Ksenija Kranjčević

Continental-Mediterranean and rural-urban differences in cardiovascular risk factors in Croatian population

Aim To compare the distribution of cardiovascular disease (CVD) factors between continental and Mediterranean areas and urban and rural areas of Croatia, as well as to investigate the differences in achieving treatment goals by the general practitioners (GP) in different settings. Methods A multicenter prospective study was performed on 2467 participants of both sexes ≥40 years old, who visited for any reason 59 general practices covering the whole area of Croatia (May-July 2008). The study was a part of the Cardiovascular Risk and Intervention Study in Croatia-family medicine (CRISIC-fm) study. Patients were interviewed using a 140-item questionnaire on socio-demographics and CVD risk factors. We measured body mass index (BMI) and waist circumference and determined biochemical variables including blood pressure, total, high-density lipoprotein-, and low-density lipoprotein-cholesterol, triglycerides, glycemia, and uric acid. Results Participants from continental rural areas had significantly higher systolic and diastolic blood pressure (P < 0.001), obesity (P = 0.001), increased waist circumference (P < 0.001), and more intense physical activity (P = 0.020). Participants from coastal rural areas had higher HDL-cholesterol, participants from continental rural and coastal urban areas had higher LDL-cholesterol, and participants from rural continental had significantly higher BMI and waist circumference. Conclusion Prevalence of CVD risk factors in Croatian population is high. Greater burden of risk factors in continental region and rural areas may be partly explained by lifestyle differences.

Family Physician Clinical Inertia in Glycemic Control among Patients with Type 2 Diabetes

Background Many patients with diabetes do not achieve target values. One of the reasons for this is clinical inertia. The correct explanation of clinical inertia requires a conjunction of patient with physician and health care system factors. Our aim was to determine the rate of clinical inertia in treating diabetes in primary care and association of patient, physician, and health care setting factors with clinical inertia. Material/Methods This was a national, multicenter, observational, cross-sectional study in primary care in Croatia. Each family physician (FP) provided professional data and collected clinical data on 15–25 type 2 diabetes (T2DM) patients. Clinical inertia was defined as a consultation in which treatment change based on glycated hemoglobin (HbA1c) levels was indicated but did not occur. Results A total of 449 FPs (response rate 89.8%) collected data on 10275 patients. Mean clinical inertia per FP was 55.6% (SD ±26.17) of consultations. All of the FPs were clinically inert with some patients, and 9% of the FPs were clinically inert with all patients. The main factors associated with clinical inertia were: higher percentage of HbA1c, oral anti-diabetic drug initiated by diabetologist, increased postprandial glycemia and total cholesterol, physical inactivity of patient, and administration of drugs other than oral antidiabetics. Conclusions Clinical inertia in treating patients with T2DM is a serious problem. Patients with worse glycemic control and those whose therapy was initiated by a diabetologist experience more clinical inertia. More research on causes of clinical inertia in treating patients with T2DM should be conducted to help achieve more effective diabetes control.

Association between hyperuricemia, prediabetes, and prehypertension in the Croatian adult population--a cross-sectional study.

BackgroundThe association between hyperuricemia, hypertension, and diabetes has been proved to have strong association with the risk for cardiovascular diseases, but it is not clear whether hyperuricemia is related to the early stages of hypertension and diabetes. Therefore, in this study we investigated the association between hyperuricemia, prediabetes, and prehypertension in Croatian adults, as well as that between purine-rich diet and hyperuricemia, prediabetes, or prehypertension.MethodsA stratified random representative sample of 64 general practitioners (GP) was selected. Each GP systematically chose participants aged ≥ 40 year (up to 55 subjects) . Recruitment occurred between May and September 2008. The medical history, anthropometric, and laboratory measures were obtained for each participant.Results59 physicians agreed to participate and recruited 2485 subjects (response rate 77%; average age (± standard deviation) 59.2 ±10.6; 61.9% women. In bivariate analysis we found a positive association between hyperuricemia and prediabetes (OR 1.66, 95% CI 1.09–2.53), but not for prehypertension (OR 1.68, 95% CI 0.76–3.72). After controlling for known confounders for cardiovascular disease (age, gender, body mass index, alcohol intake, diet, physical activity, waist to hip ratio, total cholesterol, low density lipoprotein, high density lipoprotein, and triglycerides), in multivariate analysis HU ceased to be an independent predictor(OR 1.33, CI 0.98–1.82, p = 0.069) for PreDM. An association between purine-rich food and hyperuricemia was found (p<0.001) and also for prediabetes (p=0.002), but not for prehypertension (p=0.41). The prevalence of hyperuricemia was 10.7% (15.4% male, 7.8% female), 32.5% for prediabetes (35.4% male, 30.8% female), and 26.6% for prehypertension (27.2% male, 26.2% female).ConclusionHyperuricemia seems to be associated with prediabetes but not with prehypertension. Both, hyperuricemia and prediabetes were associated with purine-rich food and patients need to be advised on appropriate diet.Trial registrationCurrent Controlled Trials ISRCTN31857696

How well do anthropometric indices correlate with cardiovascular risk factors? A cross-sectional study in Croati.

