Ambulatory blood pressure monitoring for risk stratification in obese and non-obese subjects from 10 populations.

Overweight clusters with high blood pressure (BP), but the independent contribution of both risk factors remains insufficiently documented. In a prospective population study involving 8467 participants (mean age 54.6 years; 47.0% women) randomly recruited from 10 populations, we studied the contribution of body mass index (BMI) to risk over and beyond BP, taking advantage of the superiority of ambulatory over conventional BP. Over 10.6 years (median), 1271 participants (15.0%) died and 1092 (12.9%), 637 (7.5%) and 443 (5.2%) experienced a fatal or nonfatal cardiovascular, cardiac or cerebrovascular event. Adjusted for sex and age, low BMI (<20.7 kg m(-2)) predicted death (hazard ratio (HR) vs average risk, 1.52; P<0.0001) and high BMI (> or = 30.9 kg m(-2)) predicted the cardiovascular end point (HR, 1.27; P=0.006). With adjustments including 24-h systolic BP, these HRs were 1.50 (P<0.001) and 0.98 (P=0.91), respectively. Across quartiles of the BMI distribution, 24-h and nighttime systolic BP predicted every end point (1.13 < or = standardized HR < or = 1.67; 0.046 < or = P<0.0001). The interaction between systolic BP and BMI was nonsignificant (P > or = .22). Excluding smokers removed the contribution of BMI categories to the prediction of mortality. In conclusion, BMI only adds to BP in risk stratification for mortality but not for cardiovascular outcomes. Smoking probably explains the association between increased mortality and low BMI.

Identification of the hemodynamic modulators and hemodynamic status in uncontrolled hypertensive patients.

Only 20-30% out of the treated hypertensive patients in Europe are achieving blood pressure (BP) control. Among other recognized factors, these poor results could be attributable to the fact that for many doctors it is very difficult to detect which is the predominant hemodynamic cause of the hypertension (hypervolemia, hyperinotropy or vasoconstriction). The aim of the study was to use non-invasive thoracic electrical bioimpedance (TEB) to evaluate hemodynamic modulators and subsequent hemodynamic status in uncontrolled hypertensive patients, receiving at least two antihypertensive drugs. A number of 134 uncontrolled hypertensive patients with essential hypertension were evaluated in nine European Hypertension Excellence centers by means of TEB (the HOTMAN(®) System). Baseline office systolic and diastolic BP averaged 156/92 mmHg. Hemodynamic measurements show that almost all patients (98.5%) presented at least one altered hemodynamic modulator: intravascular hypervolemia (96.4%) and/or hypoinotropy (42.5%) and/or vasoconstriction (49.3%). Eleven combinations of hemodynamic modulators were present in the study population, the most common being concomitant hypervolemia, hypoinotropy and vasoconstriction in 51(38%) patients. Six different hemodynamic states (pairs of mean arterial pressure and stroke index) were found. Data suggest that there is a strong relation between hypertension and abnormal hemodynamic modulators. This method might be helpful for treatment individualization of hypertensive patients.

Blood pressure, cardiovascular outcomes and sodium intake, a critical review of the evidence.

Consideration of the role of NaCl (salt) in the pathogenesis and treatment of essential hypertension is one of the overriding research themes both in experimental and clinical medicine. The evidence relating blood pressure to salt intake in humans originates from population studies and randomized clinical trials of interventions on dietary salt intake. Estimates from meta-analyses of trials in normotensive subjects generally are similar to estimates derived from prospective population studies (+ 1.7-mmHg increase in systolic blood pressure per 100 mmol increment in 24­hour urinary sodium). This estimate, however, does not translate into an increased risk of incident hypertension in subjects consuming a high-salt diet. Prospective studies relating health outcomes to 24­h urinary sodium excretion produced inconsistent results. Taken together, available evidence does not support the current recommendations of a generalized and indiscriminate reduction of salt intake at the population level. The public should be properly educated about the pros and cons of a decrease in sodium intake, in particular if they are healthy.

Coronary artery calcification, common carotid artery intima-media thickness and aortic pulse wave velocity in patients on peritoneal dialysis.

