Frequency of office blood pressure measurements and the seasonal variability of blood pressure: results of the Hungarian Hypertension Registry.

PURPOSE: Hypertension is a major public health problem, thus, its timely and appropriate diagnosis and management are crucial for reducing cardiovascular morbidity and mortality. The aim of the new Hungarian Hypertension Registry is to evaluate the blood pressure measurement practices of general practitioners (GPs), internists and cardiologists in outpatient clinics, as well as to assess the seasonal variability of blood pressure. MATERIALS AND METHODS: Omron M3 IT devices were used during four-month periods between October 2018 and April 2023 in GP practices and in hypertension clinics. The blood pressure data were then transmitted online from the monitors' cuffs to a central database using the Medistance system of Omron. RESULTS: Family physicians (n = 2491), and internists/cardiologists (n = 477) participated in the study. A total of 4804 821 blood pressure measurements were taken during 10 four-month evaluation periods. In the ten periods, the daily average number of measurements was between 3.0 and 5.6. Following ESH diagnostic criteria, the proportion of subjects in optimal, normal and high-normal blood pressure categories were 14, 13.4 and 16.7%, respectively. Altogether 56% of the measurements belonged to stage 1, stage 2 or stage 3 hypertension categories (31.6, 17.1 and 7.4%, respectively). On average, a difference of 5/2 mmHg was observed between winter and summer data in systolic and diastolic blood pressures, respectively. The average systolic blood pressure values were higher in GP practices with more than 2000 patients than in the ones with less than 1500 patients (141.86 mmHg versus 140.02 mmHg, p < 0.05). CONCLUSION: In conclusion, the low daily average number of blood pressure measurements indicates a limited blood pressure screening awareness/capacity in the case of Hungarian family physicians. In GP practices with more patients, blood pressure is usually less well-controlled. These results suggest that the further promotion of home blood pressure monitoring is necessary.

What is the background?The standard method for the diagnosis of hypertension and for the control of treatment efficacy in hypertensive patients is office blood pressure measurement.Until now we had no real-life data on the blood pressure measurement practices of general practitioners (GPs), internists and cardiologists.Although seasonal differences in blood pressure values are well known, we had no data on the extent of these changes.What is new?In this real-world, nationwide observational study we were able to measure the frequency of blood pressure measurements in the daily practice of GPs, internists and cardiologists in Hungary, which was found to be very low compared to the number of patients they treat. In practices with more patients, blood pressure is generally less well-controlled.We could also detect a significant seasonal variation in systolic and diastolic blood pressure values over the observed time periods.What is the impact?The low daily average number of blood pressure measurements indicates a limited blood pressure screening awareness/capacity in the case of Hungarian family physicians, supporting the further promotion of home blood pressure measurement.The marked seasonal blood pressure changes demonstrated by our study require attention and the individual adjustment of treatment in different seasons.

Nature of Cardiac Rehabilitation Around the Globe.

BACKGROUND: Cardiac rehabilitation (CR) is a clinically-effective but complex model of care. The purpose of this study was to characterize the nature of CR programs around the world, in relation to guideline recommendations, and compare this by World Health Organization (WHO) region. METHODS: In this cross-sectional study, a piloted survey was administered online to CR programs globally. Cardiac associations and local champions facilitated program identification. Quality (benchmark of ≥ 75% of programs in a given country meeting each of 20 indicators) was ranked. Results were compared by WHO region using generalized linear mixed models. FINDINGS: 111/203 (54.7%) countries in the world offer CR; data were collected in 93 (83.8%; N = 1082 surveys, 32.1% program response rate). The most commonly-accepted indications were: myocardial infarction (n = 832, 97.4%), percutaneous coronary intervention (n = 820, 96.1%; 0.10), and coronary artery bypass surgery (n = 817, 95.8%). Most programs were led by physicians (n = 680; 69.1%). The most common CR providers (mean = 5.9 ±â€¯2.8/program) were: nurses (n = 816, 88.1%; low in Africa, p < 0.001), dietitians (n = 739, 80.2%), and physiotherapists (n = 733, 79.3%). The most commonly-offered core components (mean = 8.7 ±â€¯1.9 program) were: initial assessment (n = 939, 98.8%; most commonly for hypertension, tobacco, and physical inactivity), risk factor management (n = 928, 98.2%), patient education (n = 895, 96.9%), and exercise (n = 898, 94.3%; lower in Western Pacific, p < 0.01). All regions met ≥ 16/20 quality indicators, but quality was < 75% for tobacco cessation and return-to-work counseling (lower in Americas, p = < 0.05). INTERPRETATION: This first-ever survey of CR around the globe suggests CR quality is high. However, there is significant regional variation, which could impact patient outcomes.

