Success and failure of cardiovascular disease prevention in Czech Republic over the past 30 years. Czech part of the EUROASPIRE I-IV surveys.

Cardiovascular (CV) mortality was reduced more than 50 % in the Czech population at the turn of the century, due to an improvement of major CV risk factors in the general population, interventional procedures implemented into the treatment of acute coronary events, and new drugs (ACE inhibitors, statins etc.) for CV prevention (Czech MONICA and post-MONICA studies, 1985-2008). An insufficient level of preventive efforts is described in the Czech patients after acute coronary syndrome (Czech part of the EUROASPIRE studies, 1995-2013). Drug underdosing and wrong patients' compliance to life style and drug therapy recommendations represent two main reasons of this unsatisfactory situation. The residual vascular risk of patients with stable coronary heart disease (CHD) is still high due to a poor control of conventional risk factors on the one hand, and due to increasing weight and glucose metabolism abnormalities on the other hand. Patients with insulin resistance and glucose disorders have more frequently non LDL C dyslipidemia (atherogenic dyslipidemia), hypertriglyceridemic waist and high atherogenic index of plasma (AIP>0.24), i.e. markers of residual CV risk. Among others increased dose of statins and combined lipid modifying therapy should be implemented in patients with CHD, diabetes or metabolic syndrome.

A comparison of secondary prevention practice in poststroke and coronary heart disease patients.

OBJECTIVES: It is evident that patients with atherosclerotic vascular disease (AVD) benefit from appropriate secondary prevention. In clinical reality, the secondary prevention in AVD patients other than those with coronary heart disease (CHD) is often overlooked. Therefore, we compared the adherence to secondary prevention principles between poststroke and CHD patients. STUDY DESIGN: Descriptive (cross-sectional) study with prospective mortality follow-up. METHODS: We examined 1729 chronic patients with AVD (mean age 65.9 (±SD 9.6) years), 964 with CHD, and 765 poststroke (pooled data of Czech samples of EUROASPIRE III, IV, and the ESH stroke survey). The interview was performed 6-36 months after the coronary event/revascularization or the first ischemic stroke, while the mortality follow-up 5 years after this interview. RESULTS: Poststroke patients had a significantly higher risk of persistent smoking, blood pressure ≥140/90 mmHg and LDL ≥2.5 mmol/L than CHD patients [odds ratios adjusted for age, gender and survey were 1.63 (95% CI: 1.13-2.33), 1.38 (95% CI: 1.13-1.69) and 2.26 (95% CI: 1.84-2.78), respectively]. In contrast, poststroke patients showed a lower risk of inappropriate glucose control and hypertriglyceridemia [0.66 (95%CI: 0.54-0.82) and 0.74 (95%CI: 0.61-0.91), respectively]. The prescription rates of antiplatelets/anticoagulants, antihypertensives and statins were also significantly lower in poststroke than in CHD patients (89.4 vs 93.7, 85.9 vs 97.5, and 57.7 vs 89.8, respectively). Mortality analysis was performed in a subsample of 815 subjects interviewed in 2006/07. The 5-year all-cause mortality rates were 25.8% and 13.3% in poststroke and coronary patients, respectively (P = 0.0023); the hazard ratio for stroke adjusted for major risk factors was 1.85 (95% CI: 1.31-2.63). CONCLUSIONS: Compared to CHD patients, poststroke patients are strongly handicapped in terms of poor adherence to secondary prevention target, prescription of basic pharmacotherapies and mortality risk.

Exploring potential mortality reductions in 9 European countries by improving diet and lifestyle: A modelling approach.

BACKGROUND: Coronary heart disease (CHD) death rates have fallen across most of Europe in recent decades. However, substantial risk factor reductions have not been achieved across all Europe. Our aim was to quantify the potential impact of future policy scenarios on diet and lifestyle on CHD mortality in 9 European countries. METHODS: We updated the previously validated IMPACT CHD models in 9 European countries and extended them to 2010-11 (the baseline year) to predict reductions in CHD mortality to 2020(ages 25-74years). We compared three scenarios: conservative, intermediate and optimistic on smoking prevalence (absolute decreases of 5%, 10% and 15%); saturated fat intake (1%, 2% and 3% absolute decreases in % energy intake, replaced by unsaturated fats); salt (relative decreases of 10%, 20% and 30%), and physical inactivity (absolute decreases of 5%, 10% and 15%). Probabilistic sensitivity analyses were conducted. RESULTS: Under the conservative, intermediate and optimistic scenarios, we estimated 10.8% (95% CI: 7.3-14.0), 20.7% (95% CI: 15.6-25.2) and 29.1% (95% CI: 22.6-35.0) fewer CHD deaths in 2020. For the optimistic scenario, 15% absolute reductions in smoking could decrease CHD deaths by 8.9%-11.6%, Salt intake relative reductions of 30% by approximately 5.9-8.9%; 3% reductions in saturated fat intake by 6.3-7.5%, and 15% absolute increases in physical activity by 3.7-5.3%. CONCLUSIONS: Modest and feasible policy-based reductions in cardiovascular risk factors (already been achieved in some other countries) could translate into substantial reductions in future CHD deaths across Europe. However, this would require the European Union to more effectively implement powerful evidence-based prevention policies.

