High Level of Unwarranted Clinical Variation in the Use of Lower Extremity Revascularisation Procedures in Hungary (2013-2017).

OBJECTIVE: Assessment of variations in the use of lower extremity open vascular surgical procedures (LEOPEN) and lower extremity endovascular procedures (LEENDO) across small geographic areas in Hungary from 2013 to 2017. Introduction of a new metric giving a rough estimate of unwarranted clinical variation in revascularisation practice. METHODS: Spatial variation (at local administrative unit level) of referral for LEOPEN and LEENDO was evaluated through a retrospective analysis using healthcare administrative data of all beneficiaries in Hungary. The same assessment was performed for percutaneous coronary intervention in acute myocardial infarction (PCIAMI). The latter was considered a reasonable comparator (similar at risk population, well organised, guideline driven patient pathways, small room for referral discretion). Consequently, the ratio of spatial variations of LEOPEN and LEENDO to PCIAMI (as a reference) are thought to reflect unwarranted clinical variation. RESULTS: A total of 109 882 procedures were identified in the database (LEOPEN, LEENDO, PCIAMI) affecting 85 083 patients. While estimates of spatial variations for LEOPEN and LEENDO turned out to be high (systematic component of variation [SCV] 0.09 and 0.21, respectively), PCIAMI showed a low SCV value of 0.02. Consequently, the ratios of SCVs were SCV/SCVref = 4.67 (LEOPEN) and SCV/SCVref = 10.3 (LEENDO), indicating high levels of unwarranted clinical variation. CONCLUSION: The analysis showed that patients living in different locations of Hungary face very different odds of having lower extremity revascularisation procedures (open or endovascular). This spatial variation is thought to be related mainly to the failure in vascular service organisation. The newly introduced numerical estimate of unwarranted clinical variation may support within, and also between, system comparisons.

A summary of data of screening of the lower limb peripheral arterial diseases in the region of Northern Hungary / Tapasztalataink az alsó végtagi perifériás artériás érbetegség szurésérol az Észak-Magyarország régióban

INTRODUCTION: The screening tool for diagnosing lower extremity arterial disease (LEAD) is the assessment of the ankle-brachial index (ABI). In patients at risk for LEAD, the purpose of screening is to avoid major adverse limb events, such as amputation. However, resting ABI can easily produce a false negative result. AIM: In light of this, our goal was to test the usefulness of an easily performed, fast and cost-effective screening method and to determine the proportion of subjects without definitive diagnoses among patients screened in general practice (with special attention to groups having negative ABI with symptoms and patients with non-compressible arteries). METHOD: 680 patients were screened from the region of Northern Hungary. We used the Edinburgh Questionnaire, recorded medical histories, major risk factors, current complaints, and medication. Physical examinations were performed, including ABI testing. RESULTS: 34% complained about lower extremity claudication; 23% had abnormal ABI values; 14% of the patients within the normal ABI range had complaints of dysbasia; 12% were in the non-compressible artery group. The ABI-negative symptomatic group's risk factor profile showed a close similarity to the clear LEAD-positive and non-compressible artery groups. CONCLUSION: The percentage of LEAD could be higher than the number of patients diagnosed by ABI screening. Nearly a quarter of the population fell into the non-compressible artery and ABI-negative symptomatic groups. When screening purposely for LEAD, these patients deserve special attention due to the insufficient selectivity and sensitivity of measurements. If there is a high clinical suspicion of LEAD in spite of normal ABI values, further assessment may be considered. Orv Hetil. 2020; 161(33): 1381-1389.

The combined effect of regular alcohol consumption and smoking on blood pressure and on the achievement of blood pressure target values in treated hypertensive patients / A rendszeres alkoholfogyasztás és a dohányzás hatása a vérnyomásra és a vérnyomáscélértékek elérési arányára kezelt hypertoniás betegekben

INTRODUCTION: The combined effect of alcohol consumption and smoking on hypertension in hypertensive patients is still not completely clear, although both are known to be cardiovascular risk factors. AIM: The aim of our study was to compare the blood pressure, the achievement of target blood pressure and heart rate of non-smokers and non-drinkers in the middle-aged hypertensive patients with those who smoke and drink regularly. METHOD: From the database of the Hungarian Hypertension Registry, 12 615 patients (6341 men and 6274 women) aged 45-64 years were included in the current analysis, who self-reported smoking habit and alcohol consumption. RESULTS: The mean age of the patients was 55.8 ± 5.7 years (males) and 56.1 ± 5.5 years (females). The percentage of regular smokers was 40.8% and 27.2% among men and women, respectively. 38.1% of males and 12.5% of females were regular alcohol drinkers. The ratio of patients reaching goal blood pressure values was higher in all investigated groups of females than males (p<0.001). Regular smokers and drinkers have lower percentage of reaching goal blood pressure values: 31.1% versus 46.6% in males (p<0.001) and 41.1% versus 49.8% in females (p<0.01), respectively. The average of pulse rate was higher in patients who are smokers and regular drinkers. CONCLUSION: Regular alcohol consumption and smoking decrease the chance of reaching blood pressure goal values in middle-aged, treated hypertensive patients. Orv Hetil. 2020; 161(30): 1252-1259.

