and where 10 years later.

The aim of this study was to find out and compare characteristics of cardiac patients who, after hospital treatment, participated in cardiac rehabilitation programmes at the Polyclinic for Cardiovascular Prevention and Rehabilitation in Zagreb during 1999 and 2009. The results show an increase in mean patients' age (men: 55.5 to 61.53; p = 0.000 and women: 58.95 to 62.66; p = 0.01), an increase of the proportion of those +/- 65 years by 23% in both genders (men: 17% to 40%; women: 27% to 50%), an increase in the proportion of women (21.16% to 28.22%), a marked increase in the proportion of post - PCI patients with stenting (men: 15.58% to 61.92%; women: 9.68% to 62.20%), reduction of patients with BMI < 25.00 kg/m2 (men: 47.19% to 13.93%; women: 54.84% to 24.41%) and a constantly high proportion of patients with hypercholesterolemia (above 85%). It is obvious that systematic action is required to improve awareness of risk factors and desirable health behaviour.

The prevalence of smoking among Croatian hospitalized coronary heart disease patients.

The aim of this paper was to investigate the prevalence of smoking using selected anthropometric variables in a sample of hospitalized coronary heart disease (CHD) patients in Croatia (N = 1,298). A total of 444 subjects (34.6%) were non-smokers, 548 (42.6%) were smokers and 293 (22.8%) were ex-smokers. Men, on average, smoked more cigarettes per day than women (22.62 vs. 19.84 cigarettes, p < 0.001) and they also had bigger index "pack-years" than women (36.96 vs. 33.91, p = 0.024). Men were more often smokers and ex-smokers than women (47.4% vs. 30.8% for smokers and 25.0% vs. 22.8% for ex-smokers, p < 0.001). In this study a high prevalence of smoking was found among CHD patients in Croatia. Unless it is decreased, it can be expected that CHD patients in Croatia will continue to experience adverse effects more often than other CHD patients in the rest of Europe.

The CroHort study: cardiovascular behavioral risk factors in adults, school children and adolescents, hospitalized coronary heart disease patients, and cardio rehabilitation groups in Croatia.

Based on repeated measurement of health behaviors the CroHort Study showed that health behavior explains a great deal more of class inequalities in mortality than observed in previous studies. These include decreasing prevalence of smoking and increase in obesity, hypertension and diabetes mellitus. The lowest prevalence of health risks was recorded among children and adolescents, followed by general adult population from the CroHort Study. Hospitalized coronary heart disease patients had higher risks prevalence than general population, while the highest prevalence of risks was recorded among patients in cardiac rehabilitation program. The higher levels of stress were associated to lower financial conditions, poorer social functioning and poorer mental health for both men and women. Higher levels of stress were also associated with heart problems, higher alcohol consumption in men while in women stress was associated to poorer general health, higher age and lower levels of education.

[Reason for dietary salt reduction and potential effect on population health--WHO recommendation]. / Razlozi za smanjenje soli u prehrani i potencijalni ucinak na zdravlje populacije--preporuke Svjetske zdravstvene organizacije.

It is well known that reduction of salt results in lowering blood pressure and cardiovascular incidents. Daily salt is double the recommended daily quantity and mainly comes from processed food. The assessment of daily salt intake for Croatia is 12 g/day (WHO recommendation is <5 g/day). The main source of sodium is processed food and food prepared in restaurants (77%), natural content of sodium in food (12%), added salt at table (6%) and prepared meals at home (5%). Reduction of salt by 50% would save nearly 180,000 lives per year in Europe. It is necessary to establish better collaboration with food manufacturers in order to reduce the content of salt in processed food and to achieve appropriate salt intake per day in accordance with the WHO recommendation. Further, it is necessary to encourage food manufacturers to produce food and meals with low or reduced salt content (shops, catering, changes in recipes, offer salt substitutions). This kind of collaboration is based on bilateral interests that can result in positive health effects. One of the most important public health tasks is to educate consumers and to give them choice when buying food. This can be achieved by effective campaigns and social marketing, by ensuring a declaration of salt content on the product, or specially designed signs for food products with low or reduced salt content.

[Secondary prevention and cardiac rehabilitation]. / Sekundarna prevencija i rehabilitacija kardiovaskularnih bolesnika.