An increasing body of evidence suggests that atherosclerosis in patients with uremia differs from that found in general population in terms of advancement and localization of vascular lesions. It has also been suggested that different non-invasive techniques of vascular system evaluation are designed to show different types of lesions (i.e. vascular calcification, stiffness or 'classical' atherosclerosis). The aim of the study was to search for possible associations between results obtained with three different non-invasive methods of vascular system assessment in three different vascular sites in patients treated with peritoneal dialysis (PD). 61 patients (28 F, 33 M), mean age of 50.4+/-13.6 years, on maintenance PD for a median period of 10 months (range 1-96 months) were included. Coronary artery disease (CAD) was present in 21 subjects. In all subjects coronary artery calcification score (CaSc) using multi-row spiral computed tomography (MSCT), aortic pulse wave velocity (AoPWV) and ultrasound-based common carotid artery intima-media thickness (CCA-IMT) were performed as methods for assessing coronary calcium burden, arterial stiffness and atherosclerosis, respectively. Median value of CaSc equaled 11.5 Agatston units (range 0-5502.8 units). Median AoPWV was 10.4 m/s (range 7.56-18.1 m/s), and median CCA-IMT-0.6 mm (range 0.3-1.0 mm). In 16 patients (26.2%) at least one plaque in at least one common carotid artery was found on ultrasound. CaSc correlated with AoPWV (R=0.32, p<0.01) and with CCA-IMT (R=0.35, p<0.005), whereas no association was found between AoPWV and CCA-IMT. AoPWV, but not CaSc nor IMT correlated with blood pressure. The values of CCA-IMT and AoPWV increased together with consecutive Agatston categories (with p<0.001 for differences in AoPWV and p<0.05 for CCA-IMT). Patients with at least one plaque found in at least one CCA and patients with CAD were characterized with significantly higher values of CaSc, IMT and PWV, when compared to plaque-free and CAD- negative subjects, respectively. Association between CaSc and both IMT and PWV may suggest that the mechanism of three assessed vascular pathologies may be based, to some extent, on the process of pathologic calcium-phosphate deposition. Lack of correlation found between PWV and IMT may suggest that aortic stiffness and carotid atherosclerosis may partially differ in their pathologic background and/or are dissociated in time.

The selected pathophysiological aspects of PPARs activation.

Peroxisome proliferator activated receptors (PPARs) belong to a subfamily of transcription nuclear factors. Three isoforms of PPARs have been identified: alpha, beta/delta and gamma, encoded by different genes and distributed in various tissues. They play important roles in metabolic processes like regulation of glucose and lipid redistribution. They also have anti-atherogenic, anti-inflammatory as well as anti-hypertensive functions. In hypertension-induced cardiac hypertrophy, both PPARa and PPARg activation reveal cardio-protective effect. Despite these beneficial functions, several recent experimental reports point to the possibille unfavorable effects of PPARs activation in lipid metabolism (lipotoxicity) in cardiomyocytes, which can lead to pathologic cardiac hypertrophy in such diseases as diabetes type 2, metabolic syndrome or obesity. This paper reviews evidences and hypotheses about the new pathophysiological aspects of PPARs activation.

Ambulatory blood pressure, left ventricular mass and vascular phenotypes in relation to the endothelial nitric oxide synthase gene Glu298Asp and intron 4 polymorphisms in a population-based family study.

Reduced nitric oxide production is associated with pathological changes in the cardiovascular system. In a study of randomly chosen families, we analysed the relationship between two polymorphisms (Glu298Asp and intron 4) of the endothelial nitric oxide synthase (eNOS) and ambulatory blood pressure (ABP), left ventricular mass index (LVMI) and vascular phenotypes. The study population consisted of 127 parents and 167 offspring. All subjects underwent 24 h ABP monitoring using a SpaceLabs 90207 device. 2D and M-mode echocardiograms were obtained. Pulse wave velocity between the common carotid and femoral artery was measured with the Complior device, and the carotid intima-media thickness (IMT) was assessed by ultrasound. For statistical analysis, covariables and correlations between relatives were taken into account. The frequency of genotypes was as follows: for Glu298Asp: 55.1%-Glu/Glu, 40.1%-Glu/Asp and 4.8%-Asp/Asp; for intron 4: 65.0%-4 b/b, 33.3%-4 b/a and 1.7%-4 a/a, being in Hardy-Weinberg equilibrium (P > or = 0.29). There was no relationship between the eNOS gene polymorphisms and ABP or LVMI either in parents or their offspring. Among parents, carriers of the 298Asp allele had higher IMT values as compared with Glu/Glu homozygotes (0.94 vs 0.70 mm; P = 0.007). Among offspring, there was a similar tendency (0.60 vs 0.53 mm; P = 0.10), which was confirmed by transmission disequilibrium tests for quantitative variables (P > or = 0.07). Our findings indicate that the Glu298Asp polymorphism of eNOS identifies patients with larger carotid IMT, also in younger subjects.

