Acute heart failure - an EFIM guideline critical appraisal and adaptation for internists.

BACKGROUND: Over the past two decades, several studies have been conducted that have tried to answer questions on management of patients with acute heart failure (AHF) in terms of diagnosis and treatment. Updated international clinical practice guidelines (CPGs) have endorsed the findings of these studies. The aim of this document was to adapt recommendations of existing guidelines to help internists make decisions about specific and complex scenarios related to AHF. METHODS: The adaptation procedure was to identify firstly unresolved clinical problems in patients with AHF in accordance with the PICO (Population, Intervention, Comparison and Outcomes) process, then conduct a critical assessment of existing CPGs and choose recommendations that are most applicable to these specific scenarios. RESULTS: Seven PICOs were identified and CPGs were assessed. There is no single test that can help clinicians in discriminating patients with acute dyspnoea, congestion or hypoxaemia. Performing of echocardiography and natriuretic peptide evaluation is recommended, and chest X-ray and lung ultrasound may be considered. Treatment strategies to manage arterial hypotension and low cardiac output include short-term continuous intravenous inotropic support, vasopressors, renal replacement therapy, and temporary mechanical circulatory support. The most updated recommendations on how to treat specific patients with AHF and certain comorbidities and for reducing post-discharge rehospitalization and mortality are provided. Overall, 51 recommendations were endorsed and the rationale for the selection is provided in the main text. CONCLUSION: Through the use of appropriate tailoring process methodology, this document provides a simple and updated guide for internists dealing with AHF patients.

Methods proposed for monitoring the implementation of evidence-based research: a cross-sectional study.

OBJECTIVES: Evidence-based research (EBR) is the systematic and transparent use of prior research to inform a new study so that it answers questions that matter in a valid, efficient, and accessible manner. This study surveyed experts about existing (e.g., citation analysis) and new methods for monitoring EBR and collected ideas about implementing these methods. STUDY DESIGN AND SETTING: We conducted a cross-sectional study via an online survey between November 2022 and March 2023. Participants were experts from the fields of evidence synthesis and research methodology in health research. Open-ended questions were coded by recurring themes; descriptive statistics were used for quantitative questions. RESULTS: Twenty-eight expert participants suggested that citation analysis should be supplemented with content evaluation (not just what is cited but also in which context), content expert involvement, and assessment of the quality of cited systematic reviews. They also suggested that citation analysis could be facilitated with automation tools. They emphasized that EBR monitoring should be conducted by ethics committees and funding bodies before the research starts. Challenges identified for EBR implementation monitoring were resource constraints and clarity on responsibility for EBR monitoring. CONCLUSION: Ideas proposed in this study for monitoring the implementation of EBR can be used to refine methods and define responsibility but should be further explored in terms of feasibility and acceptability. Different methods may be needed to determine if the use of EBR is improving over time.

Predictors of Recovery Following Lumbar Microdiscectomy for Sciatica: A Systematic Review and Meta-Analysis of Observational Studies.

Chronic post-surgical pain is reported by up to 40% of patients after lumbar microdiscectomy for sciatica, a complaint associated with disability and loss of productivity. We conducted a systematic review of observational studies to explore factors associated with persistent leg pain and impairments after microdiscectomy for sciatica. We searched eligible studies in MEDLINE, Embase, and CINAHL that explored, in an adjusted model, predictors of persistent leg pain, physical impairment, or failure to return to work after microdiscectomy for sciatica. When possible, we pooled estimates of association using random-effects models using the Grading of Recommendations Assessment, Development, and Evaluation approach. Moderate-certainty evidence showed that the female sex probably has a small association with persistent post-surgical leg pain (odds ratio (OR) = 1.15, 95% confidence interval (CI) = 0.63 to 2.08; absolute risk increase (ARI) = 1.8%, 95% CI = -4.7% to 11.3%), large association with failure to return to work (OR = 2.79, 95% CI = 1.27 to 6.17; ARI = 10.6%, 95% CI = 1.8% to 25.2%), and older age is probably associated with greater postoperative disability (ß = 1.47 points on the 100-point Oswestry Disability Index for every 10-year increase from age (>/=18 years), 95% CI = -4.14 to 7.28). Among factors that were not possible to pool, two factors showed promise for future study, namely, legal representation and preoperative opioid use, which showed large associations with worse outcomes after surgery. The moderate-certainty evidence showed female sex is probably associated with persistent leg pain and failure to return to work and that older age is probably associated with greater post-surgical impairment after a microdiscectomy. Future research should explore the association between legal representation and preoperative opioid use with persistent pain and impairment after microdiscectomy for sciatica.