Cardiac Rehabilitation Availability and Density around the Globe.

BACKGROUND: Despite the epidemic of cardiovascular disease and the benefits of cardiac rehabilitation (CR), availability is known to be insufficient, although this is not quantified. This study ascertained CR availability, volumes and its drivers, and density. METHODS: A survey was administered to CR programs globally. Cardiac associations and local champions facilitated program identification. Factors associated with volumes were assessed using generalized linear mixed models, and compared by World Health Organization region. Density (i.e. annual ischemic heart disease [IHD] incidence estimate from Global Burden of Disease study divided by national CR capacity) was computed. FINDINGS: CR was available in 111/203 (54.7%) countries; data were collected in 93 (83.8% country response; N = 1082 surveys, 32.1% program response rate). Availability by region ranged from 80.7% of countries in Europe, to 17.0% in Africa (p < .001). There were 5753 programs globally that could serve 1,655,083 patients/year, despite an estimated 20,279,651 incident IHD cases globally/year. Volume was significantly greater where patients were systematically referred (odds ratio [OR] = 1.36, 95% confidence interval [CI] = 1.35-1.38) and programs offered alternative models (OR = 1.05, 95%CI = 1.04-1.06), and significantly lower with private (OR = .92, 95%CI = .91-.93) or public (OR = .83, 95%CI = .82-84) funding compared to hybrid sources.Median capacity (i.e., number of patients a program could serve annually) was 246/program (Q25-Q75 = 150-390). The absolute density was one CR spot per 11 IHD cases in countries with CR, and 12 globally. INTERPRETATION: CR is available in only half of countries globally. Where offered, capacity is grossly insufficient, such that most patients will not derive the benefits associated with participation.

Treatment of Hypertensive and Hypercholesterolaemic Patients with the Triple Fixed Combination of Atorvastatin, Perindopril and Amlodipine: The Results of the CORAL Study.

INTRODUCTION: Hypertension and hypercholesterolaemia are important contributors to the development and progression of atherosclerosis. The coexistence of these two conditions is rather common: hypercholesterolaemia is present in 40-60% of hypertensive patients. Remarkably, patient compliance with antihypertensive regimens is better than with statin therapy. Thus, the inclusion of statins and blood pressure-lowering agents into a fixed combination might even double the effectiveness of statin therapy, and thereby achieve significantly greater reduction of cardiovascular risk. The CORAL study was a 3-month, prospective, multicentre, observational, non-interventional survey, which evaluated the blood pressure- and lipid-lowering efficacy of the triple fixed combination of atorvastatin/perindopril/amlodipine, administered in various dose combinations. METHODS: The efficacy of the triple fixed combination was reflected by the changes of the blood pressure readings taken in the office and during 24-h blood pressure monitoring (3 months elapsed between visits 1 and 3). The laboratory parameters obtained during data acquisition were also recorded. RESULTS: After 3 months of therapy, mean office blood pressure decreased from 158.5 ± 16.7/91.7 ± 9.4 to 132.2 ± 8.3/80.1 ± 6.8 mmHg (p < 0.0001), whereas mean 24-h blood pressure decreased from 146.0 ± 14.5/82.5 ± 12.1 to 132.1 ± 13.2/75.6 ± 9.9 mmHg. With regard to metabolic parameters, the inclusion of pre-existing statin therapy in the fixed combination led to further, significant reduction of lipid parameters as follows: total cholesterol level from 6.18 ± 1.15 to 5.16 ± 0.88 mmol/L, LDL-cholesterol from 3.41 ± 1.01 to 2.80 ± 0.82 mmol/L and triglyceride level from 2.26 ± 1.17 to 1.82 ± 0.83 mmol/L (all p < 0.0001). CONCLUSION: Treatment with the fixed triple combination of atorvastatin, perindopril and amlodipine might take us closer to the optimal therapy for hypertensive patients with hypercholesterolaemia. The expected improvement of patient adherence to treatment may result in an increase of the percentage patients who achieve both blood pressure control and the LDL-cholesterol targets recommended in guidelines. Moreover, this may translate into the further decline of the risk of prospective cardiovascular events. FUNDING: Egis Pharmaceuticals.

