Patients with high cardiovascular risk in outpatient care in Slovakia: lessons from the NEMESYS and STAIRS studies

Česká verzia

Authors: J. Lietava ¹; V. Kosmálová ¹; J. Murín ²; D. Bartko Za Riešiteľov ³
Authors place of work: II. Interná klinika, Univerzitná nemocnica LF UK Bratislava, Slovenská republika ¹; I. Interná klinika, Univerzitná nemocnica LF UK Bratislava, Slovenská republika ²; Ústredná univerzitná vojenská nemocnica Ružomberok, Slovenská republika ³
Published in the journal: Kardiol Rev Int Med 2011, 13(2): 109-116

Summary

The effective treatment of out-patients represents a basic strategy in the fight against cardiovascular disease and is precisely defined in numerous specialist guidelines, supported by evidence-based medicine. Its effectiveness is, however, rarely analysed in real-life medicine. The stratified

treatment of patients in primary preventative care is based on the SCORE system, which identifies high-risk patients, although so far only approximate estimates have been made of the numbers of high-risk patients in the care of first-instance doctors. Results: The proportion of high-risk patients being treated in outpatient care at general practitioners is relatively low – only 14%, with men showing higher prevalence of high, absolute risk (AR ≥ 5) compared to women: 25.0% vs. 6.8%, as well as a higher absolute risk compared to women: AR 2.96 vs. 1.38 (p < 0.001). The NEMESYS study documents the high prevalence of metabolic syndrome (MS) (48.7%) (IDF 2005). In agreement with data given in specialist literature, women show a higher prevalence compared to men (52.6% vs. 42.0%) (p < 0.001). AR is twice as high in those with MS compared to patients without MS (total: 2.70 vs. 1.36; men: 4.34 vs. 2.10; women: 1.94 vs. 0.84). AR in MS patients is higher in men compared to women (4.34 vs. 1.94). Monitoring levels of arterial hypertension were low, reaching figures of 36.5% in men and 38.0% in women. Treatment for hypertension does not take account of AR levels: patients with low, as well as high, AR received the same treatment and at inadequate levels. Patients with MS were more likely to receive treatment using all groups of antihypertensive drugs (OR 1.61–2.7) and used more medicines (2.13 vs. 1.86) than patients without MS, although the effectiveness of treatment was lower. Pharmacoeconomic analysis found equal annual costs for treatment of men and women (hypertension: 257 € vs. 263 €, MS 334 € vs. 321 € and diabetes mellitus 392 € vs. 384 €). Conclusion of NEMESYS study: It is theoretically possible, in outpatient care, to identify patients with a high absolute risk of ≥ 5 and it is pharmacoeconomically possible to provide them with the necessary treatment. The STAIRS study analysed the possibility of identifying heart failure in patients with arterial hypertension on the basis of clinical and anamnestic indicators of lowered tolerance to stress. Hypertonics with chronic heart failure showed a significantly lower tolerance for steps managed (18.8 vs. 29.2 steps; p = 0.001), but achieved a significantly greater improvement following short-term antihypertensive treatment (11.1 vs. 4.2 steps; p = 0.001). NYHA III patients tolerated less steps (13.8 ± 9.6 vs. 21.3 ± 13.3 steps; p = 0.001) and had lower stress tolerance (54.2 ± ± 25.0 vs. 42.0 ± 22.3; p = 0,001) than patients with NYHA II. Where patients tolerated 20 steps without dyspnoea as the crucial point for the identification of chronic heart failure, OR reached a value of 2.14 (1.50–3.06; p = 0.001). Sensitivity to tolerance of < 20 steps was low 0.42 (0.40–0.56) and specificity was appropriate 0.75 (0.73–0.76). Conclusion of STAIRS study: The methodologically undemanding anamnesis of dyspnoea during stress or the investigation of the number of tolerated steps can identify, to a satisfactory level of certainty, patients with suspected heart failure.

Keywords:
NEMESYS – STAIRS – metabolic syndrome – SCORE absolute risk – chronic heart failure – tolerance to exercise – NYHA

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