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.

[Combined therapy of arterial hypertension]. / Kombinovaná terapie arteriální hypertenze.

For a successful treatment of arterial hypertension, in most patients it is necessary to prescribe at least two antihypertensive medicines. A well chosen fixed combination of antihypertensives improves lifelong compliance with treatment, another important approach to improving treatment compliance being regular education of the patient regarding the appropriateness of regular medicine taking in relation to the risks of untreated hypertension. Currently, when initiating treatment of uncomplicated hypertension, the combination of diuretics with betablockers is being abandoned, especially for their metabolic adverse effects. The most frequent combination of recommended antihypertensive medicinal products is a combination of reninangiotensin system inhibitors, i.e. ACE inhibitors or sartans, with calcium channel blockers or diuretics. Some studies about the efficacy of this modern combined antihypertensive therapy are mentioned.

[Opinion of the Czech Atherosclerosis Society's committee (CSAT) on the ESC/EAS guidelines related to the diagnostics and treatment of dyslipidemias issued in 2011]. / Stanovisko výboru CSAT k doporucením ESC/EAS pro diagnostiku a lécbu dyslipidemií z roku 2011.

This position statement of the Executive Committee of the Czech Society for Atherosclerosis (CSAT) summarizes the most important aspects and novelties of the latest European guidelines for the management of dyslipidemia. In particular the position statement comments on: cardiovascular risk stratification, indications for plasma lipid and lipoprotein levels assessment as well as target lipid values, evaluation of current options for both lifestyle and pharmacological treatment of lipid metabolism disorders and, also, recommendation for laboratory monitoring of patients treated with lipid lowering agents. The statement deals with actual concepts of management of dyslipiemia in everyday practice, e.g. therapy of dyslipidemia in special patients´ groups. This statement does not replace the latest guidelines but focuses on the changes from the former guidelines for dyslipidemia management, published by CSAT in 2007.

[The ankle brachial index in type 2 diabetes]. / Kotníko-pazni index u nemocných s diabetes mellitus 2. typu.

INTRODUCTION: The ankle brachial index (ABI), i.e. the ratio of systolic blood pressure (SBP) on the ankle and on the arm, is diagnostic for peripheral occlusive artery disease and a marker of cardiovascular (CV) risk. The association between the low ABI < 0.9 and the CV risk in type 2 diabetes (T2DM) subjects was investigated. METHODS: We examined 253 T2DM subjects (135 males, 118 females, aged 66 +/- 9 years). The blood pressures were measured in the supine position with the 2 mm Hg accuracy; Doppler ultrasound was used for the ankle SBP and the mercury sphygnomanometer for the arm SBP. The high CV risk was defined as manifest CV diseases, elevated coronary calcium score (CAC) by Agatston (> 101) or according to the global CV Risk Score > or = 5% (SCORE). STATISTICAL METHOD: Wilcoxon's unpaired test, chi2 test, multiple logistic regression. RESULTS: The ABI < 0.9 was found unilateral in 23 T2DM (8%), bilateral in 24 (9%), in older males (71 +/- 8 years) with higher CAC (600 +/- 707) (p < 0.01), higher total cholesterol (5.4 +/- 1.3 mmol/L) and total homocystein (17.2 +/- 7.1 micromol/L) (p <0.05) in comparison to those with the ABI > or = 0.9 (age 66 +/- 9 years, CAC 234 +/- 458, total cholesterol 5.0 +/- 0.9, total homocystein 14.3 +/- 78). Many CV risk factors correlated positively with the low ABI < 0.9; it was significantly independently associated with age (p < 0.001), smoking (p < 0.01), LDL-cholesterol, total homocystein and CAC (p < 0.05). Low ABI < 0.9 predicted ischemic stroke in subjects with T2DM and manifest CV diseases in the further 3 years. There was no correlation between the ABI and the ultrasensitive C-reactive protein. CONCLUSION: Low ABI < 0.9 was in a strong association with the CV risk. The ABI measurement is a simple, noninvasive, time-nonconsuming and inexpensive method for subclinical atherosclerosis detection; the ABI can supply standard methods for the CV risk prediction.

Lower serum levels of interleukin-6 in a population sample with symptoms of depression than in a population sample without symptoms of depression.