Cardiac rehabilitation availability and delivery in Europe: How does it differ by region and compare with other high-income countries?: Endorsed by the European Association of Preventive Cardiology.

AIMS: The aims of this study were to establish cardiac rehabilitation availability and density, as well as the nature of programmes, and to compare these by European region (geoscheme) and with other high-income countries. METHODS: A survey was administered to cardiac rehabilitation programmes globally. Cardiac associations were engaged to facilitate programme identification. Density was computed using global burden of disease study ischaemic heart disease incidence estimates. Four high-income countries were selected for comparison (N = 790 programmes) to European data, and multilevel analyses were performed. RESULTS: Cardiac rehabilitation was available in 40/44 (90.9%) European countries. Data were collected in 37 (94.8% country response rate). A total of 455/1538 (29.6% response rate) programme respondents initiated the survey. Programme volumes (median 300) were greatest in western European countries, but overall were higher than in other high-income countries (P < 0.001). Across all Europe, there was on average only 1 CR spot per 7 IHD patients, with an unmet regional need of 3,449,460 spots annually. Most programmes were funded by social security (n = 25, 59.5%; with significant regional variation, P < 0.001), but in 72 (16.0%) patients paid some or all of the programme costs (or ∼18.5% of the ∼€150.0/programme) out of pocket. Guideline-indicated conditions were accepted in 70% or more of programmes (lower for stable coronary disease), with no regional variation. Programmes had a multidisciplinary team of 6.5 ± 3.0 staff (number and type varied regionally; and European programmes had more staff than other high-income countries), offering 8.5 ± 1.5/10 core components (consistent with other high-income countries) over 24.8 ± 26.0 hours (regional differences, P < 0.05). CONCLUSION: European cardiac rehabilitation capacity must be augmented. Where available, services were consistent with guidelines, but varied regionally.

Association of Exercise Capacity with Physical Functionality and Various Aspects of Fatigue in Patients with Coronary Artery Disease.

The aim of this study was to examine associations between exercise capacity-indexed as the metabolic equivalent of the task-and various aspects of subjective fatigue, physical functionality, and depression in patients with coronary artery disease. A cross-sectional design was used. Patients with stable coronary artery disease (N = 240) underwent an exercise stress test and completed self-report assessments of depression, subjective physical limitations, vital exhaustion, and the impact of fatigue on physical, social, and cognitive functions. Associations between exercise capacity and these self-report variables were assessed using bivariate correlations and a series of multivariate regressions. Exercise capacity was negatively associated with vital exhaustion, physical limitations, and impact of fatigue on physical and social functioning but not on cognitive functioning. There was a marginal association between exercise capacity and depression. The associations between exercise capacity and fatigue remained significant even after controlling for effects of age, body mass index, gender, education, and comorbid diabetes mellitus. The main conclusion of the study is that in patients with coronary artery disease, exercise capacity has the strongest predictability for physical fatigue, but, importantly, it also independently predicts the feeling of loss of energy and malaise.