Context-dependency of the relation between left ventricular mass and AGT gene variants.

In the European Project on Genes in Hypertension (EPOGH), we investigated in three populations to what extent in a family-based study, left ventricular mass (LVM) was associated with the C-532T and G-6A polymorphisms in the angiotensinogen (AGT) gene. We randomly recruited 221 nuclear families (384 parents and 440 offspring) in Cracow (Poland), Novosibirsk (Russia), and Mirano (Italy). Echocardiographic LVM was indexed to body surface area, adjusted for covariables, and subjected to multivariate analyses, using generalized estimating equations and quantitative transmission disequilibrium tests in a population-based and family-based approach, respectively. We found significant differences between the two Slavic centres and Mirano in left ventricular mass index (LVMI) (94.9 vs 80.4 g/m2), sodium excretion (229 vs 186 mmol/day), and the prevalence of the AGT -6A (55.7 vs 40.6%) and -532T (16.8 vs 9.4%) alleles. In population-based as well as in family-based analyses, we observed positive associations of LVMI and mean wall thickness (MWT) with the -532T allele in Slavic, but not in Italian male offspring. Furthermore, in Slavic male offspring, LVMI and MWT were significantly higher in carriers of the -532T/-6A haplotype than in those with the -532C/-6G or -532C/-6A allele combinations. In women, LVMI was neither associated with single AGT gene variants nor with the haplotypes (0.19 < P <0.98). In Slavic offspring carrying the AGT -532C/-6G or -532C/-6A haplotypes, LVMI significantly increased with higher sodium excretion (+3.5 g/m2/100 mmol; P=0.003), whereas such association was not present in -532T/-6A haplotype carriers (P-value for interaction 0.04). We found a positive association between LVMI and the AGT -532T allele due to increased MWT. This relation was observed in Slavic male offspring. It was therefore dependent on gender, age and ecogenetic context, and in addition it appeared to be modulated by the trophic effects of salt intake on LVM.

Fluorophotometric evaluation of blood-retinal barrier permeability in patients with essential hypertension.

AIM: The fluorophotometric evaluation of the blood-retinal barrier (BRB) integrity in patients with essential hypertension (EH) without signs of BRB damage. MATERIAL AND METHODS: 55 subjects participated in the study: 36 patients with EH and 19 normotensive healthy volunteers; 22 men and 33 women. The protocol included ophthalmic examination, fluorescein angiography, fluorophotometry, laboratory tests (total cholesterol, LDL and HDL cholesterol, triglycerides, fibrinogen, serum creatinine concentration, fasting glucose concentration, oral glucose test), urinary cotinine concentration measurement and cotinine-creatinine ratio (CCR) calculation. RESULTS: BRB permeability (P(BRB)) in patients with EH was significantly higher than in the control group (2.24 +/- 0.68 vs. 1.64 +/- 0.64 nm/s; p = 0.003). In hypertensive patients with CCR >50 ng/mg, the P(BRB) was significantly higher than the P(BRB) in healthy volunteers not exposed to smoke (2.32 vs. 1.68 nm/s; p < 0.05). CONCLUSIONS: The P(BRB) in patients with EH is significantly higher than that in the normotensive control group, which shows the damaging effect of EH on the BRB.

Ascending aortic blood pressure waveform may be related to the risk of coronary artery disease in women, but not in men.