Coronary heart disease is a chronic disease with multifactorial etiology. The risk depends on several, already well-known, risk factors such as hypertension, diabetes mellitus, dyslipidemia, smoking, obesity, physical inactivity, stress, etc. Multiple risk factors will increase the risk. The variety of risk factors requires a multidisciplinary approach--a team of different experts guided by a cardiologist who ensures an appropriate rehabilitation program. This should include secondary prevention as an important part of coronary heart disease patient treatment. It is based on the generally accepted medical, professional and scientific principles and long standing international experience. Papers written by experts and published on behalf of the World Health Organization, European Society of Cardiology, European Society of Hypertension, European Association for Cardiovascular Prevention and Rehabilitation, and other societies, define the basic characteristics of cardiac rehabilitation programes: aims, forms, content, indications and ways of implementing it in order to make it comprehensive, and to help regain the patients' temporarily lost ability to return to normal life and work. The cardiac patient will be fully educated to manage his exercise program and secondary prevention for life. Taking into account the situation that we have in our country, in relation to social structure, demography, legislation and types of health insurance, we would recommend that post-acute coronary syndrome patients undergo a cardiac rehabilitation program, which includes secondary prevention. After the education and rehabilitation program, aimed at individual needs, patients will continue under the guidance of his/her GP, consulting the specialist only when needed. In this way, the positive effects of cardiac rehabilitation will be long lasting.

[Epidemiology of acute coronary syndrome in the City of Zagreb]. / Epidemiologija akutnog koronarnog sindroma u Gradu Zagrebu.

AIM: Amongst cardiovascular diseases (CVD), acute coronary syndrome (ACS) is an important cause of cardiovascular mortality. The aim of the study was to examine ACS in Zagreb, to determine how it is treated, and to assess the extent to which new guidelines have been implemented in daily practice. During the last decades, great improvements have been made in the prevention and management of ACS. We wished to ascertain how these improvements have been implemented in our hospitals in the year 2003. METHODS: We carried out a retrospective study including patients in the City of Zagreb that had been discharged from the hospital with the diagnosis of ACS. The community-based Registry of Acute Coronary Syndrome for the City of Zagreb for the year 2003 served as the source of data. Records on 1,733 ACS patients were analyzed. In 1,349 hospitalized patients, the following parameters were investigated: length of hospital stay; time from onset of symptoms to arrival in hospital; rate of angiography and reperfusion and medical therapy after discharge. RESULTS: Study results showed that 1,105 (64%) patients were discharged from hospital, 244 (14%) died in hospital, and 384 (22%) died outside hospital. There were 1,136 (84%) patients with AMI, 638 (56%) with ST segment elevation MI, 391 (34%) with non-ST segment elevation MI and 107 (10%) of patients with possible MI and MI with undetermined ECG. Patient records revealed that 688 (51%) stayed in hospital between 8 and 14 days. The time from symptom onset to hospital arrival was less than 6 hours in 566 patients, 349 (44%) men and 217 (39%) women; 6 to 12 hours in 157 patients, 79 (10%) men and 78 (14%) women; and over 12 hours in 410 patients, 238 (30%) men and 172 (31%) women. The time of symptom onset was unknown in 216 patients, 127 (16%) men and 89 (16%) women. Angiography and reperfusion therapy were performed in 557 (41%) patients, 373 (47%) men, and 184 (33%) women; PCI/PCI + stent in 33% of men with ST or non-ST segment elevation, and 25% of women with ST segment elevation and 19% of women with non-ST segment elevation. Fibrinolytic therapy was performed in 86 patients, 53 (7%) men and 30 (5%) women. Amongst ACS patients (N=966), 85% took aspirin, 70% beta-blockers, 69% angiotensin converting enzyme inhibitors and 63% statins. DISCUSSION AND CONCLUSION: Compared to other studies, non-ST segment elevation MI and unstable angina seemed to be less often diagnosed. Patients arrived in hospital rather late after symptom onset, and this was probably one of the reasons that reperfusion therapy could not be sufficiently applied. We also noted that physicians did not always follow the generally accepted guidelines to enable a better outcome by use of preventative measures and higher rate of effective therapy. There are important lessons to be learnt from this study for both patients and physicians.

[Obesity and overweight in Croatia]. / Pretilost i prekomjerna tjelesna tezina u hrvatskoj.