Exercise-based cardiac rehabilitation in twelve European countries results of the European cardiac rehabilitation registry.

AIM: Results from EuroCaReD study should serve as a benchmark to improve guideline adherence and treatment quality of cardiac rehabilitation (CR) in Europe. METHODS AND RESULTS: Data from 2.054 CR patients in 12 European countries were derived from 69 centres. 76% were male. Indication for CR differed between countries being predominantly ACS in Switzerland (79%), Portugal (62%) and Germany (61%), elective PCI in Greece (37%), Austria (36%) and Spain (32%), and CABG in Croatia and Russia (36%). A minority of patients presented with chronic heart failure (4%). At CR start, most patients already were under medication according to current guidelines for the treatment of CV risk factors. A wide range of CR programme designs was found (duration 3 to 24weeks; total number of sessions 30 to 196). Patient programme adherence after admission was high (85%). With reservations that eCRF follow-up data exchange remained incomplete, patient CV risk profiles experienced only small improvements. CR success as defined by an increase of exercise capacity >25W was significantly higher in young patients and those who were employed. Results differed by countries. After CR only 9% of patients were admitted to a structured post-CR programme. CONCLUSIONS: Clinical characteristics of CR patients, indications and programmes in Europe are different. Guideline adherence is poor. Thus, patient selection and CR programme designs should become more evidence-based. Routine eCRF documentation of CR results throughout European countries was not sufficient in its first application because of incomplete data exchange. Therefore better adherence of CR centres to minimal routine clinical standards is requested.

Vital exhaustion and anxiety are related to subjective quality of life in patients with acute myocardial infarct before cardiac rehabilitation.

AIMS AND OBJECTIVES: To examine psychological risk factors and somatic factors in patients after myocardial infarction. To study the relationship between somatic and psychological factors, their influence on subjective quality of life (well-being) and also to examine possible gender differences. BACKGROUND: There has been a growing body of evidence that psychosocial factors are risk factors for incident and recurrent myocardial infarction. DESIGN: Descriptive correlational and cross-sectional survey design. METHODS: In patients (n = 97, 67 men), the level of depression and anxiety, vital exhaustion, sleep disturbances and well-being were assessed. Left ventricular ejection fraction, left ventricular diastolic diameter, body mass index, metabolic equivalents and the number of diseased vessels were retrieved from medical records. RESULTS: Anxiety, vital exhaustion and sleep disturbances were significantly higher in women than in men. Well-being showed a significant linear correlation with body mass index, anxiety, depression, vital exhaustion and sleep disturbances scores. After adjustment for psychological risk factors and somatic parameters, only vital exhaustion and anxiety correlated significantly with well-being. However, there were gender differences in predictive variables of well-being. Anxiety in men and vital exhaustion in women showed a linear correlation with the subjective quality of life. CONCLUSION: Our study revealed that only vital exhaustion and anxiety showed a significant correlation with well-being in patients. RELEVANCE TO CLINICAL PRACTICE: During cardiac rehabilitation, it is important to detect and treat not only depression but also vital exhaustion and anxiety, because by reducing these psychological conditions, we can improve well-being.

Standards for the use of cardiopulmonary exercise testing for the functional evaluation of cardiac patients: a report from the Exercise Physiology Section of the European Association for Cardiovascular Prevention and Rehabilitation.