Community-acquired pneumonia - An EFIM guideline critical appraisal adaptation for internists.

BACKGROUND: In real-life settings, guidelines frequently cannot be followed since many patients are multimorbid and/or elderly or have other complicating conditions which carry an increased risk of drug-drug interactions. This document aimed to adapt recommendations from existing clinical practice guidelines (CPGs) to assist physicians' decision-making processes concerning specific and complex scenarios related to acute CAP. METHODS: The process for the adaptation procedure started with the identification of unsolved clinical questions (PICOs) in patients with CAP and continued with critically appraising the updated existing CPGs and choosing the recommendations, which are most applicable to these specific scenarios. RESULTS: Seventeen CPGs were appraised to address five PICOs. Twenty-seven recommendations were endorsed based on 7 high, 9 moderate, 10 low, and 1 very low-quality evidence. The most valid recommendations applicable to the clinical practice were the following ones: Respiratory virus testing is strongly recommended during periods of increased respiratory virus activity. Assessing the severity with a validated prediction rule to discriminate where to treat the patient is strongly recommended along with reassessing the patient periodically for improvement as expected. In adults with multiple comorbidities, polypharmacy, or advanced age, it is strongly recommended to check for possible drug interactions before starting treatment. Strong graded recommendations exist on antibiotic treatment and its duration. Recommendations on the use of biomarkers such as C-reactive protein or procalcitonin to improve severity assessment are reported. CONCLUSION: This document provides a simple and reliable updated guide for clinical decision-making in the management of complex patients with multimorbidity and CAP in the real-life setting.

A systematic review of meta-research studies finds substantial methodological heterogeneity in citation analyses to monitor evidence-based research.

OBJECTIVES: This systematic review aimed to identify the characteristics and application of citation analyses in evaluating the justification, design, and placement of the research results of clinical health studies in the context of earlier similar studies. STUDY DESIGN AND SETTING: We searched MEDLINE (Ovid), Embase (Ovid), and the Cochrane Methodology Register for meta-research studies. We included meta-research studies assessing whether researchers used earlier similar studies and/or systematic reviews of such studies to inform the justification or design of a new study, whether researchers used systematic reviews to inform the interpretation of new results, and meta-research studies assessing whether redundant studies were published within a specific area. The results are presented as a narrative synthesis. RESULTS: A total of 27 studies were included. How authors of citation analyses define their outcomes appears rather arbitrary, as does how the reference of a landmark review or adherence to reporting guidelines was expected to contribute to the initiation, justification, design, or contextualization of relevant clinical trials. CONCLUSION: Continued and improved efforts to promote evidence-based research are needed, including clearly defined and justified outcomes in meta-research studies to monitor the implementation of an evidence-based approach.

Pulmonary embolism - An EFIM guideline critical appraisal and adaptation for practicing clinicians.

BACKGROUND: Several trials have been conducted in the last decades that challenged the management of patients with acute pulmonary embolism (PE) in terms of diagnosis and treatment. Updated international clinical practice guidelines (CPGs) endorsed the evidence from these trials. The aim of this document was to adapt recommendations from existing CPGs to assist physicians in decision making concerning specific and complex scenarios related to acute PE. METHODS: The flow for the adaptation procedure was first the identification of unsolved clinical issues in patients with acute PE (PICOs), then critically appraise the existing CPGs and choose the recommendations, which are the most applicable to these specific and complex scenarios. RESULTS: Five PICOs were identified and CPGs appraisal was performed. Concerning diagnosis of PE when computed tomographic pulmonary angiography is not available/contraindicated and d-dimer is less specific, perfusion lung scan is the preferred option in the majority of clinical scenarios. For the treatment of PE when relevant clinical conditions like pregnancy or severe renal failure are present heparin is to be used. Poor evidence and low-level recommendations exist on the best bleeding prediction rule in patients treated for PE. The duration of anticoagulation needs to be tailored concerning the presence of predisposing factors for index PE and the consequent risk for recurrence. Finally, recommendations on the opportunity to screen for cancer and thrombophilia patients without recognized thrombosis risk factors for PE are reported. Overall, 35 recommendations were endorsed and the rationale for the selection is reported in the main text. CONCLUSION: By the use of proper methodology for the adaptation process, this document offers a simple and updated guide for practicing clinicians dealing with complex patients.