Recent studies have demonstrated that fractional pulse pressure and fractional diastolic pressure are related to the risk of coronary artery disease. However, the effect of the ascending aortic pressure waveform on the risk of coronary artery disease in men and women analyzed separately has not been reported. The objective of the study was to assess the relation between ascending aortic blood pressure waveform and the presence of coronary artery disease in men and in women. The study group consisted of 447 patients (302 men and 145 women; mean age: 57.6+/-9.8 years) with preserved left ventricular function who were undergoing first diagnostic coronary angiography. After multivariate stepwise adjustments, the odds ratio (OR) and confidence interval (CI) of having coronary artery disease in women was (OR are reported for standard deviation increase in each variable): pulse pressure OR 1.61 (95% CI 1.06-2.46); fractional systolic pressure OR 1.72 (95% CI 1.08-2.71); fractional diastolic pressure OR 0.58 (95% CI 0.37-0.92); fractional pulse pressure OR 1.72 (95% CI 1.08-2.71); and pulsatility index OR 1.74 (95% CI 1.09-2.78). None of the studied variables was independently related to the presence of coronary artery disease in men. In conclusion, fractional systolic and diastolic pressure, pulse pressure, fractional pulse pressure and the ratio of pulse pressure to diastolic pressure may be independently related to the risk of coronary artery disease in women, but not in men.

Comparison of dual-chamber pacing with nonsurgical septal reduction effect in patients with hypertrophic obstructive cardiomyopathy.

OBJECTIVES: The aim of the study was to compare the influence of dual-chamber pacing vs. nonsurgical septal reduction on hemodynamic and morphological parameters in patients with obstructive form of hypertrophic cardiomyopathy. METHODS: Nineteen patients with dual-chamber pacing (group I) and 9 patients who underwent nonsurgical septal reduction (group II) were studied at baseline and after a 6-month follow-up. The changes of left ventricular outflow tract gradient and posterior wall thickness (as an index of left ventricular hypertrophy regression) were compared. RESULTS: The baseline left ventricular outflow tract gradient was comparable between group I and group II (77+/-25 vs. 82+/-25 mm Hg, p>0.05). At 6-month follow-up, the left ventricular outflow tract gradient was reduced to a similar level in both groups (28+/-19 vs. 25+/-12 mm Hg, p>0.05). At baseline, posterior wall hypertrophy was comparable between groups (12.9+/-1.7 vs. 13.6+/-2.2 mm, p>0.05). During follow-up, the posterior wall thickness was unchanged in the pacing group (12.9+/-1.7 vs. 12.6+/-1.6 mm, p>0.05), whereas nonsurgical septal reduction induced regression of left ventricular hypertrophy in myocardial region remote from the infarcted septal segment (13.6+/-2.2 vs. 10.5+/-2.3 mm, p<0.003). CONCLUSION: Despite comparable reduction of instantaneous left ventricular outflow tract gradient, the nonsurgical septal reduction decreased posterior wall thickness, whereas pacing did not reduce left ventricular hypertrophy. Thus, regression of left ventricular hypertrophy that appeared solely after nonsurgical septal reduction may reflect the more permanent reduction of left ventricular pressure overload. Thus, not only hemodynamic but also morphological benefit from nonsurgical septal reduction seems to indicate the superiority of this method over dual-chamber pacing.

Ambulatory blood pressure and left ventricular structure and function in relation to the G-protein beta3-subunit polymorphism C825T in White Europeans.

