Alena Krajčoviechová

Longitudinal trends in major cardiovascular risk factors in the Czech population between 1985 and 2007/8. Czech MONICA and Czech post-MONICA.

OBJECTIVE The aim of our study was to assess longitudinal trends in major CV risk factors in a representative population sample of the Czech Republic. METHODS Three cross-sectional surveys of CV risk factors were conducted within the WHO MONICA project in six Czech districts in 1985 (n=2570), 1988 (n=2768), and 1992 (n=2343). In 1997/98, 2000/01, and 2007/08, another three screenings for CV risk factors (a 1% random sample, aged 25-64, mean age 45 years) were conducted in the six original districts (n=1990; 2055; and 2246, respectively). RESULTS Over a period of 22/23 years, there was a significant decrease in the prevalence of smoking in males (from 45.0 to 30.5%; p<0.001) and no change in smoking habits in females. BMI increased in males and did not change in females. Both systolic and diastolic blood pressure decreased significantly in both genders, while the prevalence of hypertension declined only in females. Awareness of hypertension also rose as did the proportion of individuals treated by antihypertensive drugs in both genders. Hypertension control improved in either gender. A remarkable drop in total cholesterol was seen in both sexes (males: from 6.21 + or - 1.29 to 5.29 + or - 1.10 mmol/L; p<0.001; females: from 6.18 + or - 1.26 to 5.30 + or - 1.06 mmol/L; p<0.001). CONCLUSIONS The striking improvement in CV risk factors documented between 1985 and 2007/8 most likely contributed to the decrease in CV mortality in the Czech Republic.

Longitudinal trends in cardiovascular mortality and blood pressure levels, prevalence, awareness, treatment, and control of hypertension in the Czech population from 1985 to 2007/2008

Objectives To assess longitudinal trends in cardiovascular mortality and population mean blood pressure, prevalence, awareness, treatment, and control of hypertension in a representative Czech population sample from 1985 to 2007/2008. Methods Source data on mortality rates were provided by the Czech Statistical Office and further processed by the Institute for Health Information and Statistics of the Czech Republic. Six independent cross-sectional population surveys were conducted in 1985, 1988, 1992, 1997/1998, 2000/2001, and 2007/2008 with randomly selected men and women aged 25–64 years and resident in six districts of the Czech Republic (Praha-východ, Benešov, Pardubice, Chrudim, Cheb, and Jindřichův Hradec). The total number of participants was 13 972. Results Since 1985, there has been a significant continuous, almost linear decline in standardized total, cardiovascular disease, ischemic heart disease, and stroke mortality (P < 0.001). There was a significant downward trend in the population mean SBP (from 133.6 ± 20.2 to 129.5 ± 18.5 mmHg; P < 0.001) and DBP (from 84.1 ± 11.3 to 82.5 ± 10.0 mmHg; P < 0.001) from 1985 to 2007/2008. This was associated with a significant decrease in the prevalence of hypertension only in women (from 42.5 to 37.2%; P < 0.001). Awareness of hypertension increased in both sexes (men, from 41.4 to 68.4%; women, from 58.9 to 71.4%; both P < 0.001) as did the number of individuals on antihypertensive medication (men, from 21.1 to 58.2%, women: from 38.9 to 58.9%; both P < 0.001). Control of hypertension improved significantly (from 3.9 to 24.6%) over the same period. Conclusion The reduction in population blood pressure and improved hypertension control may have contributed substantially to the decrease in cardiovascular disease mortality in the Czech Republic.

Large artery stiffness and carotid flow pulsatility in stroke survivors.