Cardiopulmonary exercise testing (CPET) is a methodology that has profoundly affected the approach to patients' functional evaluation, linking performance and physiological parameters to the underlying metabolic substratum and providing highly reproducible exercise capacity descriptors. This study provides professionals with an up-to-date review of the rationale sustaining the use of CPET for functional evaluation of cardiac patients in both the clinical and research settings, describing parameters obtainable either from ramp incremental or step constant-power CPET and illustrating the wealth of information obtainable through an experienced use of this powerful tool. The choice of parameters to be measured will depend on the specific goals of functional evaluation in the individual patient, namely, exercise tolerance assessment, training prescription, treatment efficacy evaluation, and/or investigation of exercise-induced adaptations of the oxygen transport/utilization system. The full potentialities of CPET in the clinical and research setting still remain largely underused and strong efforts are recommended to promote a more widespread use of CPET in the functional evaluation of cardiac patients.

[Occurrence of anxiety and depression disorders after acute cardiac events during hospital rehabilitation. Application of the Hospital Anxiety and Depression Scale as a screening instrument]. / A szorongásos és depressziós zavarok elofordulása akut kardiológiai állapotokat követo asztályos rehabilitáció során. A kórházi szorongás és depresszió skála szurotesztként történo alkalmazása.

UNLABELLED: Hospital Anxiety and Depression Scale (HADS) is one of the most frequently used screening instruments for comorbid psychiatric disorders in patients with somatic diseases. Depression and anxiety disorders occurring after acute coronary events predict a worse prognosis and rehabilitation outcome and impair the patient's quality of life. Therefore, diagnosis and treatment of depression and anxiety are important clinical issues. METHODS: Item characteristics, different aspects of reliability and validity of the HADS test parameters have been analysed on the basis of a follow-up study of 747 patients after acute coronary events participating in a hospital rehabilitation program. Short form of the Beck Depression Inventory, Spielberger State Anxiety Inventory, Hamilton Anxiety and Hamilton Depression Questionnaires were used as references. Criterion validity and cut-off points of HADS subscales were determined according to MINI+, a standardised diagnostic interview. RESULTS: The Depression (D) and Anxiety (A) subscales of the Hungarian version of HADS demonstrated high internal consistency (HADS-D: Cronbach =0,81, HADS-A: =0,85). Explorative factor analysis yielded a two-factor (1st: anxiety and 2nd: depression) structure. HADS subscales have shown high correlations with scales measuring similar constructs and validated in Hungarian. Empirical cut-off points of both subscales were determined with ROC analysis (HADS-D: 9 points, HADS-A 8 points). Sensitivity and specificity at these cut-off points fell into the acceptable 0.7 - 0.9 range. CONCLUSION: On the basis of these results, HADS can be used as a reliable and valid instrument for the measurement and identification of anxiety and depression symptoms and disorders in cardiac patients.

[Psychological factors considerably influence the results of 6-min walk test after coronary bypass surgery]. / A pszichológiai tényezok jelentosen befolyásolják a 6 perces járásteszt eredményeit ACBG-mutét után.

UNLABELLED: The 6-min walk test (6MWT) is a simple, low-cost method for estimating physical exercise capacity of cardiac patients, when exercise test cannot be performed, as in patients early after coronary artery bypass surgery. As the test requests active cooperation of patients, possibly not only somatic, but psychological factors can influence the results. 358 patients who arrived to Phase II residential cardiac rehabilitation after their first coronary artery bypass surgery were included in the prospective study. 6-MWT was performed at the beginning and at the end of 3 weeks program. Hospital Anxiety and Depression Scale (HADS), Type-D personality test were filled in 3 weeks after surgery. RESULTS: Patients characterized as Type-D personality (8.5%) covered considerably shorter distance than non-Type-D patients both at the beginning (255 +/- 91 m vs. 319 +/- 106 m, p < 0.01) and at the end of 6MWT (361 +/- 91 m vs. 411 +/- 106 m, p < 0.05) without any substantial differences in heart rate or rating of perceived exertion. Patients with high level of anxiety (16.5%) had lower walking distance compared to non anxious patients both at the beginning and the ending test (274 +/- 97 m vs. 320 +/- 106 m, p < 0.01 and 374 +/- 110 m vs. 413 +/- 104 m, p < 0.05), and evaluated higher rate of perceived exertion (12.5 +/- 1.1 vs. 11.9 +/- 1.4, p < 0.05 and 11.7 +/- 0.8 vs. 11.3 +/- 1.3, p < 0.05). Patients who were depressed according to HADS (14%) walked shorter distance than non depressed patients both at the beginning (267 +/- 88 m vs. 320 +/- 107 m, p < 0.01), and end of 6MWT (347 +/- 99 m vs. 416 +/- 104 m, p < 0.001). There were no differences in somatic function of patients with and without psychological alternations. CONCLUSION: Psychological factors (Type D personality, anxiety and depression) considerably influence 6MWT walking distance after coronary artery bypass surgery.