The 825T allele of the G-protein beta(3)-subunit is associated with increased intracellular signalling. Its association with hypertension is inconsistent. We, therefore, studied the C825T polymorphism in relation to ambulatory blood pressure as well as left ventricular structure and function in two European populations. We genotyped 248 parents and 318 offspring, enrolled in the European Project on Genes in Hypertension in Cracow, Poland (n=286) and in Novosibirsk, Russian Federation (n=280). The 24-h ambulatory blood pressure was recorded using oscillometric SpaceLabs 90207 monitors. Within each centre, a single observer performed two-dimensionally guided M-mode echocardiography and Doppler sonography to measure left ventricular structure (American Society of Echocardiography conventions) and diastolic function: early (E) and late (A) peak diastolic inflow velocities. We used analysis of covariance and generalized estimating equations to allow for covariables and nonindependence among related subjects. Genotype frequencies were similar (P=0.25) in Cracow and Novosibirsk and amounted to 44.7% for CC, 47.2% for CT, and 8.1% for TT. Among parents (mean age: 51.3 years)-but not among offspring (mean age 25.1 years)-24-h, daytime and night time systolic blood pressures were 5-6 mmHg higher in TT homozygotes than in C allele carriers. In TT homozygous parents (-8.2 cm/sec, P=0.004) as well as in TT homozygous offspring (-7.5 cm/sec, P=0.02), the E-wave was significantly reduced, which in offspring also resulted in a lower E/A ratio (-0.25, P=0.002). Neither in parents nor in offspring, left ventricular mass index was associated with the C825T polymorphism. In conclusion, in TT homozygotes of both generations, early left ventricular relaxation was reduced. In TT homozygous parents, the latter observation might be because of the higher systolic pressure associated with the TT genotype.

An association between aortic pulse wave velocity, blood pressure and chronic inflammation in ESRD patients on peritoneal dialysis.

Increased aortic pulse wave velocity (AoPWV) has been identified as a risk factor for cardiovascular morbidity in the general population and in patients on dialysis. Most of the studies in ESRD patients refer to subjects on hemodialysis. Influence of the inflammatory process on aortic stiffening remains largely unknown. The aim of the present study was to evaluate potential relationships between AoPWV and blood pressure, basic anthropometric parameters, selected growth factors and markers of the inflammatory process in ESRD patients treated with peritoneal dialysis. The study population consisted of 43 patients (19 F, 24 M) with a mean age of 50.6 +/- 13.4 years on PD for a mean period of 21.9 +/- 20.7 months. AoPWV was measured using two pressure transducers placed on the carotid and femoral arteries and connected to an automatic processor (Complion Colson AS, Paris, France). Serum levels of Tumor Necrosis Factor alpha (TNFalpha), interleukin 6 (IL-6) and plasma basic Fibroblast Growth Factor (bFGF) were measured with ELISA; C-reactive protein and fibrinogen with nephelometry. Serum lipid profile was also assessed. Blood pressure was measured in an outpatient department under standardized conditions. Mean aortic pulse wave velocity in the study population was 10.7 +/- 2.1 m/s. No difference in AoPWV was found between men and women. AoPWV correlated significantly with age (R = 0.41; p < 0.01) but not with time on dialysis. Positive relationship between AoPWV and body weight and BMI was shown (R = 0.31; p < 0.05 and R = 0.35; p < 0.05, respectively). AoPWV correlated significantly with systolic blood pressure (SBP), mean arterial pressure (MAP) and pulse pressure (PP) (R = 0.46, p < 0.005, R = 0.46, p < 0.005 and R = 0.43, p < 0.01, respectively). AoPWV correlated with serum IL-6 and plasma bFGF (R = 0.32, p < 0.05 and R = 0.4, p < 0.01; respectively). The correlation with serum CRP was borderline significant (p < 0.53). In multiple regression analysis age (beta 0.38; p < 0.005), plasma bFGF level (beta 0.3; p < 0.05), and systolic blood pressure (beta 0.29; p < 0.05) were independently associated with pulse wave velocity. Our results suggest that AoPWV values in patients on PD are associated with factors similar to those encountered in the general population. We suggest that increased aortic stiffening may also be related to the chronic inflammatory process in PD patients.

The effect of hormone replacement therapy on arterial blood pressure and vascular compliance in postmenopausal women with arterial hypertension.