Objective: Aortic stiffness is increased in lacunar stroke. The precise mechanism linking aortic stiffness to symptomatic lacunar stroke is not well understood. The aim of this study was to compare the effects of aortic stiffness, carotid stiffness, central blood pressure, and cerebrovascular resistance on carotid flow pulsatility according to stroke subtype. Methods: Two hundred and one consecutive patients were examined 13 months after hospitalization for their first-ever ischemic stroke. The stroke subtype was classified using the Causative Classification of Stroke System. Carotid–femoral pulse wave velocity (PWV) was used as a measure of aortic stiffness. Common carotid flow pulsatility was expressed as resistive index. Central blood pressure was measured using applanation tonometry. Results: Complete data were available for 174 patients (mean age… 67 ± 10 years, 64% men). In patients with lacunar stroke, aortic PWV was higher (13.11 ± 2.74 m/s) than in individuals with large artery atherosclerosis (9.98 ± 1.87 m/s, P <0.001), cardioembolic (11.31 ± 3.18 m/s, P = 0.04) or cryptogenic stroke (11.13 ± 3.2 m/s, P = 0.01). Similarly, central SBP and resistive index were higher in patients with lacunar stroke (145 ± 23 mmHg and 0.80 ± 0.04, respectively) than those with large artery atherosclerosis (128 ± 18 mmHg, P <0.01 and 0.74 ± 0.07, P <0.01, respectively) or cryptogenic stroke (132 ± 18 mmHg, P <0.01 and 0.76 ± 0.07, P <0.05, respectively). In multivariate analysis, aortic stiffness and central pulse pressure were the main determinants of resistive index independent of stroke subtype. Conclusion: Our results suggest that aortic stiffening, by reducing the buffering function of the aorta and thereby increasing the transmission of pressure and flow pulsatility into the cerebral arterioles, may contribute to the pathogenesis of lacunar stroke.

Lower-extremity arterial stiffness vs . aortic stiffness in the general population

While determinants of aortic pulse wave velocity (aPWV) are well known, much less is known about factors affecting lower-extremity pulse wave velocity (lePWV). Unlike aPWV, increased lePWV does not predict cardiovascular risk, but limits lower-extremity blood flow and is associated with increased left ventricular mass. The aim of this study was to compare the effect of cardiovascular risk factors on aPWV and lePWV. A total of 911 individuals from the Czech post-MONICA study (a randomly selected 1% representative population sample, mean age 54±13.5 years, 47% men) were examined. Pulse wave velocity was measured using the SphygmoCor device. Aging had a large effect on aPWV, but only a small effect on lePWV. After adjustment for covariates, we observed that hypertension, diabetes, chronic kidney disease and dyslipidemia were positively and significantly associated with aPWV. However, only hypertension had a significant effect on lePWV. Increased ankle systolic blood pressure was associated with increased aPWV independently of brachial blood pressure. Ankle systolic blood pressure was more closely related to aPWV than lePWV. Subjects with an ankle-brachial index <1.0 had higher aPWV and lower lePWV compared with individuals with a normal ankle-brachial index. Lower-extremity arterial stiffness is affected by age and cardiovascular risk factors to a lesser extent than aortic stiffness. Increased ankle systolic blood pressure is linked not only to increased lower-extremity arterial stiffness, but also increased aortic stiffness. In subjects with a low ankle-brachial index, lower-extremity arterial stiffness is spuriously decreased.

Low blood pressure during the acute period of ischemic stroke is associated with decreased survival.

Objectives: There is no agreement on optimal blood pressure (BP) level during the acute phase of stroke, because studies on the relation between BP and stroke outcome have shown contradicting results. The aim of this study was to compare the relationship of admission, maximal, discharge BP and its components during hospitalization for the first-ever acute ischemic stroke with total mortality after stroke. Methods: In 532 consecutive patients (mean age 66 ± 10 years, 59% of men) hospitalized for their first-ever ischemic stroke, the association between BP and total mortality during a median follow-up of 66 weeks (interquartile range 33–119 weeks) was analyzed. Results: In multivariate analysis, both admission mean BP (MBP) and discharge SBP quartiles were independent predictors of mortality and outperformed other parameters of BP. After multivariate adjustments, patients with admission MBP below 100 mmHg had a higher risk of death than those with MBP between 100–110 and 110–121 mmHg, whereas the risk of mortality did not differ from the group with admission MBP above 122 mmHg. Similarly, patients with discharge SBP below 120 mmHg had an increased risk of death as compared to groups with SBP between 120–130 and 130–141 mmHg, whereas the risk of death was similar to that with discharge SBP above 141 mmHg. Conclusion: Among patients hospitalized for their first-ever ischemic stroke, the risk of all-cause death is significantly increased in those with admission MBP below 100 mmHg and discharge SBP below 120 mmHg, even after adjustments for other confounders.