Lower Limb Amputations and Revascularisation Procedures in the Hungarian Population: A 14 Year Retrospective Cohort Study.

OBJECTIVE: The aim of this study was to assess the long term trends of lower limb amputation and revascularisation in Hungary over 14 years. METHODS: This was a retrospective cohort study that included all patients who underwent lower limb amputation or revascularisation over a 14 year period (2004-2017) in Hungary. Inpatient administrative data claims covering the entire beneficiary population were incorporated. Lower limb amputations (both minor and major) and revascularisation procedures (both open and endovascular) were identified in the claims files. Incidence rates were calculated and time trends were assessed via a generalised additive model. RESULTS: From 2004 to 2017, a total of 121 351 lower limb amputations (61 154 minor; 60 197 major) and 149 355 revascularisation procedures (89 243 open; 60 112 endovascular) were detected in 140 581 patients. The number of minor amputations decreased moderately in the last few years of the study period, while major amputations showed a slight decline (15%) beginning after 2013, which was more marked (22%) following adjustment for age. While the crude incidence of open vascular surgery procedures decreased by 31% (from 74.5/105 to 51.4/105), endovascular procedures showed growth by 79% (from 33.7/105 to 60.4/105) over the whole observation period. CONCLUSION: Observed amputation and revascularisation trends in Hungary are similar to the international experience. The major difference is a more than one decade lag in the starting point of the decline of amputations and in the move towards endovascular procedures. The number of amputations is more than twofold higher and the number of revascularisations is close to half that reported internationally. This comprehensive report of two vascular care performance indicators reveals an east/west vascular health divide in Europe and indicates the need to improve amputation prevention.

Screening of peripheral arterial disease in primary health care.

BACKGROUND AND PURPOSE: The screening tool for diagnosing lower extremity arterial disease is the assessment of the ankle-brachial index (ABI), which is widely used in general practice. However, resting ABI can easily produce a false negative result. In light of this, our goal was to determine the proportion of definitive diagnoses (peripheral arterial disease [PAD] confirmed or refuted) among patients screened in general practice, and the rate of cases in which the need for further specialized examination is necessary, with special attention to groups having non-compressible arteries and ABI negative symptomatic status. The aim of our work is to improve the efficiency of primary health care screening in PAD and reduce the extremely high domestic amputation ratio. PATIENTS AND METHODS: Eight hundred and sixteen patients were screened. We used the Edinburgh Questionnaire and recorded medical histories, major risk factors, current complaints, and medication. Physical examinations were performed, including ABI testing. RESULTS: Thirty-three percent complained about lower extremity claudication; 23% had abnormal ABI values; 13% of the patients within the normal ABI range had complaints of dysbasia; and 12% were in the non-compressible artery group. The ABI-negative symptomatic group's risk factor profile showed a close similarity to the clear PAD-positive and non-compressible artery groups. CONCLUSION: The percentage of PAD could be higher than the number of patients diagnosed by ABI screening. Nearly a quarter of the population fell into the non-compressible artery and ABI-negative symptomatic groups, together defined as the "murky zone". When screening purposely for PAD, these patients deserve special attention due to the insufficient selectivity and sensitivity of measurements. If there is high clinical suspicion of PAD in spite of normal ABI values, further assessment may be considered.

[Ischemic origin of diabetic foot disease. Epidemiology, difficulties of diagnosis, options for prevention and revascularization]. / A diabeteses láb ischaemiás eredete. Epidemiológia, a diagnózis nehézségei, prevenciós és revascularisatiós lehetoségek.

"Diabetic foot" as definition covers a multifactorial clinical condition. According to the recent epidemiological data, the role of lower limb ischemia is getting more influential over other pathological causes, like neuropathy, infections and bone or soft tissue deformity. In diabetes, vascular disease leads to increased risk for leg ulcers and minor or major amputations. The traditional diagnostic tools for recognition of peripheral arterial disease have limited value because of diabetes specific clinical manifestations. Available vascular centers with special expertise and diagnostic tools are the prerequisite for efficient diagnosis supporting timely recognition of peripheral arterial disease. In course of treatment of diabetic foot with ischemic origin, beyond effective medical treatment revascularization (open vascular surgery or endovascular procedures) has paramount importance for prevention of limb loss. Vascular teams of vascular specialists, vascular surgeons and interventional radiologist in dedicated centers in multidisciplinary cooperation with other professions represent public health issue in effective prevention. Orv. Hetil., 2017, 158(6), 203-211.

High prevalence of peripheral arterial disease in hypertensive patients: the Evaluation of Ankle-Brachial Index in Hungarian Hypertensives screening program.