Arterial pathology is a major contributor to cardiovascular disease, morbidity and mortality. Women are at higher risk of cardiovascular disease after menopause. Arterial stiffness determined by pulse wave velocity, increases with age both in men and women, whereas arterial compliance in premenopausal women is greater than in men of similar age. This difference is lost in the postmenopausal years, with evidence of rapid decline in arterial compliance in the perimenopausal period. Loss of hormonal modulation is a likely explanation for reduced arterial compliance in postmenopausal women. Long-term treatment with hormone replacement therapy (HRT) may be expected to partially reverse the increase in arterial stiffness. The aim of the study was to analyse the effect of HRT on blood pressure and arterial compliance in postmenopausal women with arterial hypertension receiving hypotensive drugs. The results in the present study of postmenopausal women with mild to moderate arterial hypertension receiving HRT showed only a transient tendency towards lower blood pressure. In our study HRT was found to improve arterial compliance at 3 months after HRT, and the effect was maintained throughout 12 months. The increased arterial compliance in women receiving HRT was independent of blood pressure. In parallel with decreasing pulse wave velocity women receiving HRT had lower total and low-density lipoprotein cholesterol. The conclusions were that after 1 year HRT in postmenopausal women with arterial hypertension improves circadian blood pressure pattern, but it does not affect significantly blood pressure values and variability. The present study also shows that HRT significantly inhibits age-related rigidity of large arteries.

Efficacy and safety of dofetilide in the prevention of symptomatic episodes of paroxysmal supraventricular tachycardia: a 6-month double-blind comparison with propafenone and placebo.

BACKGROUND: Existing drug therapies for paroxysmal supraventricular tachycardia (PSVT) have potentially serious adverse effects. Dofetilide, a pure class III antiarrhythmic agent, may offer an effective and safe alternative for treating PSVT. This study compared the efficacy and safety of dofetilide with that of propafenone and placebo in the prevention of PSVT. METHODS: This multicenter, randomized, placebo-controlled, parallel-group study compared the effectiveness of oral dofetilide 500 microg given twice daily with that of propafenone 150 mg given 3 times a day and placebo in preventing the recurrence of PSVT in 122 symptomatic patients. Episodes of PSVT were documented by symptom diaries and Hertcard (Hertford Medical, Hertfordshire, UK) event recorders. RESULTS: After 6 months of treatment, patients taking dofetilide, propafenone, and placebo had a 50%, 54%, and 6% probability, respectively, of remaining free of episodes of PSVT (P <.001 for both dofetilide and propafenone vs placebo). Both dofetilide and propafenone also decreased the frequency of episodes of PSVT; the median numbers of episodes in the dofetilide- and propafenone-treated groups were 1 and 0.5, respectively, compared with 5 in the placebo-treated group. Dofetilide was well tolerated; no proarrhythmia occurred. Three patients taking propafenone had serious treatment-related adverse effects that required drug discontinuation. CONCLUSIONS: Dofetilide and propafenone were equally effective in preventing the recurrence of or decreasing the frequency of PSVT.

Impact of gender on the left ventricular cavity size and contractility in patients with hypertrophic cardiomyopathy.

BACKGROUND: The aim of the study was to assess gender-specific differences in left ventricular cavity size, contractility and left ventricular outflow tract obstruction in patients with hypertrophic cardiomyopathy. METHODS: We studied retrospectively 129 referred patients with hypertrophic cardiomyopathy (77 males and 52 females). The echocardiographically measured left ventricular end-systolic, end-diastolic dimensions, fractional shortening and occurrence of left ventricular outflow tract gradient > or =30 mmHg were compared between sexes. Logistic regression analysis was used to calculate the predictive values of left ventricular dimensions and contractility for left ventricular outflow tract obstruction for each gender separately. RESULTS: Left ventricular end-diastolic and end-systolic dimensions were significantly smaller in females than males (41.7+/-5.3 vs. 45.1+/-4.9 mm, P=0.0003; 23.1+/-44 vs. 25.6+/-5.3 mm, P=0.007 respectively). On the contrary, the value of fractional shortening was comparable in both sexes (44.7+/-7.3 vs. 43.6+/-7.9%, P>0.05). The left ventricular outflow tract gradient occurred in females as frequently as in males (28.8 vs. 33.8%, P>0.05). By logistic regression analysis the predictors of left ventricular outflow tract gradient in females were left ventricular end-systolic diameter (relative risk=0.74; confidence interval (CI) 0.61 to 0.91; P=0.0038), left ventricular end-diastolic diameter (relative risk=0.82; CI 0.72 to 0.96; P=0.0061) and fractional shortening (relative risk=1.11; CI 1.01 to 1.22; P=0.036). The most potent predictor appeared to be left ventricular end-systolic dimension. In males none of these parameters identified patients with left ventricular outflow tract obstruction. CONCLUSIONS: Females with hypertrophic cardiomyopathy featured smaller left ventricular cavity size, which predisposed to left ventricular outflow tract obstruction (the most potent predictor of left ventricular outflow tract obstruction was left ventricular end-systolic dimension). Higher left ventricular contractility also determined left ventricular outflow tract gradient occurrence in females with hypertrophic cardiomyopathy. In males despite a larger left ventricular cavity size the left ventricular outflow tract obstruction occurred with a similar frequency as in females. Left ventricular outflow tract obstruction was not predicted by left ventricular cavity size or contractility in males.