A high ankle-brachial index is associated with increased aortic pulse wave velocity: the Czech post-MONICA study

Background: Ankle brachial index (ABI) has been increasingly used in general practice to identify individuals with low ABI at high cardiovascular risk. However, there has been no consensus on the clinical significance of high ABI. The aim of our study was to compare aortic stiffness as a marker of cardiovascular risk in individuals with low (<1.0), normal (1.0–1.4), and high ABI (>1.4). Methods: A total of 911 individuals from the Czech post-MONICA study (a randomly selected 1% representative population sample, aged 54 ± 13.5 years, 47% of men) were examined. ABI was measured using a handheld Doppler and aortic pulse wave velocity (aPWV) using the Sphygmocor device. Results: Of the 911 individuals, 28 (3.1%) had low ABI and 23 (2.5%) high ABI. There was a U-shaped association between aPWV and ABI. aPWV was significantly higher in individuals with low and high ABI compared with the normal ABI group (11.1 ± 2.8, 8.3 ± 2.3, p < 0.001; 10.8 ± 2.5, 8.3 ± 2.3 m/s, p < 0.001, respectively). In a model adjusted for age, sex, systolic, diastolic, mean blood pressure and examiner, aPWV remained increased in both extreme ABI groups compared with the normal ABI group. In logistic regression analysis, aPWV together with glucose level, male sex, and a history of deep venous thrombosis were independent predictors of high ABI, while cholesterol was not. Conclusion: This is the first study showing increased aortic stiffness in individuals with high ABI, presumably responsible for increased left ventricular mass described previously in this group. These findings suggest increased cardiovascular risk of high ABI individuals.

Blood pressure control and risk profile in poststroke survivors: a comparison with the general population.

Objective: Recurrent strokes are associated with higher mortality, greater disability, and increased healthcare costs compared with first-ever stroke. Lifestyle measures and drug treatment in secondary prevention decrease the risk of recurrence while improving the quality of life of patients. The objective of this study was to determine the prevalence of hypertension and other cardiovascular risk factors in stroke survivors and population controls. Methods and results: A total of 424 poststroke survivors (aged 66.0 ± 10.4 years) were examined 6–36 months after their first ischemic stroke. Controls of similar age and from the same geographic region were selected from the database of the Czech post-Multinational MONItoring of trends and determinants in CArdiovascular disease Study. Hypertension was found to be the most prevalent risk factor affecting 91.5% of stroke survivors and 71.8% of controls. Use of antihypertensive drugs was reported in 79.5% of stroke survivors and 56.7% of controls. However, blood pressure lower than 140/90 mmHg was achieved in only 49.5% of hypertensive stroke survivors. More than 60% of stroke survivors used statins but low-density lipoprotein-cholesterol lower than 2.5 mmol/l was achieved in only 47.4 and 37% of male and female poststroke survivors, respectively. About a third of poststroke patients continue to smoke, and obesity is a major problem, particularly in women (prevalence 47%), who also have a high prevalence of diabetes. Conclusion: We found a high prevalence and poor control of major cardiovascular risk factors in patients surviving their first-ever ischemic stroke, thus showing poor implementation of guidelines for secondary prevention in clinical practice.

2B.07: DIASTOLIC BLOOD PRESSURE MODIFIES THE ASSOCIATION OF URIC ACID WITH ALBUMIN/CREATININE RATIO IN PRE-METABOLIC SYNDROME.