Quality and methodology of clinical practice guidelines on antiviral pharmacotherapy for COVID­19 during the early phase of the pandemic.

INTRODUCTION: Despite availability of reliable guidelines development methods, the risk of producing less reliable documents may be higher when the guidelines are developed rapidly. OBJECTIVES: The aim of this study was to assess quality of guidelines on coronavirus disease 2019 (COVID-19), developed in the early stages of COVID-19 pandemic and assess if recommendations for pharmacotherapy were supported by evidence. METHODS: We performed the search for documents, that considered antiviral therapies and contained a recommendations for clinicians. The quality of the guidelines was assessed using the AGREE II-Global Rating Scale Instrument and series of additional criteria. RESULTS: The analysis included 40 publications. The median of quality of documents assessed with the AGREE II-GRS tool was 2.0 (interquartile range 1.5-2.5). Most documents did not fulfill the rigour of guideline development quality criteria. The AGREE II-GRS scores did not differ significantly across the type of the document, issuing institution and the mode of publication. 75% of documents provided recommendations for the use of antiviral medications despite apparent lack of sufficient evidence supporting such treatments. Of the included documents, 75% were not updated within the 2 months after the publication of the first randomized controlled trial on COVID-19 antiviral therapy. CONCLUSIONS: Most guidelines or guidance documents published during the early phase of the COVID-19 pandemic were of poor quality, contained recommendations for the use of antiviral therapy for SARS-CoV-2 infection despite only very low quality of evidence available, and were not updated on a regular basis.

Clinical practice guidelines adaptation for internists - An EFIM methodology.

The rising number of clinical guidelines poses a new challenge to the internists. The main problems are: 1) available documents suffer from heterogeneous methodological quality, and 2) most of clinical guidelines target an 'ideal' patient affected by a single condition, while in real practice internists must face with comorbid patients typically undergoing a polypharmacy. To help address this challenge, EFIM Clinical Practice Working Group started a project aimed to answer a series of relevant clinical questions, by selecting the best available guidance containing recommendations applicable to complex patients under polypharmacy. The project started with the creation of a research protocol containing details about all the steps needed to write the Clinical Practice Guideline Summary. In particular, this methodological document specifies the rules: 1) to select topics and clinical questions; 2) to build up a panel of experts, carefully managing eventual conflict of interests; 3) to critically appraise clinical guidelines (using a validated tool as AGREE II), selecting the most valid and applicable to the common clinical practice (using ADAPTE; 4) to address and solve potential disagreements among the selected documents.

The challenge of implementing Less is More medicine: A European perspective.

The concept of Less is More medicine emerged in North America in 2010. It aims to serve as an invitation to recognize the potential risks of overuse of medical care that may result in harm rather than in better health, tackling the erroneous assumption that more care is always better. In response, several medical societies across the world launched quality-driven campaigns ("Choosing Wisely") and published "top-five lists" of low-value medical interventions that should be used to help make wise decisions in each clinical domain, by engaging patients in conversations about unnecessary tests, treatments and procedures. However, barriers and challenges for the implementation of Less is More medicine have been identified in several European countries, where overuse is rooted in the culture and demanded by a society that requests certainty at almost any cost. Patients' high expectations, physician's behavior, lack of monitoring and pernicious financial incentives have all indirect negative consequences for medical overuse. Multiple interventions and quality-measurement efforts are necessary to widely implement Less is More recommendations. These also consist of a top-five list of actions: (1) a novel cultural approach starting from medical graduation courses, up to (2) patient and society education, (3) physician behavior change with data feedback, (4) communication training and (5) policy maker interventions. In contrast with the prevailing maximization of care, the optimization of care promoted by Less is More medicine can be an intellectual challenge but also a real opportunity to promote sustainable medicine. This project will constitute part of the future agenda of the European Federation of Internal Medicine.