Summary Background Usefulness of anthropometric indices (AI) as predictors of CV risk is unclear and remains controversial. Material/Methods To evaluate the correlation between AI and CV risk factors in the Croatian adult population and to observe possible differences between coastal and inland regions and urban and rural settlements. CRISIC-fm (ISRCTN31857696) is a prospective, randomized cohort study conducted in GP (general practitioner) practices in Croatia. Between May and July 2008, 59 GPs each recruited 55 participants aged ≥40 years, who visited a practice for any reason. Height, weight, waist and hip circumference and blood pressure were measured. Blood samples were analyzed in accredited laboratories. Results Out of 2467 participants (61.9% women, 38.1% men), 36.3% were obese, with fewer in coastal than inland areas. More obese people were in rural areas. Logistic regression showed BMI was the most important predictor of hypertension, diabetes and dyslipidemia in both regions (except for diabetes in the coastal area), and for urban and rural settlements (except for diabetes in rural areas). WtHR was a significant predictor for hypertension and dyslipidemia in the coastal (but only for hypertension in the inland area), and in urban settlements (in rural only for hypertension). None of the AI showed significant correlation with total CV risk, but WC and BMI did with stroke risk. Receiver operating curve (ROC) analyses showed that WtHR was a better predictor than all other AI for hypertension and dyslipidemia. Conclusions Results encourage the use of BMI and WtHR as important tools in predicting CV risk in GP’s practice.

Is a targeted and planned GP intervention effective in cardiovascular disease prevention? A randomized controlled trial

Background The optimal intensity and duration of the intervention to achieve sustained risk reduction in patients at high and very high cardiovascular (CV) risk still need to be established. The aim of this study was to evaluate the impact of general practitioner’s (GP’s) systematic and planned intervention on total CV risk reduction and a change in individual CV risk factors. Material/Methods This was a cluster-randomized trial (ISRCTN31857696) including 64 practices and 3245 patients aged ≥40. The participating GPs and their examinees were randomized into an intervention or to a control group (standard care). Intervention group practitioners followed up their examinees during 1, 3, 6, 12, and 18 months. The main outcome measures were change in proportion of patients with low, moderate, high, and very high CV risk, and change in individual CV risk factors from the first to the second registration. Results The proportion of patients with very high CV risk was lower in the intervention group, the same as of patients with high blood pressure, total and LDL cholesterol, and increased intake of alcohol. The mean systolic (−1.49 mmHg) and diastolic (−1.57 mmHg) blood pressure, triglycerides (−0.18 mmol/L), body mass index (−0.22), and waist (−0.4 cm) and hip circumference (−1.08 cm) was reduced significantly in the intervention group. There was no additional impact in the intervention group of other tested CV risk factors. Conclusions Systematic and planned GP’s intervention in CVD prevention reduces the number of patients with very high total CV risk and influences a change in lifestyle habits.

Short form of the mini nutritional assessment is a better proxy for nutritional status in elderly than the body mass index: cross-sectional study

Background: Malnutrition increases with age, but elderly nutritional status is difficult to ascertain and may be region‐specific. The objective of this study was to define the cut‐off value for body mass index (BMI) indicative of malnutrition in the elderly Croatian population. Methods: This was a cross‐sectional study of the multicenter, randomized controlled trial conducted in 59 Croatian general practices between May 2008 ‐ August 2010 (Cardiovascular Risk and Intervention Study in Croatia [CRISIC‐fm], trial Registration Code: ISRCTN31857696). A total of 738 participants aged ≥ 65 were surveyed using a CRISIC‐fm questionnaire, including the Mini Nutritional Assessment‐Short Form (MNA‐SF) scale and body weight and height. The association between BMI and MNA‐SF was tested using the chi‐squared test and contingency coefficient. Receiver Operating Characteristic Curve (ROC) analysis was used to assess predictive value of BMI for malnutrition in relation to MNA‐SF and ROC curve to determine the best cut‐off value of BMI relative to the MNA‐SF. Results: Twelve (2.4%) participants were “at risk of malnutrition” by the MNA‐SF. ROC curve indicated that a BMI threshold as high as 26.5 kg/m2 is needed to identify 66% of these “at risk for malnutrition” elderly according to the MNA‐SF (area under the curve [AUC]: 0.80, P<0.001). A BMI cut‐off value of 24.5 kg/m2 has a sensitivity of 50% and a specificity of 86%. Conclusions: Higher BMI values, up to 24.5 kg/m2, should be considered as thresholds for better detecting elderly malnutrition. The current BMI cut‐off value (<18.5 kg/m2) is not applicable to elderly Croatians.