In this study we compared the levels of interleukin (IL)-6, IL-8, IL-10 and tumor necrosis factor-alpha (TNF-alpha) in population samples characterized by a high or low level of self-reported depression. We measured serum IL-6, IL-8, IL-10 and TNF-alpha in two cohorts which differed in scoring on the Zung Self-Rating Depression Scale (ZSDS). The group with a high score in ZSDS (average SDS index = 62.9) was called DEP (n=27), the group with a low score in ZSDS (average SDS index = 29.9) was called NDEP (n=16). The groups did not significantly differ in age, waist circumference and body mass index. For the assessment of serum cytokine levels multiplex immunoanalytic xMAP(LUMINEX) technology was used. We found lower IL-6 in the DEP group (medians; DEP 4.08 pg/ml vs. NDEP 6.11 pg/ml) on the border of statistical significance in multiple regression analysis (p=0.049). Serum levels of all other studied cytokines were not significantly different (medians; IL-8: DEP 2.18 pg/ml vs. NDEP 2.61 pg/ml; IL-10: DEP 2.85 pg/ml vs. NDEP 2.94 pg/ml; TNF-alpha: DEP 2.32 pg/ml vs. NDEP 2.30 pg/ml). These results are in contradiction to the prevailing opinion that pro-inflammatory cytokine levels are elevated in people with symptoms of depression.

[Monitoring of cardiovascular risk factors in patients with diabetes type 2]. / Kontrola kardiovaskulárních rizikových faktoru u diabetiku 2. typu.

The control of basic cardiovascular risk factors was examined in a sample of 415 diabetes type 2 patients, aged 66 +/- 10 years, with a 9.4 +/- 8 years long history of diabetes, both genders represented proportionally; 95% of the sample were hypertensive. The recommended blood pressure value was achieved by 13% males and 17% females. Antihypertensive monotherapy was indicated in 40% of the sample. Renin-angiotensin-aldosteron system inhibitors were prescibed to 90% of the sample. The fasting glycaemia < or = 6 mmol/L were achieved in 10% males and 11% females; glycosilated hemoglobin < 4.5% in 20% males and 24% females; 60% of the sample had antidiabetic pharmacotherapy--44% males and 48% females used metformin. Total fasting plasma cholesterol < 4.5 mmol/L was achieved in 31% males and 23% females; LDL-cholesterol < 2.5 mmol/L was achieved in 31% males and 41% females. The target values for diabetics in secondary prevention of cardiovascular diseases or with subclinical atherosclerosis was achieved in 13% of the sample. Statins were prescribed in 60% of the sample, fibrates in 4%. Only 2 females achieved all the target values. Hypolipidemic and antihypertensive drug therapy is unsatisfactory; there is certainly a big potential in life style changes among the diabetic patients.

[Anxious-depressive disorders and metabolic syndrome]. / Anxiózne depresivní poruchy a metabolický syndrom.

Anxiety and depressive behavioural disorders often occur concomitantly and their incidence in the general population as well as in chronically ill is higher than anticipated. Pilsen study of male and female patients (N = 1,050) selected from a population-based sample of the primary prevention survey PILS III (Pilsen Longitudinal Study III) had proven an existence of associations between depressive behavioural disorder and metabolic syndrome (MS). Depressive disorders were nearly twice as frequent in patients with MS compared to individuals without MS (RR = 1.85; CI: 1.11-3.10). Patients with psychiatric disorders were excreting more cortisol in the urine than individuals without psychiatric disorders, while there was no difference in the excretion ofcatecholamines and serotonin. Our results provide an indirect evidence for the hypothesis suggesting that increased activation of the sympathoadrenal axis could be pathophysiologically involved in the concomitant occurrence of the typical MS risk factors and depressed mood. Anxiety and depressive disorders are linked to higher cardiometabolic risk, higher incidence of acute cardiovascular events as well as poorer prognosis for cardiac patients; they are comorbid to a range of other chronic internal diseases. The association between cardiovascular disease, diabetes and psychiatric disorders is bilateral, i.e. patients with anxiety and depression experience cardiovascular events more frequently, and the patients with type 2 diabetes and cardiometabolic diseases suffer more frequently from anxious-depressive disorder. In clinical practice, we should search for anxious-depressive disorders. At present, the patients with anxiety or depression should be considered in the primary disease prevention as patients at high risk of atherosclerotic vascular diseases as well as MS and type 2 diabetes. Treatment of these diseases as part of secondary prevention in patients with anxiety and depression must be more rigorous and intensive than in patients without these psychiatric disorders.

[Macrovascular and microvascular complications in type 2 diabetes patients]. / Makrovaskulární a mikrovaskulární komplikace u diabetiku 2. typu.