Association between low-grade chronic inflammation and depressed left atrial compliance in heart failure with preserved ejection fraction: A retrospective analysis.

BACKGROUND: A novel paradigm of diastolic heart failure with preserved ejection fraction (HFpEF) proposed the induction of coronary microvascular dysfunction by HFpEF comorbidities via a systemic pro-inflammatory state and associated oxidative stress. The consequent nitric oxide deficiency would increase diastolic tension and favor fibrosis of adjacent myocardium, which implies not only left ventricular (LV), but all-chamber myocardial stiffening. Our aim was to assess relations between low-grade chronic systemic inflammation and left atrial (LA) pressure-volume relations in real-world HFpEF patients. METHODS: We retrospectively analyzed medical records of 60 clinically stable HpEFF patients in sinus rhythm with assayed high-sensitive C-reactive protein (CRP) during the index hospitalization. Subjects with CRP >10 mg/L or coexistent diseases, including coronary artery disease, were excluded. LV and LA diameters and mitral E/E' ratio (an index of LA pressure) were extracted from routine echocardiographic records. A surrogate measure of LA stiffness was computed as the averaged mitral E/e' ratio divided by LA diameter. RESULTS: With ascending CRP tertiles, we observed trends for elevated mitral E/e' ratio (p <0.001), increased relative LV wall thickness (p = 0.01) and higher NYHA functional class (p = 0.02). The LA stiffness estimate and log-transformed CRP levels (log-CRP) were interrelated (r = 0.38, p = 0.003). On multi- variate analysis, the LA stiffness index was independently associated with log-CRP (ß ± SEM: 0.21 ± 0.07, p = 0.007) and age (ß ± SEM: 0.16 ± 0.07, p = 0.03), which was maintained upon adjustment for LV mass index and relative LV wall thickness. CONCLUSIONS: Low-grade chronic inflammation may contribute to LA stiffening additively to age and regardless of the magnitude of associated LV hypertrophy and concentricity. LA stiffening can exacerbate symptoms of congestion in HFpEF jointly with LV remodeling.

Antiplatelet and anticoagulant agents for primary prevention of thrombosis in individuals with antiphospholipid antibodies.

