S. Yu. Martsevich

OUTPATIENT REGISTER OF CARDIOVASCULAR DISEASES IN THE RYAZAN REGION (RECVASA): PRINCIPAL TASKS, EXPERIENCE OF DEVELOPMENT AND FIRST RESULTS

Aim. To estimate risk factors and comorbidity structure, cardiovascular diseases outcomes, evaluate their diagnostics and treatment quality in real outpatient practice using a register of patients with arterial hypertension (HT), ischemic heart disease (IHD), chronic heart failure (CHF) and atrial fibrillation (AF) in the Ryazan Region – the territorial subject ofRussian Federation with high cardiovascular mortality rate. Material and methods. The total of 1000 HT, IHD, CHF, AF patients, applied for general practitioners or cardiologists of theRyazan outpatient clinics in March-May of 2012 were sequentially enrolled in the outpatient REgister of CardioVAscular diseases (RECVASA). Results. According to outpatient cards data HT, IHD, CHF and AF were diagnosed in 99.0%; 70.9%; 74.8% and 13.7% of the 1000 cases, respectively. 820 (82%) patients revealed a concomitant cardiovascular pathology (cardiac comorbidity), at that the most frequent was combination of HT with IHD and CHF (50.4%). Diabetes mellitus was diagnosed in 209 (20.9%) patients. 770 (77%) patients were assessed on their total cholesterol level; smoking status and family history of heart diseases were estimated in 28 (2.8%) and 49 (4.9%) patients, respectively. Exercise tolerance test (stress-test) was carried out in 2% of the patients (including 2.8% of the IHD patients), 24-hour blood pressure (BP) and ECG monitoring – in 0.7% and 5.5%, respectively; echocardiography and ultrasound of brachiocephalic arteries (BCA) – in 25.6% and 8.6%, respectively; coronary angiography – in 1.6% (which includes 2.3% of the IHD patients). The following drug groups were prescribed most frequently: antiplatelet agents – in 60.4% of the cases (584 patients received acetylsalicylic acid and 20 – clopidogrel), ACE inhibitors – in 62.9%, β-blockers – in 43.9% of the patients. Target BP level was achieved in 245 of 956 cases (25.6%). 50.6% of IHD patients and 51.1% of hypercholesterolemic patients received statins. Conclusion. The pilot stage of the RECVASA study revealed a high incidence rate of cardiac comorbidity (82%) in patients with hypertension, IHD, CHF and AF, insufficient estimation of cardiovascular risk factors, inadequate frequency of stress-tests, 24-hour BP and ECG monitoring, echocardiography, BCA sonography, coronary angiography use, as well as a scarce prescription of warfarin in AF and statins in hypercholesterolemic patients. Improvement of correspondence to national guidelines is the main reserve for enhancement of diagnostics and treatment quality in patients with HT, IHD, CHF, AF and hypercholesterolemia.

ASSESSING FACTORS THAT FORM PATIENT’S ATTITUDE TO TREATMENT PRECEDING HOSPITALIZATION FOR ACUTE CORONARY SYNDROM (DATA OF QUESTIONNAIRE WITHIN THE LIS REGISTER)

Aim. To determine the most significant factors forming patient’s attitude to treatment and factors of adherence to treatment preceding hospitalization in patients with acute coronary syndrome (ACS). Material and methods. A register of patients admitted to Lyubertsy Regional Hospital №2 for ACS from 01.12.2011 to 01.12.2012 was used in the study. A total of 272 patients (men – 157, women – 115) were enrolled into the study. Age range was between 31 and 89 years, mean age was 63.6±12.6 years. Acute myocardial infarction was diagnosed in 181 patients, unstable angina pectoris – in 91 patients. While in hospital all the patients had filled out the questionnaire on therapy adherence. Results. Half of the 272 patients (133 persons) enrolled into the study had regularly been followed-up for chronic diseases in different medical centers; 138 patients (50.7%) had not been followed-up before the reference hospitalization. According to the valid Morisky-Green test results 120 patients (44.1%) were adherent to treatment, in 141 (51.8%) patients the adherence was unsatisfactory, 11 persons (4.1%) did not answer the test questions. Younger patients adhered to doctors’ recommendations better. According to the patients (125 patients – 46%) the most effective strategy to improve treatment adherence was the obtaining of detailed information about their disease and methods of its treatment provided by the doctor. 32 patients (11.8%) pointed out the importance of lowering drug costs. 11 patients of 272 respondents demanded more care from their doctor; 4 persons suggested that better quality of medical care organization would help to ameliorate treatment adherence. Regular follow-up for chronic diseases with detailed informing about the condition by a physician positively influences adherence to recommended therapy. Patients of commercial medical centers and patients without any medical follow-up least of all adhered to treatment. Conclusion. Specially designed questionnaire allowed to determine the most significant factors that form patients’ attitude to therapy preceding the reference hospitalization and factors of adherence to treatment prescribed before the hospitalization. All the significant factors were related to the physician-patient relationships, what emphasizes the important role of both doctors and patients in improvement of treatment adherence.