The prevalence of chronic vascular complications is higher in patients with type 2 diabetes mellitus (DM2). The objective of our cross-sectional study was to assess the incidence and types of macrovascular (MVC) and microvascular (mvc) complications and to analyse their relation to the different risk factors and biomarkers in order to improve their prevention. SET OF PATIENTS AND METHODOLOGY: 415 patients (219 men and 196 women) with an average age of 66 +/- 9 years enrolled in the study. A total of 95% of patients with DM2 had a history of hypertension, 27% had MVC (of which 55% had ischaemic heart disease), and 54% had mvc (ofwhich 95% had diabetic nephropathy). RESULTS: The patients with vascular complications were significantly older and had a longer history of DM2; they did not differ for their systolic blood pressure, but had a higher pulse pressure and took more antihypertensives. They did not differ for their lipid levels or the respective therapy. Diabetic patients with MVC and mvc had higher insulin resistance, higher plasmatic levels of total homocysteine and a higher incidence ofalbuminuria or proteinuria. The factors which significantly and independently associated with MVC were male gender, age over 60 years, higher hs-C-reactive protein (hs-CRP) exceeding 1 mg/l, glycaemia over 5.6 mmol/l, lower diastolic blood pressure and lower HDL-cholesterol; mvc associated with higher age over 60 years, a history of DM2 exceeding 8 years, and hs-CRP above 1 mg/l. CONCLUSION: Our results show that patients with DM2 have a high incidence ofvascular complications significantly associated with age, DM2 history and higher hs-CRP, irrespective of the other monitored parametres.

Even mild changes in free thyroxine could influence the degree of heart failure measured by its biological surrogates.

Both, severe hypo- or hyperthyroidism may alter hemodynamic parameters. The aim of our study was to ascertain, whether also distinct changes within normal range of free thyroxine (fT4) would be associated with an impairment of left ventricle function in patients with chronic heart failure. Hundred-forty-eight patients (m121, f27, mean age 63.8 +/- 1.14 years) with chronic heart failure, fT4 levels within the normal range (9-22 pmol/l) and without thyrostatics or substitution treatment. Degree of heart failure was quantified by plasma B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP). Patients with fT4 in the range 11.9-14.6 pmol/l [optimal, second-third quintile] had significantly lower NT-proBNP (718 +/- 70.4 pg/ml), than those with fT4 < or = 11.8 [low-normal, bottom quintile](1236 +/- 223.6 pg/ml; p<0.03) and those with fT4 over 14.6 pmol/l [high-normal, top two quintiles] (1192 +/- 114.9 pg/ml; p<0.0002). These differences remain significant, also if adjusted for age, gender and other confounders; adjusted odds ratio was 1.30 (1.05-1.59) for optimal vs. low-normal and 1.27 (1.04-1.55) for optimal vs. high-normal. Similar statistical differences were also found in BNP, but only when optimal and high-normal fT4 ranges were compared. In conclusion, the severity of heart failure seems to be also influenced by only mild deviations of fT4 concentrations from optimal levels.

[Cortisol levels are more closely associated with depressiveness and other psychopathologies than catecholamine levels]. / Hladina kortizolu souvisí s depresivitou a jinými psychopatologiemi více nez hladiny katecholaminu.

OBJECTIVE: Quantification of changes in the levels of the above hormones, i.e. cortisol, adrenalin, noradrenalin and dopamine depending on the presence of depressive symptoms and other psychopathological symptoms. SAMPLE: 259 randomly selected individuals from the population of the city of Pilsen. METHOD: Zung self-assessment scale and SCL-90 questionnaire were used to assess depressiveness and other psychopathologies. Serum cortisol levels were measured, as well as the levels ofcortisol and catecholamine (adrenalin, noradrenalin and dopamine) in a 24-hour urine sample. The studied sample was divided, by an arbitrarily defined limit, into a group with a higher and a group with a lower excretion of the monitored hormones. RESULTS: The group with cortisol excretion higher than 300 nmol/24 h had a significantly higher score in terms of the SCL-90 questionnaire interpersonal sensitiveness, depression, anxiety, phobia, paranoidism and psychoticism as compared with the group with cortisol excretion below 300 nmol/24 h (p < 0.05). The group with cortisol excretion above 300 nmol/24 h had also a significantly higher score on Zung's self-assessment depression scale as compared with the group with cortisol excretion below 300 nmol/24 h (p < 0.05). Division of the sample according to the score on Zung's self-assessment depression scale (SDS index > or = 50) has shown that women with a record of depressive symptoms had a statistically significant higher of urinary cortisol excretion in 24 hours (average 219.40 as compared with 191.64 nmol/24 h, respectively, p = 0.02). The group of men with depressive symptoms according to the score obtained on Zung self-assessment scale only showed a trend towards higher urinary noradrenalin excretion in 24 hours (average of 69.77 as compared with 63.84 microg/24 h, p = 0.17). CONCLUSION: As shown by the above results, there is a link between 24-hour urinary cortisol excretion levels and the monitored parameters of psychic condition.