[Krakow Program for Secondary Prevention of Ischaemic Heart Disease. Part I. Genesis and objectives]. / Krakowski Program Wtórnej Prewencji Choroby Niedokrwiennej Serca. Czesc I: geneza i cele.

In recent years a number of studies concerning ischaemic heart disease prevention have been published. Evidence from clinical and epidemiological research has led to the formation of new guidelines, especially in the field of secondary prevention. Polish Cardiac Society also published recommendations on prevention of ischaemic heart disease. Relatively little is known about how well physicians in Poland follow the guidelines. No comprehensive studies concerning risk factories management after myocardial infarction or myocardial revascularization has been conducted in Poland. Patients with established coronary heart disease were deemed to be the top priority for prevention. However, little is known about quality of medical care in this high risk population. Therefore the Cracovian Program for Secondary Prevention of Ischaemic Heart Disease was planned. The aims of the Cracovian Program are: to monitor quality of clinical care (both in clinical and general practice) in the field of secondary prevention of ischaemic heart disease, and to assess factors influencing quality of medical care. The secondary aim of the survey is to improve integration of secondary prevention into clinical practice through meetings with physicians from Cracow cardiology departments and general practitioners, as well as to improve patient compliance and motivating them to change their lifestyle. In the first stage, which was carried out in 1997-98, an evaluation was conducted to access the realization of recommendations concerning secondary prevention. An assessment of integration of ischaemic heart disease prevention into clinical practice can now be performed. The genesis, aims and methods of the Cracovian Program for Secondary Prevention of Ischaemic Heart Disease are discussed in this paper. The quality of hospital, as well as postdischarge care in the field of secondary prevention is described in the next two publications.

[Krakow Program for Secondary Prevention of Ischaemic Heart Disease. Part III. Secondary prevention of ischaemic heart disease after discharge]. / Krakowski Program Wtórnej Prewencji Choroby Niedokrwiennej Serca. Czesc III: Wtórna prewencja choroby niedokrwiennej serca w okresie poszpitalnym.

UNLABELLED: Even though the majority of actions undertaken within the secondary prevention of ischaemic heart disease should be initiated while the patient is still hospitalized, the maximum benefit (measured as decreased cardiovascular risk) achieved depends mostly on the continuation and modification of these actions in the postdischarge period. There is not much known about the quality of medical care provided for patients after hospitalization due to ischaemic heart disease. The aim of the study was to assess the quality of postdischarge care in the field of secondary prevention of ischaemic heart disease. METHODS: Consecutive patients (age > or = 70 years; residing in the Cracow province) were identified according to the following clinical diagnoses or procedures: acute myocardial infarction, unstable angina, CABG and PCI. Out of 536 patients 418 took part in the control visit 6-18 months after discharge. Risk factors and medication used were assessed. RESULTS: High total cholesterol (> or = 5.2 mmol/l) was found in 65.8% of patients, high blood pressure (> or = 140/90 mmHg) in 46.2%, obesity (BMI > or = 30 kg/m2) in 24.6%, fasting glucose over 6.0 mmol/l in 17.7% and smoking in 16.3%. The frequency of antiplatelet drugs and beta-blockers use decreased whereas that of lipid-lowering drugs increased in the postdischarge period. The highest frequency of use of antiplatelets and lipid-lowering drugs, as well as the best control of hypercholesterolemia was found in the PCI group, whereas the lowest frequency of smoking was found in the CABG group. CONCLUSIONS: Insufficient control of risk factors and the frequency of secondary prevention using drugs was found. There is a need to intensify secondary prevention in patients with ischaemic heart disease in the postdischarge period.