[Distribution of lipoprotein associated phospholipase A2 in Czech population and its interaction with conventional cardiovascular risk]. / Distribuce s lipoproteiny asociované fosfolipázy A2 v ceské populaci a její interakce s konvencním kardiovaskulárním rizikem.

INTRODUCTION: Lipoprotein associated phospholipase A2 (Lp PLA2) represent new cardiovascular risk factor and potential treatment target. We aimed to analyze the epidemiological situation of this factor in Czech population. METHODS AND RESULTS: The study population consisted from 1 962 subjects, a random samples of general population (postMONICA study), and from patients with manifest coronary or cerebrovascular disease (Czech samples of EUROASPIRE III survey). Lp PLA2 activity was estimated using commercial kits by diaDexus Inc. in frozen samples. Increased activity (by definition, i.e. > 195 nmol/ min/ ml) was observed in 21.1 % of sample, no apparent difference between subject with and without manifest vascular disease was found. Males showed higher Lp PLA2 activity, than females (179.6 vs 146, resp., p < 0.0001), while no substantial increase with age was observed. Taking Lp PLA2 activity > 195 as dependent variable, following independent variables entered the multiple logistic regression: male gender [with odds ratio 4.26 (3.26- 5.58)], low HDL cholesterol (i.e. < 1.0 mmol/ l in males or < 1.2 mmol/ l in females) [3.49 (2.62- 4.64)], LDLcholesterol > 2.5 mmol/ l [6.95 (4.79- 10.07)] and lipid  lowering treatment [0.59 (0.44- 0.79)]. In subject without manifest vascular disease, 6.3 % of them showed co incidence of markedly increased Lp PLA2 activity with high conventional risk (SCORE > 10 %). Expanding this group by intermediate risk subjects (ie. with Lp PLA2 activity 152- 194 and/ or SCORE 5- 9.9 %) leads to increase of this prevalence to 28.9 % of primary prevention subjects. CONCLUSION: Increased Lp PLA2 activity is in Czech population highly prevalent and with exception of lipid parameters, generally independent from conventional cardiovascular risk. However, up to 29 % of subject in primary prevention amalgamate increased Lp PLA2 activity with high conventional cardiovascular risk.

[An anaesthesiologist's perspective on requirements for pre-surgery examinations]. / Pozadavky na predoperacní vysetrení z pohledu anesteziologa.

A preoperative check-up remains still an issue. The preoperative check-up should thoroughly evaluate an actual state of patients health, an anticipated perioperative course should be taken into account. An internist should closely collaborate not only with a surgeon, but with an anaesthesiologist as well. As guidelines cover this topic only sparsely, different approach might result either in excess or in insufficient examinations. Therefore an anaesthesia department should have its own guidelines available that would cover required preoperative check-ups considering expected operation. These guidelines should be then sent to the internist. Preoperative check-up should be done with an adequate margin before the operation, the internist should deliver a complete report including executed laboratory check-ups and consultations with specialists.

Relation of central and brachial blood pressure to left ventricular hypertrophy. The Czech Post-MONICA Study.

Central blood pressure (BP) has been shown to be a better predictor of target organ damage and cardiovascular events than brachial BP. Whether central BP is a better predictor of left ventricular hypertrophy (LVH) determined by electrocardiography (ECG) is not known. Radial applanation tonometry and ECG were performed in 728 subjects from the Czech Post-MONICA Study (a randomly selected 1% population sample). LVH was determined using the Sokolow-Lyon index and Cornell product; central pressure was derived from radial pulse. Of 657 subjects included in the analysis, 17 (9.4%) below 45 years and 43 (9%) over 45 years had LVH. In multiple linear regression analysis, the Sokolow-Lyon index in younger individuals was only associated with male sex and low BMI, with no association with BP found. In older individuals, LVH was associated with higher central and brachial BP. In separate binary logistic regression analyses adjusted for covariates, the odds ratio for central systolic pressure was higher than those for brachial systolic and pulse pressure in LVH prediction. Noninvasively determined central pressure in subjects over 45 years is more strongly related to ECG LVH than brachial pressure. This further supports a closer association of central pressure with target organ damage. Voltage criteria of LVH are not independently associated with central or brachial BP in younger individuals.