BACKGROUND: Antiphospholipid syndrome (APS) is an autoimmune disease characterised by the presence of antiphospholipid (aPL) antibodies that have prothrombotic activity. Antiphospholipid antibodies are associated with an increased risk of pregnancy complications (recurrent miscarriage, premature birth, intrauterine growth retardation) and thrombotic events (both arterial and venous). The most common thrombotic events include brain ischaemia (stroke or transient ischaemic attack) and deep vein thrombosis. To diagnose APS, the presence of aPL antibodies in two measurements and at least one thrombotic event or pregnancy complication are required. It is unclear if people with positive aPL antibodies but without any previous thrombotic events should receive primary antithrombotic prophylaxis. OBJECTIVES: To assess the effects of antiplatelet or anticoagulant agents versus placebo or no intervention or other intervention on the development of thrombosis in people with aPL antibodies who have not had a thrombotic event. We did not address obstetric outcomes in this review as these have been thoroughly addressed by other Cochrane Reviews. SEARCH METHODS: We searched the Cochrane Vascular Specialised Register (4 December 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) (last search 29 November 2017), MEDLINE Ovid, Embase Ovid, CINAHL, and AMED (searched 4 December 2017), and trials registries (searched 29 November 2017). We also checked reference lists of included studies, systematic reviews, and practice guidelines, and contacted experts in the field. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that compared any antiplatelet or anticoagulant agents, or their combinations, at any dose and mode of delivery with placebo, no intervention, or other intervention. We also included RCTs that compared antiplatelet or anticoagulant agents with each other or that compared two different doses of the same drug. We included studies performed in people of any age and with no history of thrombosis (as defined by APS Sapporo classification criteria or updated Sydney classification criteria), but with aPL antibodies confirmed on at last two separate measurements. The studies included both pregnant women who tested positive for aPL antibodies and had a history of recurrent obstetric complications, as well as non-pregnancy related cases with positive screening for antibodies, in accordance with the criteria mentioned above. DATA COLLECTION AND ANALYSIS: Pairs of authors independently selected studies for inclusion, extracted data, and assessed the risk of bias for the included studies and quality of evidence using GRADE. Any discrepancies were resolved through discussion or by consulting a third review author when necessary. In addition, one review author checked all the extracted numerical data. MAIN RESULTS: We included nine studies involving 1044 randomised participants. The studies took place in several countries and had different funding sources. No study was at low risk of bias in all domains. We classified all included studies as at unclear or high risk of bias in two or more domains. Seven included studies focused mainly on obstetric outcomes. One study included non-pregnancy-related cases, and one study included both pregnancy-related cases and other patients with positive results for aPL antibodies. The remaining studies concerned women with aPL antibodies and a history of pregnancy failure. Four studies compared anticoagulant with or without acetylsalicylic acid (ASA) versus ASA only and observed no clear difference in thrombosis risk (risk ratio (RR) 0.98, 95% confidence interval (CI) 0.25 to 3.77; 4 studies; 493 participants; low-quality evidence). No major bleeding was reported, but minor bleeding risk (nasal bleeding, menorrhagia) was higher in the anticoagulant with ASA group as compared with ASA alone in one study (RR 22.45, 95% CI 1.34 to 374.81; 1 study; 164 participants; low-quality evidence). In one study ASA was compared with placebo, and there were no clear differences in thrombosis (RR 5.21, 95% CI 0.63 to 42.97; 1 study; 98 participants; low-quality evidence) or minor bleeding risk between the groups (RR 3.13, 95% CI 0.34 to 29.01; 1 study; 98 participants; low-quality evidence), and no major bleeding was observed. Two studies compared ASA with low molecular weight heparin (LMWH) versus placebo or intravenous immunoglobulin (IVIG), and no thrombotic events were observed in any of the groups. Moreover, there were no clear differences in the risk of bleeding requiring transfusion (RR 9.0, 95% CI 0.49 to 164.76; 1 study; 180 participants; moderate-quality evidence) or postpartum bleeding (RR 1.30, 95% CI 0.60 to 2.81; 1 study; 180 participants; moderate-quality evidence) between the groups. Two studies compared ASA with high-dose LMWH versus ASA with low-dose LMWF or unfractionated heparin (UFH); no thrombotic events or major bleeding was reported. Mortality and quality of life data were not reported for any of the comparisons. AUTHORS' CONCLUSIONS: There is insufficient evidence to demonstrate benefit or harm of using anticoagulants with or without ASA versus ASA alone in people with aPL antibodies and a history of recurrent pregnancy loss and with no such history; ASA versus placebo in people with aPL antibodies; and ASA with LMWH versus placebo or IVIG, and ASA with high-dose LMWH versus ASA with low-dose LMWH or UFH, in women with aPL antibodies and a history of recurrent pregnancy loss, for the primary prevention of thrombotic events. In a mixed population of people with a history of previous pregnancy loss and without such a history treated with anticoagulant combined with ASA, the incidence of minor bleeding (nasal bleeding, menorrhagia) was increased when compared with ASA alone. Studies that are adequately powered and that focus mainly on thrombotic events are needed to draw any firm conclusions on the primary prevention of thrombotic events in people with antiphospholipid antibodies.

Relationship between gender and clinical characteristics, associated factors, and hypertension treatment in patients with resistant hypertension.