[Krakow Program for Secondary Prevention of Ischaemic Heart Disease. Part II. Secondary prevention of ischaemic heart disease during hospitalization]. / Krakowski Program Wtórnej Prewencji Choroby Niedokrwiennej Serca. Czesc II: Wtórna prewencja choroby niedokrwiennej serca w okresie hospitalizacji.

UNLABELLED: Hospitalization due to ischaemic heart disease provides a possibility to introduce patients education, to initiate non-pharmacological treatment and to assure patient compliance. The aim the study was to assess the frequency of risk factors and the quality of care in the field of secondary prevention in patients hospitalized due to acute coronary syndromes or subjected to myocardial revascularization. METHODS: The study was carried out in cardiac departments of six hospitals serving the area of the city. Consecutive patients (age < or = 70 years; residing in the Cracow province) were identified according to the following clinical diagnoses or procedures: first or recurrent acute myocardial infarction, first or recurrent unstable angina, first coronary artery bypass grafting or first percutaneous coronary intervention. RESULTS: Data of 536 patients (140 women and 396 men; mean age--56.6 +/- 8.4 years; hospitalized from 1.07.1996 to 30.09.1997) were collected from medical records. The rate of blood pressure measurement during the first 24-hours of hospitalization was 88.8%. Total cholesterol, HDL cholesterol, and triglycerides were assessed in 32.8%, 30.2%, and 32.3% of patients respectively during the first 24-hours of hospitalization. The height and weight were found in 54.9% and 85.1% of medical records. Obesity (BMI > or = 30 kg/m2) was found in 20.3% of patients, 36.7% smoked, 56.0% had hypertension, 15.5% diabetes and 79.5% had hyper-cholesterolemia. Medication at discharge was: antiplatelet drugs 86.7%, beta-blockers 66.4%, ACE inhibitors 50.2% and lipid lowering drugs 27.1%. CONCLUSION: There is a need to initiate a comprehensive programme in order to improve quality of care in the field of secondary prevention of ischaemic heart disease.

[Instruction of patients and a delay of treatment in myocardial infarction and unstable angina in the Krakow Program of Secondary Prevention of Ischaemic Heart Disease (IHD)]. / Instruowanie chorych a opóznienie leczenia w zawale serca i w niestabilnej dusznicy w ramach krakowskiego programu wtórnej prewencji choroby niedokrwiennej serca (ChNS).

Shortening the time between the onset of pain and start of the efficacious treatment is an important mean to lower case-fatality in myocardial infarction (MI). The goal of this publication was to assess: 1) current time between the onset of pain and: a) calling medical service by the patient b) first examination by a doctor, and c) first administration of intravenous treatment, 2) reasons of the delay in calling medical service by the patient, 3) whether patients with a diagnosis of ischaemic heart disease (IHD) prior to hospitalization were instructed how to behave in case of chest pain, and 4) whether instructing how to behave in case of chest pain was related with a time between the onset of pain and calling medical service by the patient. Studied group were 515 patients hospitalised in 6 in-patient clinics of cardiology with MI or unstable angina (UA) or hospitalised for first PTCA or CABG, 427 (83%) agreed to participate, out of whom 184 had MI or UA including 110 patients having typical chest pain. In hospitalized patients with MI or UA with typical chest pain 62% received intravenous treatment within first 4 hours after the pain onset. 35% patients received first intravenous treatment later than 6 hours after the onset of pain and out of them 2/3 after 12 hours. The main component of the delay was the long time between the onset of pain and the call for medical service. 46% patients called for medical service later than 1 hour after the onset and in 80% of them the reason was lack of knowledge on the risk and how to behave in case of chest pain. Patients who earlier received instruction had four times higher chance to call medical service within the first hour after the onset of pain (Odds Ratio = 4.11, 95% confidence interval 1.13-15.0). Only half of all patients hospitalised due to acute episode of IHD or for revascularization procedures received intensive instructions from a doctor. Adopting a detailed instruction on how to behave in case of chest pain as a standard procedure for patients with IHD may be an important mean to lower case-fatality in MI.