AIM: Obesity has become a growing public health problem. The number of obese people in the world is increasing, carrying a number of risks for the development of cardiovascular and other diseases. There are no easy or short-term solutions for this problem. The causes differ and the number of obese and overweight people varies from region to region. The aim of the study was to estimate the distribution of obese and overweight people in Croatia. METHODS: The study was carried out in 2003 in a sample of 9070 subjects, representative of the population of Croatia. We used three measures of obesity and overweight: body mass index (BMI); waist circumference, and waist/hip ratio (WHR). Overweight is defined as BMI of 25.00-29.99 kg/m2, and obesity as BMI of 30 kg/m2. The other two measures vary according to sex. Waist circumference greater than 102 cm (40 in) in men and greater than 88 cm (35 in) in women is considered to show unfavorable fat distribution, and WHR > or = 1 in men and > or =0.85 implies an increased risk of heart disease, diabetes, hypertension, and some forms of cancer. Weighted data were analyzed with SPSS statistical software. RESULTS: The analysis of each of the variables yielded the following results: BMI: generally, more than 1 in 5 adults (about 720,000) in Croatia were obese with no sex differences. The highest rate of obesity was found in the inland part of the country and lowest along the Adriatic coast. Overweight was more common than obesity, showing some sex differences [705,000 (43%) men and 625,000 (34%) women]. The greatest number of overweight men lived along the Adriatic cost and in Zagreb, the capital of Croatia, while the greatest number of overweight women lived along the Adriatic coast. The greatest number of overweight young men lived along the Adriatic coast and of young overweight women in the east inland part of Croatia. Waist circumference showed great sex differences: 54% of women (993,000) had waist circumference greater than 88 cm (35 in), and 37% of men (607,000) had waist circumference greater than 102 cm (40 in). The greatest number of men with such waist circumference were found in the inland part, and in the middle and southernmost part of the Adriatic coast. The greatest number of women with waist circumference over 88 cm lived in the continental part of Croatia. WHR showed even greater sex difference: 41.0% of women (754,000) and 18.5% of men (303,000) had unfavorable WHR. The greatest number of men and women with unfavorable WHR lived in the inland and southern parts of Croatia. CONCLUSIONS: Obesity and overweight pose major problems in Croatia. There are regional and sex differences, and differences according to the variables observed. In order to get proper insight in the current situation, we recommend that BMI be adjusted for fat distribution and comorbid conditions.

Acute coronary syndrome and the 1992-1995 war in Bosnia and Herzegovina: a 10-year retrospective study.

OBJECTIVE: To examine the effects of war in Bosnia and Herzegovina on the occurrence of acute coronary syndrome among civilians. METHODS: The incidences of acute myocardial infarctions (first and recurrent) and unstable angina pectoris were examined among the residents of Mostar and the nine neighboring districts. The study population was the population that lived in the area before the war (182,000 in the 1991 census). Others who immigrated into the area were not taken into consideration. Five consecutive years (1987-1991) before the war and 5 consecutive years (1992-1996) during the war were analyzed. RESULTS: In the 5-year period during the war, 267 men and 161 women suffered from acute myocardial infarctions, compared with 246 men and 119 women in the 5-year period before the war. The wartime increase in acute myocardial infarctions for the combined male-female population was statistically significant (p = 0.025). For women, the wartime increase was statistically significant only for the age group of 60 to 69 years (p = 0.007). The smaller increase among men was not statistically significant (p = 0.354). The increase to a wartime number of 52 cases of recurrent myocardial infarctions from a prewar level of 24 was statistically significant (p = 0.001). The percentage of fatal myocardial infarctions among women, however, was lower during the war (18.6%) than before the war (32.8%) (p = 0.048). During the war, 109 men with unstable angina pectoris were hospitalized, compared with 84 before the war; the cases among women were 76 and 41, respectively. The increase was statistically significant among women (p = 0.001) but not among men (p = 0.072). There was a statistically significant increase (p < 0.001) in the total number of unstable angina pectoris cases during the war (185 cases, compared with 125 prewar cases). CONCLUSION: The common population during the war in Bosnia and Herzegovina had increased numbers of acute myocardial infarctions and unstable angina pectoris cases.

Colorectal carcinoma cells (Caco-2) secrete stroma-inducing growth factors in a stroma-oriented direction.

Understanding of the mechanisms by which epithelial tumor cells induce their supportive stroma in carcinomas is of great general interest for the development of new therapeutic anticancer strategies. In the present study we investigated whether polarized colorectal carcinoma cells (Caco-2) release well-known stroma-inducing factors diffusely or specifically at the stroma-oriented cell pole. We demonstrate that Caco-2 cells secrete vascular endothelial growth factor, tumor necrosis factor alpha and platelet-derived growth factor preferentially towards a basolateral stroma-oriented direction. Other cytokines such as several interleukines, basic fibroblastic growth factor and prostaglandin E2 are not secreted in significant amounts by Caco 2 cells. We conclude that the directed secretion of stroma-regulating factors might play a central role in the regulation of both tumor angiogenesis and tumor invasion in carcinomas with a polarized growth pattern.

[Epidemiologic importance of acute coronary syndrome in the population of the city of Zagreb]. / Epidemiolosko znacenje akutnog koronarnog sindroma u populaciji Grada Zagreba.