REAL PRACTICE OF STATINS USE AND ITS DEPENDENCE ON FOLLOW-UP IN THE SPECIALIZED MEDICAL CENTRE IN PATIENTS WITH HIGH CARDIOVASCULAR RISK (ACCORDING TO THE PROFILE REGISTER)

Aim. To analyze tactics of statins use in patients with high cardiovascular risk on the base of the PROFILE register data. Material and methods. Patients (n=274) who were enrolled into the PROFILE register from May, 1st till December, 31st, 2011 were divided into 3 groups: a control group (82 patients who sought medical care in the medical centre for the first time), the main group A (167 patients who were regularly followed-up in the medical centre) and the main group B (25 patients who stopped follow-up in the medical centre over 2 years ago). The incidence rates of statins use and lipid target level achievement, as well as safety of statin therapy were studied in the groups. Results. 25.6, 70.7 and 52% of patients received statins in control group, main group A, and main group B, respectively. Target levels (according to the clinical guidelines) of the low density cholesterol (LDC) had been reached in 26.3% of patients in the main group A. This characteristic was not valid in the patients of control and main group B because of small size of these groups. Achievement of target LDC level was observed more often in use of statins in moderate and high doses, use of the original drugs, and use of rosu- vastatin. Safety of statin therapy (aspartate and alanine transaminases, creatine kinase activity, and total bilirubin) was comparable in the groups of patients who reached or did not reach target LDC levels. Conclusion. High cardiovascular risk patients who were regularly followed-up in the specialized medical centre received statins therapy significantly more often. However statins use is often not correspond to the modern clinical guidelines.

PROSPECTIVE OUTPATIENT REGISTRY OF MYOCARDIAL INFARCTION PATIENTS (PROFILE-MI): STUDY DESIGN AND FIRST RESULTS

Aim. To characterize patients included to the registry PROFILE-MI; to present data reflecting the condition of patients before the onset of acute myocardial infarction (MI). Material and methods. Totally, 160 patients included: 106 males, 54 females — 66,2%/33,8%, respectively, consequently visited cardiologist in the City Polyclinics №9 of Moscow or one of two its branches, after hospitalization for MI. Results. Mean age of patients 70,4±10,8 (39-87) y.o., males were in average 10 years younger than women. About 40% were >60 y.o., about a half were retired, and of those most were women, ~1/3 of patients were already disabled; in ~3/4 there was arterial hypertension. For smoking and lipid disorders, in most patients there was no data: only for 29,4 and 46,9%, respectively; diabetes was found in 28,1%. Anamnesis of coronary heart disease (CHD) had been registered in anamnesis of 47 (29.4%), and most of those already experienced myocardial infarction (MI). Half of the included patients had had visited medical institutions during 2 year period before the MI event, most of them — local outpatient institutions (polyclinics), but 1/3 of patients did not request for medical help during last ≥2 years. Conclusion. Patients included to PROFILE-MI registry, had in general similar demographic and clinical parameters with other registries of MI in Russia. Most post MI patients already had cardiovascular diseases of atherosclerotic origin, or a combination of traditional CHD risk factors, so MI onset was quite predictable. Most of them were not under the coverage of primary and secondary CHD preventions before MI event.

ASSESSMENT OF CHANGES IN QUALITY OF PREHOSPITAL TREATMENT OF PATIENTS WITH ACUTE CORONARY SYNDROME IN THE LAST FEW YEARS: LIS-1 VS LIS-3 REGISTRIES

Aim. To assess the changes in prehospital treatment of patients with acute coronary syndrome during the last years on the basis of the LIS-3 registry data. Material and methods . Data of acute coronary syndrome hospital registry LIS-3 (2013-2015, n=397) and acute myocardial infarction hospital registry LIS-1 (2005-2007, n=1133) were used. To assess quality of prehospital treatment the fact of taking specific pharmacological groups of medications for primary and secondary cardiovascular diseases prevention was taken into consideration. Results. Patients in the LIS-3 registry, in comparison with patients in the LIS-1 registry, more often took antiplatelet drugs (23.2% vs 15.7%, respectively; p 0.05). The quality of prehospital treatment did not differ significantly in survived and deceased patients of LIS-3 registry (p>0.05). Conclusion. Only slight improvement in the quality of prehospital therapy in patients with acute coronary syndrome was revealed, mainly due to more frequent use of antiplatelet drugs and statins. It may be explained by poor detection of early forms of ischemic heart disease and underestimation of the importance of risk factors correction, both on the part of patients and on the part of physicians.