BACKGROUND AND AIM: Recent meta-analyses indicate that the pooled prevalence of resistant hypertension (RHT) barely differs between the sexes. However, differences between women and men with RHT in patient characteristics, associated factors, and hypertension (HT) management are still not well-described. METHODS: In the cross-sectional questionnaire-based observational study we included 7306 hypertensive females and 5069 hypertensive males, ≥ 18 years old, and treated for at least 12 months with antihypertensive drugs. We defined HT control as blood pressure (BP) levels both < 140 mm Hg/< 90 mm Hg. Patients were divided into three groups: controlled HT, uncontrolled HT (not fulfilling the criteria of RHT), and RHT (uncontrolled HT despite using three antihypertensive drugs including diuretic). Cardiovascular (CV) risk was evaluated according to 2013 ESH/ESC guidelines. RESULTS: There were no differences in the rates of controlled HT (47.6% vs. 47.0%), uncontrolled HT (27.3% vs. 28.8%), and RHT (25.1% vs. 24.2%) between women and men, respectively (p = 0.17). Among patients with RHT, women were older than men and had lower diastolic BP and estimated glomerular filtration rate (eGFR) as well as higher pulse pressure (PP). Cerebro-vascular diseases (16.9% vs. 14.3%; p = 0.062), abdominal obesity, and metabolic syndrome (MS, 70.5% vs. 60.1%; p < 0.001) were more frequent among women than men with RHT. Women with RHT had higher rate of high/very high added CV risk in comparison to men. In a multivariate model higher PP, presence of MS, CV disease, and eGFR < 60 mL/min/1.73 m² were related to the presence of RHT both in males and females. In women RHT was also related to abdominal obesity, cerebro-vascular diseases, and diseases causing disability. In men, RHT was additionally related to diseases requiring treatment with non-steroidal anti-inflammatory drugs. CONCLUSIONS: Although there were no differences in the rate of RHT between women and men, we identified gender-related differences in CV risk profiles in RHT patients and in factors related with the presence of RHT. When divided into age groups, RHT was less frequent in women aged less than 40 years and aged between 40 and 65 years, and among patients 65 years and older there was a tendency towards a higher rate of HT in women.

Clinical guidelines development process in Poland

Clinical practice guidelines are set of recommendations for cliniciansa bout the care of patients. The aim of clinical practice guidelines is to support clinical decision-making, rationalize diagnostic and therapeutic procedures and provide high-quality healthcare. Development of clinical practice guidelines should be a systematic process based on evidence based medicine (EBM). However, as practice shows, they are not always reliable and are not developed according to the recommended world-wide methodology. The purpose of this article is to provide an outline of the clinical guidelines development process and to present international instruments for guidance development, evaluation and adaptation

The Cochrane collaboration ­ the role in the evolution of evidence-based medicine and development of cooperation in Poland

Evidence-based medicine (EBM) is an approach to decision making on the basis of the reliable and up to date best evidence. EBM is regarded as the gold standard all over the world. Cochrane Collaboration is one of the institutions, which promote EBM among physicians, policy makers and other health care workers. Cochrane Collaboration is international non-profit organization bringing together people from all over the world, the aim of which is to create and disseminate reliable scientific information. The Cochrane Collaboration develops and publishes systematic reviews on medical and diagnostic procedures. The article presents the history of the Cochrane Collaboration, the Cochrane Library and the first Cochrane Branch in Poland. Cochrane Branch in Poland is hosted by the Systematic Reviews Centre created in 2015 within the Faculty of Medicine at the Jagiellonian University Medical College in Krakow. The authors presented the activities of the Cochrane Collaboration, the scope of activities of Polish Branch and briefly principles for the development of Cochrane systematic reviews.

Factors associated with resistant hypertension in a large cohort of hypertensive patients: the Pol-Fokus study.