[Czech atherosclerosis society guidelines for the diagnosis and treatment of dyslipidemia in adults]. / Doporucení pro diagnostiku a lécbu dyslipidémií v dospelosti, vypracované výborem Ceské spolecnosti pro aterosklerózu.

The present guidelines are based on the recommendations published in 2005 entitled "Prevention of Cardiovascular Diseases in Adulthood" summarizing the conclusions of nine Czech medical societies and agree with them in the assessment of individual risk of mortality from cardiovascular disease (CVD) according to SCORE tables. They reflect new research data in pathophysiology of dyslipidemias (DLP) and particularly the results of recent clinical trials of lipid-lowering therapy and their meta-analyses. They establish priorities for the screening and management of DLP, present suitable diagnostic methods, additional investigations of potential use in risk assessment, including some emerging risk factors and detection of sub-clinical atherosclerosis in persons in a moderate-risk category. Major changes include a lower LDL-cholesterol treatment target (< 2.0 mmol/L for all CVD individuals) and a possible use of apolipoprotein B as a secondary target in selected persons (< 0.9 g/L in high risk without CVD, < 0.8 g/L for CVD patients) and nonHDL-cholesterol (< 3.3 mmol/L in high risk without CVD, < 2.8 mmol/L for CVD patients). Therapy of individual DLP phenotypes (monotherapy and combination therapy) as well as basic principles for control examination at lipid-lowering medication are described. Recommended therapeutic lifestyle changes are shown. Enclosed are five annexes: DLP diagnosis; causes of secondary DLP; additional investiga- tions of potential use in risk stratification; familial hypercholesterolemia; list of recommended foods; two variants of SCORE tables for risk assessment for the Czech Republic; the scheme of recommended procedures and treatment algorithm in DLP asymptomatic individuals.

[The effect of treatment with fenofibrate on the risk profile of patients with metabolic syndrome and mixed dyslipidemia treated on an outpatient basis]. / VIiv lécby fenofibrátem na rizikový profil nemocných s metabolickým syndromem a smísenou dyslipidemií lécených ambulantne.

The study has shown that patients with metabolic syndrome and typical dyslipidemia treated on an outpatient basis by general practitioners or specialists are those whose anamneses include IHD or diabetes and who are very often indicated for combined statin-fibrate therapy. Fenofibrate therapy combined with a single lifestyle intervention in the form of individual interview resulted in the following improvement of the risk profile of the above patients: significant decrease in body weight and waist circumference, decrease in blood pressure and fasting glycemia; improvement of typical dyslipidemia in 90% of patients, however, only 30% of patients achieved the target TG levels below 1.7 mmol/l and the HDL-cholesterol levels above 1.3 mmol/l and 1 mmol/l in women and men, respectively. A total of 60% of patients no longer met the criteria for MS after 6 months of therapy. However, LDL-cholesterol and total cholesterol levels in patients with IHD or with diabetes were very unsatisfactory; only 6% of patients had achieved the recommended level of target LDL-cholesterol below 2.5 mmol/l before the intervention, i.e. 94% of the patient sample was indicated for statin therapy. 86% of patients with LDL-cholesterol above 2.5 mmol/l remained in our patient sample after non-pharmacological and pharmacological fibrate therapy. The results show that combined statin--fibrate therapy would be the best therapy for patients with IHD or diabetes who meet the MS criteria and whose typical dyslipidemia is expressed.

[Czech Atherosclerosis Society Guidelines for the diagnosis and treatment of dyslipidemias in adults]. / Doporulení pro diagnostiku a lécbu dyslipidemlí v dospelosti, vypracované výborem Ceské spolecnosti pro aterosklerózu.

The present guidelines are based on the recommendations published in 2005 entitled "Prevention of Cardiovascular Diseases in Adulthood" summarizing the conclusions of nine Czech medical societies and agree with them in the assessment of individual risks of mortality from cardiovascular disease (CVD) according to SCORE tables. They reflect new research data in pathophysiology of dyslipidemias (DLP) and particularly the results of recent clinical trials of lipid-lowering therapy and their meta-analyses. They establish priorities for the screening and management of DLP, present suitable diagnostic methods, additional investigations of potential use in risk assessment, including some emerging risk factors and detection of sub-clinical atherosclerosis in persons in a moderate-risk category. Major changes include a lower LDL-cholesterol treatment target (< 2.0 mmol/L for all CVD individuals) and a possible use of apolipoprotein B as a secondary target in selected persons (< 0.9 g/L in high risk without CVD, < 0.8 g/L for CVD patients) and nonHDL-cholesterol (< 3.3 mmol/L in high risk without CVD, < 2.8 mmol/L for CVD patients). Therapy of individual DLP phenotypes (monotherapy and combination therapy) as well as basic principles for control examination at lipid-lowering medication are described. Recommended therapeutic lifestyle changes are shown. Enclosed are five annexes: DLP diagnosis; causes of secondary DLP; additional investigations of potential use in risk stratification; familial hypercholesterolemia; list of recommended foods; two variants of SCORE tables for risk assessment for the Czech Republic; the scheme of recommended procedures and treatment algorithm in DLP asymptomatic individuals.