A novel oscillometric device for peripheral arterial disease screening in everyday practice. The Czech-post MONICA study.

AIM: Ankle brachial index (ABI) is a diagnostic tool for peripheral arterial disease (PAD) and a cardiovascular risk stratification tool. Despite this evidence and guidelines recommending its use in everyday practice, ABI is not widely used. Automatic ABI measurement may lower the barrier to incorporate ABI measurement into everyday practice. The aim of this study was to validate a novel automatic oscillometric ABI device (BOSO ABI) against a gold standard-Doppler device in an epidemiological setting. METHODS: In 839 patients from the Czech post-MONICA study (a randomly selected representative population sample aged over 25 years), mean age 54.3±13.8 years (47% of men), ABI measurement was performed using the BOSO ABI device and a handheld Doppler device in a random fashion. The two techniques were carried out by different investigators each blinded to the findings of the other. Analyses were conducted as proposed by Bland and Altman. RESULTS: The mean ABI difference between the two methods was 0.1±0.11, with 95% limits of agreement ranging from -0.11 to 0.30. The difference between Doppler and oscillometric ABI increased significantly with increasing mean ABI (r=0.29; P<0.001). When considering Doppler the gold standard, automated oscillometric measurement had a 76.9% sensitivity, 97.9% specificity, and 37% positive and 99.6% negative predictive values in diagnosing ABI <0.9. CONCLUSION: The BOSO ABI device cannot be used interchangeably for standard Doppler ABI measurement in diagnosing PAD. However, its high negative predictive value allows using it as a screening tool for PAD.

An inverse association between serum leptin concentration and reported alcohol intake in patients with manifest vascular disease.

BACKGROUND/OBJECTIVES: It has been reported that alcohol stimulates appetite. We aimed to establish the association between leptin, as a major food intake regulating factor, and alcohol intake in patients with chronic manifest coronary artery or cerebrovascular disease. SUBJECTS/METHODS: A cross-sectional study of 820 subjects after acute coronary syndrome, coronary revascularization or after first ischemic stroke (the Czech part of EUROASPIRE III surveys). Leptin concentrations were evaluated among predefined categories of reported weekly alcohol intake: abstainers, light drinkers (up to 2 drinks weekly, 1-44 g of pure alcohol), mild regular drinkers (3-14 drinks weekly, 45-308 g) and moderate or heavy drinkers (more than 15 drinks, ≥ 309 g of alcohol). RESULTS: Leptin showed a clear negative trend among the alcohol intake categories. Mild regular drinkers showed significantly lower leptin levels (9.3(8.2) ng/ml) compared with abstainers (18.7(18.7) ng/ml, P<0.0001) and light occasional drinkers (14.2(17.8) ng/ml, P=0.00064). The negative association between leptin and alcohol intake as a dependent variable remained significant even after adjustment for potential confounders in multiple linear regression analysis (P=0.00032). CONCLUSIONS: Drinking of small amounts of alcohol was, in our setting, associated with decreased serum leptin concentration, with a possible benefit in terms of cardiovascular risk.

Hemodynamic response to thoracoscopy and thoracotomy.

Operations in the pleural cavity are connected with circulatory changes in pulmonary circulation and general changes of hemodynamics. These changes are influenced by the position of patient's body on the operation table and by the introduction of artificial pneumothorax. Thoracoscopy is an advanced surgical approach in thoracic surgery, but its hemodynamic effect is still not known. The aim of the present study was to compare the hemodynamic response to surgeries carried out by open (thoracotomy - TT) and closed (thoracoscopy - TS) surgical approach. Thirty-eight patients have been monitored throughout the operation--from the introduction of anesthesia to completing the surgery. Monitored parameters were systolic blood pressure (BPs), diastolic blood pressure (BPd), O2 saturation (SaO2), systolic blood pressure in pulmonary artery (BPPAs), diastolic blood pressure in pulmonary artery (BPPAd), wedge pressure (P(W)), central venous pressure in right atrium (CVP), cardiac output (CO) and total peripheral resistance (TPR). No significant difference has been found in hemodynamic response between TT and TS groups. Significant changes of hemodynamic parameters occurring during the whole surgical procedure were detected in both technical approaches. The most prominent changes were found after the position of patients was changed to the hip position (significantly decreased BPs, BPd, MAP, SaO2 and BPPAs) and 5 min after the pneumothorax was established (restoration of the cardiac output to the initial value and significant decrease of the TPR). It can be concluded that the thoracoscopy causes almost identical hemodynamic changes like the thoracotomy.

Transoesophageal echocardiography in patients with stroke and low risk of embolic etiology.