INTRODUCTION:  Patients with resistant hypertension (RHT) are at high risk for coronary artery disease (CAD) and cerebrovascular disease (CVD), compared with the general hypertensive population. OBJECTIVES:  The aim of the study was to evaluate factors associated with RHT in a large sample of hypertensive patients under the care of general practitioners and specialists in Poland. PATIENTS AND METHODS:  We included 12 375 patients (mean age, 64.0 ±12.3 years; age range, 18-98 years; women, 59%) with hypertension treated for at least 1 year. Patients were divided into 3 groups: with controlled hypertension, uncontrolled hypertension (not fulfilling the criteria for RHT), and RHT. RESULTS:  Controlled hypertension, uncontrolled hypertension, and RHT were found in 47.3%, 27.9%, and 24.7% of the patients, respectively. The RHT rate was higher in patients visiting specialist offices (29.8%) and in patients with diabetes (32.5%), CAD (31.5%), CVD (33.3%), and impaired renal function (31.9%). Patients with RHT were characterized by the highest rate of high (23.5%) and very high (60.5%) added cardiovascular risk. An underuse of preferred antihypertensive drug combinations and aldosterone antagonists in patients with uncontrolled hypertension and RHT was observed. In a multivariate analysis, RHT was independently associated with male sex, higher pulse pressure, metabolic syndrome, diabetes, CAD, CVD, diseases requiring treatment with nonsteroidal anti-inflammatory drugs and an estimated glomerular filtration rate of less than 60 ml/min/1.73 m2. CONCLUSIONS:  The vast majority of patients with RHT carry a high or very high cardiovascular risk. In addition, the underuse of preferred antihypertensive drug combinations and aldosterone antagonists has been observed.

Cardiovascular risk management in type 2 diabetes of more than 10-year duration: Results of Polish ARETAEUS2-Grupa Study.

BACKGROUND: ARETAEUS 1 study showed that a great majority of patients with type 2 diabetes mellitus (T2DM) of short duration did not meet all of the treatment goals. Since then the treatment goals in T2DM have been changed. The aim of the ARETAEUS 2-Grupa Study was to assess cardiovascular (CV) risk management and meeting treatment goals in the population of T2DM of more than 10-year duration. METHODS: ARETAEUS2-Grupa was a cross-sectional questionnaire-based study conducted in Poland in 2012. Randomly selected physicians recruited 1,740 patients with T2DM diagnosed more than 10 years before the study. RESULTS: Lipid treatment goals were met respectively: for total cholesterol in 34.5% of all patients, triglycerides in 53.8%, low density lipoprotein cholesterol (LDL-C) in 26.5% and high density lipoprotein cholesterol (HDL-C) in 38.2%. Most of patients with and without coronary artery disease were receiving aspirin (90.3% and 60%, respectively) and statins (84.4% and 67.7%, respectively). The current blood pressure (BP) goal (140/90 mm Hg) was met in 43.5% of patients and the previous goal (< 130/80 mm Hg) in 12.4%. The patients were mainly treated with ≥ 3 antihypertensive drugs. All treatment goals (for HbA1c, BP and LDL-C) were reached only by 8.2% of patients, any two goals by 26.3% of patients, one goal by 39.8% of patients, none by 25.6% of patients. CONCLUSIONS: The new less restrictive treatment goals are reached more frequently but still much is to be done in the field of clinical practice guidelines implementation and CV prevention in T2DM population.

Management and treatment goals in Polish patients with type 2 diabetes of more than ten years' duration - results of ARETAEUS2-Grupa Study.

INTRODUCTION: Previous studies have shown insufficient diabetes control in patients with type 2 diabetes (T2DM). Diabetes Poland changed the target HbA1c and blood pressure (BP) values in diabetic patients in their practice guidelines in 2011, that were further sustained. To assess the management and treatment choices in T2DM of more than ten years' duration and the degree to which diabetic control criteria recommended by the Diabetes Poland clinical practice guidelines 2012 are being met. MATERIAL AND METHODS: ARETAEUS2-Grupa was a cross-sectional questionnaire-based study conducted in Poland in 2012 (April-June). It involved 1,740 patients of any age and both genders, with T2DM diagnosed more than ten years before the study, and recruited by randomly selected physicians. RESULTS: All patients received pharmacological treatment, most of them combination therapy or insulin in monotherapy. 40% of patients met the goal for HbA1c control (≤ 7%) and the median value of HbA1c was above the recommended threshold (7.2%). Only 8% of thetotal population met all three goals (HbA1c, BP and lipid levels), 26% - two goals, and 40% - only one goal. Over 25% of patients did not meet any of the treatment goals. CONCLUSIONS: We observed considerable deviations from treatment targets recommended by current clinical practice guidelines for patients with T2DM of more than ten years' duration. The frequency of cardiovascular risk factors and late diabetes complications was high, while a relatively high percentage of patients was not examined for late diabetes complications.