AIMS: Peripheral arterial disease (PAD) can be diagnosed in asymptomatic stage, measuring ankle-brachial index (ABI). Low ABI is an indicator of increased cardiovascular risk and its inclusion to traditional risk factors can improve risk prediction. The objective of the present cross-sectional part of our large-scale, multicenter, observational study was to evaluate the prevalence of PAD in a large cohort of hypertensive patients. METHODS AND RESULTS: A total of 21 892 hypertensive men and women (9162 men; mean age 61.45 years) were included in our prospective study in hypertension clinics. Clinical history, physical examination, and blood analysis were taken, and the ABI was measured with the Doppler method in all patients. The prevalence of PAD (ABI ≤ 0.9) was 14.4%. In 15.6% of the patients an ABI of 0.91-0.99, and in 9.4% of the patients high ABI (>1.3) was measured. In the low, moderate, high, and very high Systematic Coronary Risk Evaluation risk groups, the prevalence of low ABI was 8.1, 11.1, 16.3, and 26%, respectively. The prevalence of PAD was lower in hypertensive patients achieving their blood pressure target (9.6 vs. 16.8%; P < 0.001). CONCLUSIONS: Asymptomatic PAD was highly prevalent in the studied hypertensive population. The use of ABI screening may improve cardiovascular risk prediction. Optimal blood pressure goal values in PAD patients and cardiovascular morbidity/mortality data will be evaluated after the 5-year long prospective phase of the Evaluation of Ankle-Brachial Index in Hungarian Hypertensives program.

Effect of sevelamer on aortic pulse wave velocity in patients on hemodialysis: a prospective observational study.

Aortic stiffening and aortic calcification are risk factors for cardiovascular events in hemodialysis (HD) patients, and these 2 risk factors are interrelated. Sevelamer decreases aortic calcification but its effect on aortic stiffness has not been investigated previously. Thirteen HD patients commencing sevelamer treatment and 13 matched controls were followed for 11 months. Aortic pulse wave velocity (PWV), augmentation index (AIx), and levels of inhibitors of vascular calcification (fetuin-A, matrix-GLA-protein, osteoprotegerin/RANKL) were measured at baseline and at the end of follow-up, and the differences between the groups were compared. Determinants of the changes in PWV during follow-up were assessed by multivariate linear regression. At baseline, PWV was 9.93 (2.10) m/s in sevelamer-treated patients and 9.20 (2.84) m/s in control patients (p=0.464). By the end of follow-up, PWV decreased by 0.83 (2.3) m/s in sevelamer-treated patients while it increased by 0.93 (1.88) m/s in controls (p=0.042). The direction of changes in AIx were similar, but not statistically significant. There were no significant differences in the levels of inhibitors of calcification either at baseline or during follow-up. In multivariate linear regression sevelamer treatment, diabetes, heart rate, and C-reactive protein were related to the change in PWV. These data suggest that sevelamer treatment is associated with an improvement in aortic stiffness in HD patients, but it does not seem to affect serum levels of inhibitors of vascular calcification.

Intracardiac calcification is a marker of generalized atherosclerosis.

Aortic valve calcification (AVC) and carotid artery calcification (CAC) are considered to be markers of generalized atherosclerosis. However, the role of intracardiac calcification (ICC) (valvular and perivalvular calcification) is unclear. The objective of this retrospective study was to analyze the relationship between ICC and CAC, risk factors, and clinical atherosclerotic disease. Risk factors included age, sex, diabetes mellitus, hypercholesterolemia, and hypertension; clinical atherosclerosis comprised stroke, coronary artery disease, and peripheral artery disease. Between January 1, 2001, and January 1, 2004, all consecutive patients were enrolled into the study who underwent both carotid ultrasonography and transthoracic echocardiography examinations within 2 months. Patients with renal failure, substantial aortic stenosis, and carotid artery occlusion were excluded. There were 320 patients (104 men; mean +/- SEM age, 66.6 +/- 0.76 years). Positive results on carotid ultrasonography are defined as any CAC. Patients were categorized as having mild, moderate, or severe CAC. Positive results on transthoracic echocardiography were defined as any ICC; AVC was defined as mitral anulus calcification (MAC) or both. Intracardiac calcification was found in 181 patients, AVC in 51 patients, MAC in 48 patients, and calcification of both structures in 82 patients. Using multiple logistic regression analysis, ICC (odds ratio, 1.9), age (10-year periods) (odds ratio, 2.0), and the presence of peripheral artery disease (odds ratio, 1.7) were independent predictors of CAC. Carotid ultrasonography results were positive in 227 patients. For CAC, the sensitivities of AVC, MAC, both, and any ICC were 52.4%, 52.0%, 33.5%, and 71.2%, respectively, and the specificities were 84.9%, 87.1%, 92.5%, and 78.5%, respectively. The extension of ICC as 0, 1 location (AVC or MAC) , or 2 locations (AVC and MAC) was associated with the severity of CAC (P < .001, tau = 0.42). There was no difference between patients with AVC vs patients with MAC in the presence of different stages of CAC (P = .62). Intracardiac calcification (MAC or AVC) is an independent predictor of CAC as a marker of atherosclerosis, although the lack of ICC does not rule out atherosclerosis. Intracardiac calcification is related to CAC, with high specificity. The extension of ICC is related to the severity of atherosclerosis. Based on our results, antiatherothrombotic therapy should be considered in patients with ICC even before obtaining a positive carotid ultrasonography result.