[Association between free thyroxin concentration and degree of heart failure in patients with chronic heart insufficiency]. / Vztah mezi hladinami volného thyroxinu a stupnem srdecního selhání u pacientu s chronickou levostrannou kardiální insuficiencí.

BACKGROUND: It is evident, that overt thyroid dysfunction (both, hypo- or hyperthyroidism) could be associated with heart failure. The aim of our study was to establish whether also mild changes in free thyroxin (fT4) may influence the degree of heart failure in patients with chronic heart insufficiency. METHODS AND RESULTS: There were included 148 patients (m 121, f 27, mean age 63.8 +/- 1.14) with clinical chronic heart failure were, with fT4 levels within the normal range (9-22 pmol/l) and without thyroid suppression or substitution treatment. Degree of heart failure was quantified by plasma B-type natriuretic peptide (BNP), N-terminal pro-BNP (NT-proBNP) and big endothelin. Patients with fT4 in the range 11.9-14.6 pmol/l (optimal, 3rd-6th decile) had significantly lower NT-proBNP (718 +/- 70.4 pg/ml), than those with fT4 < or = 11.8 (low-normal, bottom two deciles) (1236 +/- 223.6 pg/ml; p < 0.03) and those with fT4 over 14.6 pmol/l [high-normal, top four deciles] (1192 +/- 114.9 pg/ml; p < 0.0002). These differences remain significant also if adjusted for age, gender and other confounders; adjusted odds ratio was 1.30 (1.05-1.59) for optimal vs. low-normal and 1.27 (1.04-1.55) for optimal vs. high-normal. Similar statistical differences were found also in BNP and high endothelin, but only between optimal and high-normal fT4 strata. CONCLUSIONS: The degree of heart failure could be influenced also by mild changes in fT4 concentration.

[Recommendations for the treatment of tobacco dependence]. / Doporucení pro lécbu závislosti na tabáku.

This first Czech version of guidelines formulated by the working group of mentioned medical associations is based on current literature and international guidelines. They are aimed mainly on clinical medicine and on incorporation of this treatment into the health care system according to WHO recommendations. They should serve to the treatment of tobacco dependence at any level: during any contact with the smoking patient (short intervention), in specialised centres or for the health care providers or health system itself.

[Metabolic syndrome and latent depression in the population sample]. / Metabolický syndrom a skrytá deprese v populacním vzorku.

BACKGROUND: The aim of study was to reveal the relationship between metabolic syndrome and depression in a population sample, based on clinical and metabolic parameters. METHODS AND RESULTS: We tried to estimate depression (or other psychopathologies) prevalence in a randomly chosen population sample of the Pilsen city, using special questionnaires. Further, we estimated metabolic syndrome of insulin resistance risk factors and we looked for the relationship between these two disorders. Mental state of object was classified according to the questionnaires results, currently evaluated by the psychiatrist. Metabolic syndrome of insulin resistance was diagnosed as a presence of 3 of the 5 following factors: Triglycerides > or = 1.7 mmol/l, HDL cholesterol < 1.0 mmol/l in males or < 1.3 mmol/l in females, blood pressure > or = 130/85 mmHg (and/or antihypertensive medication), fasting plasma glucose > or = 6.1 mmol/l, waist circumference >102 cm in males or > 88 cm in females. Depressive syndrome diagnosed by Zungs scale is present in 31% of the Pilsen population, in 38% females and 31% males (n = 340). In the group of depressive objects, characteristics of metabolic syndrome of insulin resistance were two times higher than in the control group. Differences in resting heart rate, triglycerides level and fasting C-peptid were significantly higher in the depressive subjects. After the corrections considering age, sex and treatment adjustment, the waist to hip ratio was in the depressive subjects statistically higher as well as the 24 hour excretion of urine cortisone. In persons with metabolic syndrome of insulin resistance the prevalence of depression and anxiety was significantly higher. CONCLUSIONS: Our results show a possible relationship between depressive disorder and risk factors of the syndrome of insulin resistance. The question remains if the depression treatment can correct some of the metabolic syndrome risk factors.