AIM: The aim of the study was to determine the number of hospitalized patients with acute coronary syndrome (ACS) in the Zagreb population. METHODS: Zagreb residents hospitalized in five Zagreb hospitals (Sveti Duh General Hospital, Merkur, Sestre Milosrdnice, Dubrava University Hospitals, and Zagreb University Hospital Center) during 2000 and 2001 with the diagnosis of ACS, were examined. Patients who suffered from acute myocardial infarction with ST elevation (STEMI), patients with acute myocardial infarction without ST elevation (NSTEMI) and patients with unstable angina (UA) were analyzed according to gender and outcome. RESULTS: During 2000, and 2001, 1453 and 1538 Zagreb residents were hospitalized for ACS, respectively, 62% of them men. STEMI was present in 54% of patients hospitalized during 2000 and 56% of those hospitalized during 2001. NSTEMI was present in 19% of patients in 2000 and 23% of patients in 2001, while the respective percentage of UA was 17% and 21%. Among STEMI patients, case fatality was higher in women (> 20%) than in men (< 20%) (p = 0.05), whereas no sex difference was observed in NSTEMI (< 20%) and in UA (about 3%) patients. CONCLUSION: Women had a higher case fatality. Case fatality was also higher in patients with STEMI than in those with NSTEMI and UA, who had a much lower case fatality. Due to the lack of data, further follow-up is needed because reliable data can help us in the prevention and treatment of ACS.

Trends in acute myocardial infarction mortality and morbidity from 1979 to 2001 in the City of Zagreb, Croatia.

AIM: To define trends in age-adjusted acute myocardial infarction mortality and morbidity in women and men in the city of Zagreb, Croatia, in the period 1979-2001. METHODS: Acute myocardial infarctions occurring in both men and women at ages between 25 and 74 years were analyzed by using 1979-2001 data from the Acute Myocardial Infarction Population-based Register for the City of Zagreb, Croatia. The patients with myocardial infarction were identified retrospectively from the hospital discharge reports and death certificates in Zagreb hospitals and the Croatian Statistical Bureau. RESULTS: Over the period of 23 years, a total of 25,359 cases of acute myocardial infarction were registered in the city of Zagreb (18,345 men and 7,014 women). The age-adjusted attack rate for men was the lowest in 1981 (170 per 100,000 population) and the highest in 1993 (274 per 100,000 population), with a decreasing trend toward 2001. The rate for women was between 49 per 100,000 population in 1979 and 86 per 100,000 population in 1993, with a decreasing trend afterwards. Between 1993 and 2001, the rate for men decreased by 68.6% and for women by 62.8% (P=0.370). The age-adjusted mortality rate showed more pronounced changes and was much higher for men then for women. The rates per 100,000 population among men varied between 80 and 140, and among women between 20 and 40. Between 1993 and 2001, the age-adjusted myocardial infarction mortality rates decreased by 56.3% and 52.5% in men and women, respectively (P=0.670). The age-adjusted prehospital mortality rate for men was much higher than the hospital mortality rate and had an obvious decreasing trend since 1993. Both rates were much lower for women. Twenty-eight-day case-fatality rate for men ranged from 38.5% to 49.1%, and from 39.0% to 64.0% for women. It did not change much in men during the observed period. Women younger than 45 years had a significantly greater risk of a fatal heart attack, whereas the risk was greater for men in the older age groups (55-74 years). CONCLUSION: The age-adjusted attack rates, mortality rates, prehospital death rates, and case-fatality rates showed a definite decline since the early 1990s for both men and women, but the decline was greater for men.

Dual role of AP-2gamma in ErbB-2-induced mammary tumorigenesis.

A causative role of the membrane-bound tyrosine kinase ErbB-2 in breast tumorigenesis has been well established. MMTV/neu transgenic mice which overexpress ErbB-2 consistently develop mammary carcinomas with a high incidence. In human breast cancer, ErbB-2 is overexpressed in 25-30 of all cases and is representing a clinical marker of a poor prognosis. Besides to gene amplification, ErbB-2 overexpression has been attributed to transcription factors of the AP-2 family which were shown to control the ErbB-2 gene promoter in cell culture studies. Particularly AP-2alpha and gamma are often coexpressed in ErbB-2-positive breast carcinomas. However, LTRgamma transgenic mice which overexpress AP-2gamma in their mammary epithelium display only a very weak upregulation of the erbB-2 gene and do not develop mammary carcinoma. These findings therefore raise the possibility of functional cooperativity between both genes in breast cancer. To experimentally address the impact of AP-2gammaon ErbB-2-induced breast carcinogenesis we crossed MMTV/neu transgenic mice with LTRgamma transgenic mice and monitored tumor development in bitransgenic female progeny. AP-2gamma overexpression negatively influenced tumor incidence, as reflected by a reduced tumor number and a prolonged tumor latency. Histological analysis revealed three major types of tumors corresponding to different stages of tumor progression. Interestingly, an increased proportion of advanced stage carcinomas was observed in bitransgenic mice. Moreover, the AP-2gamma transgene differentially affected proliferation rates between the different progression stages: proliferation was enhanced at early stages but reduced in advanced stages in comparison to control tumors. Therefore, AP-2gamma while reducing the incidence of mammary tumors is promoting tumor progression.