Objective: Serum uric acid (UA) has been associated with metabolic syndrome (MetS) and urine albumin/creatinine ratio (ACR). We questioned whether UA and ACR are associated in pre-metabolic individuals, and whether this association is modified by any component variable of the metabolic syndrome. Design and method: In a cross-sectional survey of a representative Czech population (n = 3612) aged 25–64 years, urinary albumin and creatinine excretion were determined in an early morning spot urine sample and ACR was calculated. Components of MetS were defined using the joint statement of IDF, NHBLI, AHA, WHF, IAS, and IASO. Individuals presenting with 1 or 2 components were defined as pre-metabolic. Individuals with urinary albumin excretion bellow the detection limit of 1 mg (n = 594), diabetes treated with glucose lowering medication (n = 122), current use of inhibitors of xanthine oxidase (n = 95) and incomplete data (n = 135) were excluded from this analysis. This resulted in 2666 individuals in total. Results: Six hundred and sixty-five (25%) individuals presented without any component of MetS, and 1248 (46.8%) individuals with 1 or 2 components. In individuals free of any component of MetS, there was no association between UA and ln-ACR. In pre-metabolic individuals, UA significantly correlated with ln-ACR in men (n = 639; standardized beta (SB) 0.091; p = 0.022) and in women (n = 609; SB 0.122; p = 0.003). After multivariate adjustment, UA was independently associated with ln-ACR (SB 0.058; p = 0.004), age (SB -0.247; p < 0.001), gender (SB -0.568; p < 0.001), waist-to-height ratio (SB 0.247; p < 0.001), ln-triglycerides (SB 0.087; p = 0.001), estimated glomerular filtration rate (SB -0.425; p < 0.001), and current use of diuretics (SB 0.054; p = 0.008). An independent interaction of ln-ACR with diastolic blood pressure (DBP), (p = 0.023) in relation to UA was present. In individuals with DBP over the median of 81 mmHg (n = 611), there was independent association between ln-ACR and UA (SB 0.094; p = 0.004), whereas no association between the two variables (SB 0.038; p = 0.176) was present in individuals with DBP bellow or equal to 81 mmHg (n = 637). Conclusions: Uric acid is independently associated with albumin/creatinine ratio in individuals with pre-metabolic syndrome. This association appears to be largely modified by diastolic blood pressure.

PROGRESSION TO HYPERTENSION IN THE CZECH POST-MONICA STUDY: 10-YEAR FOLLOW-UP: PP.7.297

Objective: The Framingham study showed that high-normal BP (130–139/85–89 mmHg) is associated with an increased risk for cardiovascular disease and a higher rate of progression to hypertension. The aim of our study was to follow up a cohort of individuals with high-normal BP from a representative sample of the Czech population. Design and Method : In 1997/8, a cross-sectional survey of CV risk factors was performed in 3,209 individuals from 9 districts of the Czech Republic (a 1% population sample aged 25–64 years, mean age 45.76±10.6 years; response rate 64.4%), a subgroup of 2,502 was re-examined 10 years later. At baseline, hypertension was found in 781 individuals who were excluded from this analysis. Results : A stepwise increase in hypertension incidence occurred across the three normotensive BP categories; in males, 17.7% of participants with optimal BP, 35.9% with normal, and 63.0% with high-normal BP progressed to hypertension over 10 years; the respective figures in females were 15.5%, 41.6%, and 71.9%. Conclusions: A high-normal BP at baseline was associated with a substantially increased risk of developing hypertension over a period of 10 years compared with optimal and normal BP. Age, obesity, and weight gain contributed independently to progression to hypertension. Figure 1. No caption available.

C-REACTIVE PROTEIN AND THE RISK OF DEVELOPING HYPERTENSION. THE CZECH POST-MONICA STUDY: 5B.07

Objective: Hypertension (HT) may be, in part, an inflammatory disorder. However, available results from longitudinal studies are scanty and do not allow drawing any definitive conclusions. The aim of our study was to examine whether C-reactive protein (CRP), a marker of inflammation, was associated with HT incidence in a representative sample of the Czech population. Design and Method: In 1997/8, a cross-sectional survey of CV risk factors was performed in 3,209 individuals from 9 districts of the Czech Republic (a 1% population sample aged 25–64 years, mean age 45.76 ± 10.6 years; response rate 64.4%), a subgroup of 2,502 was re-examined 10 years later. CRP was determined using a high-sensitivity assay (Immulite, USA; not performed in 137 individuals). At baseline, hypertension was found in 781 individuals who were excluded from this analysis. A total of 1,402 individuals were evaluated, 36 were excluded because of a history of MI, PTCA, CABG, stroke, and/or TIA or a revascularization procedure; 57 because of a recent history of acute febrile illness; and 88 because they were on medication interfering with CRP levels (ASA, statins, HRT). The incidence of HT over 10 years was assessed by CRP tertiles at baseline. Conclusions: The incidence of HT increased with CRP tertiles in both genders also after adjusting for age. However, the association was lost after adjusting for age, BMI, and smoking. Our 10-year follow-up data of a representative Czech population sample do not support the concept of HT being an inflammatory disease. Figure 1. No caption available.