Transoesophageal echocardiography (TEE) is currently the gold standard in the diagnosis of cardiac sources of embolization and the frequently discussed question is whether all patients with suspected embolic stroke should be screened by TEE. Based on the results of transthoracic echocardiography (TTE), we determined the significance of TEE in patients with ischemic stroke with low risk of embolic etiology. We made a retrospective evaluation of TEE examination in the period from 1(st) January 2000 to 31(st) December 2003 in patients with ischemic stroke and sinus rhythm and normal left ventricular function. TEE examination was done in 159 patients. A quarter of the patients had pathological findings in the heart: left atrial thrombus in nine (5.7%), spontaneous echocontrast in left atrium in 14 (8.8%), patent foramen ovale in 16 (10%) and other findings in seven (4.4%) patients. The finding of the thrombus or echocontrast in the left atrium correlated with the size of the left atrium and it was proved in the patients with left atrium of size above 39 mm. On the contrary, patent foramen ovale was found in younger patients (70 vs. 59 years). Our results have shown that TEE is of low relevance to patients with a normal transthoracic echocardiogram.

[Chronic heart failure in the aged]. / Chronické srdecní selhání ve stárí.

Ageing of the population, advances in the treatment of cardiovascular diseases and in the treatment of chronic heart failure cause a rapid increase of the prevalence of chronic heart failure in the population and of the number of hospital admissions on account of this diagnosis. The majority of patients with chronic heart failure are over 65 years and their ratio is increasing. The diagnosis clinical course and treatment of old patients with chronic hearth failure has specific features which become more marked with advancing age. As a role other associated diseases are present as well as factor which cause deterioration of chronic hearth failure, complicate the diagnosis and treatment. With regard to the large number in the population and the patients age ambulatory care of patients with chronic heart failure will also in future be mainly ensured by general practitioners in close collaboration with cardiologist and specialist in internal medicine. A further progression of the number and severity of hospital admissions on account of chronic heart failure may be foreseen.

[Percutaneous transluminal coronary angioplasty. Initial clinical experience]. / Perkutánní transluminální koronární angioplastika. První klinické zkusenosti.

Percutaneous transluminal coronary angioplasty was performed in 20 patients with angina pectoris (16 patients with stable AP, class II-III., 4 patients with unstable AP) in the period of 1 year. There was single-vessel disease in all patients. Left ventricular function was normal as well in all patients. PTCA was successful in 16 patients (80%), in the remaining 4 patients coronary artery stenosis was not reached with balloon catheter. There were no death, Q-wave myocardial infarction or emergency bypass surgery. Transient ischemic changes on ECG has been found in 2 patients (10%). All patients with successful PTCA were symptomatically improved in period of 1-12 months, in one half of them this improvement was confirmed with stress ECG. Control coronary angiography was made in 2 patients until now, restenosis was not found.

Studies on prophylactic efficacy of N-2-hydroxyethyl palmitamide (Impulsin) in acute respiratory infections. Serologically controlled field trials.

The results of three serologically controlled double blind field trials in army units are presented. The evaluation of results according to morbidity, regardless of aetiology, showed a significant reduction in acute respiratory diseases (ARD) after administration of Impulsin. In the 1973 trial (901 volunteers), 22.7% of ARD cases were found in the Impulsin group contrary to 34.4% in the placebo group (P less than 0.0002). The relevant values in the 1974 trial (610 volunteers) were 19.7% and 40.7% (P less than 0.002) and in the 1975 trial (353 volunteers) 10.6% and 28.8% (P less than 0.004). The study of the immunological background in representative sets of volunteers allowed determination of the aetiology, the proportion of asymptomatic infections and possible deformation of results due to preexisting protective antibodies. Manifestation rate (MR) expressing the proportion of sick persons out of all sensitive subjects with serologically proved infection was found useful. This indicator is relatively independent of randomization and is more sensitive as compared to the incidence rate. In the 1973 trial, influenza A 2 England was prevalent, the MR of infection being 15.4% in the Impulsin group and 44.9% in the placebo group (P less than 0.0002). After elimination of persons with preinfection antibodies greater than or equal to 1:256 the corresponding values of MR were 17.6% and 46.6% (P less than 0.005), reflecting the "relatively clean effect" of Impulsin. In the 1974 trial, where influenza B Hong-Kong was prevalent, MR was 14.3% and 57.1%, respectively (P less than 0.001). Preinfection antibodies were negligible. The preliminary prophylactic index of the drug seemed to be 4.3 for combined adenoviral infections (trials 1973 and 1974 taken together). In the 1975 trial, the results of serological examination were unsatisfactory. Antibodies vs. influenza A Port Chalmers were found in 24.5% of ARD only. The differnce is aetiologically unclarified ARD was statistically significant. Although displaying a significant limitation of clinical infections, the administration of Impulsin did not seem to have any influence on the formation of antibodies.