[What influences the rate of complications during phase II. residential cardiac rehabilitation after coronary events?]. / Koszorúér-eseményeket követo II. fázisú intézeti rehabilitációs kezelés alatt eszlelt szövodményeket befolyásoló tényezok.

AIM: The authors sought to investigate the occurrence of complications and adverse events among patients participating in phase II. Residential cardiac rehabilitation program after coronary event (myocardial infarction, transluminal coronary angioplasty or coronary artery bypass graft operation) and determine the factors, that can influence the rate and seriousness of these events. PATIENTS: 724 patients were included in the study prospectively, 302 after myocardial infarction (MI), 64 after coronary intervention (PCI), 358 after coronary artery bypass graft (CABG), respectively. RESULTS: During the rehabilitation program 25.5% of patients suffered from complication, the most frequent events were pleural effusion (5.6%), pericardial effusion (3.9%), Dressler's syndrome (3.5%), heart failure (2.9%), difficulties with wound healing (2.6%), angina pectoris (2.3%), and atrial fibrillation (2.1%). 168 patients (23.2%) could complete the rehabilitation program in spite of these complications, 19 patients (2.6%) had to be transferred to other hospital wards. There was no difference in complication rate among men and women. The rate of complications were different in the patient groups composed according to the last coronary event (16.6% after AMI, 6.2% after PCI, 37.2% after CABG, p < 0.001). Elderly patients (> or = 65 years) had higher complication rate (31.8% vs. 21.3%, p < 0.01). The rate of adverse events were between 0 and 42.6% in a data matrix, built up according to three categories (gender, coronary event, and age groups). CONCLUSION: With simple categories we can identify those patients, who had higher complication rate during phase II. Residential cardiac rehabilitation program after coronary event.

ICF Core Sets for chronic ischaemic heart disease.

OBJECTIVE: To report on the results of the consensus process integrating evidence from preliminary studies to develop the first version of a Comprehensive ICF Core Set, and a Brief ICF Core Set for chronic ischaemic heart disease. METHODS: A formal decision-making and consensus process integrating evidence gathered from preliminary studies was followed. Preliminary studies included a Delphi exercise, a systematic review and an empirical data collection. After training in the ICF and based on these preliminary studies relevant ICF categories were identified in a formal consensus process by international experts from different backgrounds. RESULTS: The preliminary studies identified a set of 253 ICF categories at the second, third and fourth ICF levels with 89 categories on body functions, 25 on body structures, 82 on activities and participation and 57 on environmental factors. Sixteen experts attended the consensus conference on CIHD (11 physicians with various sub-specializations and 3 physical therapists). Altogether 61 second-level categories were included in the Comprehensive ICF Core Set with 14 categories from the component body functions, one from body structures, 17 from activities and participation and 29 from environmental factors. The Brief ICF Core Set included a total of 36 second-level categories with 10 on body functions, one on body structures, 13 on activities and participation and 12 on environmental factors. CONCLUSION: A formal consensus process integrating evidence and expert opinion based on the ICF framework and classification led to the definition of ICF Core Sets for CIHD. Both the Comprehensive ICF Core Set and the Brief ICF Core Set were defined.