EVALUATION OF THE CONFORMITY OF CARDIOVASCULAR THERAPY TO CURRENT CLINICAL GUIDELINES IN THE IMPROVEMENT OF OUTCOMES IN PATIENTS AFTER STROKE (ACCORDING TO THE LIS-2 REGISTER)

Aim. To study the conformity of preventative therapy prescribed to patients during a hospital stay and at a discharge to clinical guidelines using a special algorithm, and to assess the impact of the results on a long-term mortality based on the LIS-2 register (Lyubertsy study of mortality in patients after cerebral stroke). Material and methods. The scales to assess the quality of cardiovascular care for the prevention of recurrent stroke along with the prevention of recurrent ischemic attacks index (PRIA index) for this assessment were developed according to current clinical guidelines. Analysis of the therapy was performed using PRIA index on survived hospital patients from LIS-2 register (N=753). The impact of PRIA index results on a long-term mortality (Me=2.3 years) was studied. Results. Based upon the results of the assessment obtained with PRIA index, higher treatment conformity to clinical guidelines resulted in a significantly better long-term survival. Non-conformity to clinical guidelines was due to the lack of prescription of drugs with proven efficacy and irrational choice of preventive therapy. Median of treatment quality assessment was 44.4% (22.2; 44.4). Conclusion. Low conformity of preventive therapy to clinical guidelines is found in the LIS-2 register. The algorithm for the assessment of preventive cardiovascular therapy quality allows identifying limitations in the prevention of recurrent stroke, and can serve as an example of implementation of evidence-based medicine in clinical practice.

DIAGNOSIS AND TREATMENT OF PATIENTS WITH SEVERE HYPERCHOLESTEROLEMIA IN REAL OUTPATIENT PRACTICE (ACCORDING TO THE RECVASA REGISTRY)

Hypercholesterolemia is a proven risk factor for atherosclerotic cardiovascular diseases and for their complications. Aim. To assess the quality of diagnosis and treatment of patients with severe hypercholesterolemia (total cholesterol >6.2 mmol/L) in the real outpatient practice. Material and methods. All patients with a diagnosis of arterial hypertension, ischemic heart disease, chronic heart failure, atrial fibrillation applied to primary care physicians or cardiologists in one of the randomly selected out-patient clinic of Ryazan in March-May 2012 and included into the RECVASA registry were enrolled into the study group (n=1642). Results. The group of patients with severe hypercholesterolemia consisted of 561 (44%) patients at the age of 67 (59-75) years [Me (25% -75%)]. At that, diagnosis of hyperlipidemia was indicated only in 9% of outpatient cards. Data of one or more blood chemistries including low density cholesterol (LDC) levels were presented only in 7% of outpatient cards. 83.7% of patients with severe hypercholesterolemia were classified as patients at high or very high cardiovascular risk, but statins were recommended only to 17.8% of them. Statins were mainly recommended in moderate doses; only one patient took atorvastatin 40 mg per day. Blood LDC levels were examined only in 5% of patients during statins therapy; nobody of them reached target LDC levels. Conclusion. The study data revealed the presence of a high prevalence of severe hypercholesterolemia in patients with cardiovascular diseases and poor quality of diagnosis and treatment in these patients in the real outpatient practice.

TREATMENT OF PATIENTS WITH CHRONIC ISCHEMIC HEART DISEASE IN REAL CLINICAL PRACTICE ACCORDING TO THE DATA FROM PROGNOZ IBS REGISTER (PART 2)

Aim. To assess the quality of drug therapy and its correspondence with current clinical guidelines in patients with proven stable ischemic heart disease (IHD) before admission, during inpatient stay in hospital and after hospital discharge. Material and methods. Data on 550 patients (from PROGNOZ IBS register) with detected stenosis of at least one coronary artery ≥50% were included in the analysis. Assessment of the quality of drug therapy was conducted in patients who made a follow-up visit in 3.9 years after the reference hospitalization (n=303) using a specially designed questionnaire. Adherence to treatment was studied using a phone survey. Results. According to PROGNOZ IBS register data we revealed low prescription frequency of drugs with proven effects on the cardiovascular risk in patients with stable IHD prior to hospital admission and significant pharmacotherapy improvement in specialized cardiology hospital. In specialized hospital the rate of aspirin use increased by 30%, statins - by 80%, beta-blockers - by 70%, ACE inhibitors - by 60% (p<0.0001). These medications prescription frequency decreased by 15-20% on the average in 3.9 years after discharge. Conclusion. We found significant improvement in pharmacotherapy quality of patients with stable IHD during stay in cardiology hospital, and pharmacotherapy quality reduction after discharge.

РЕГИСТРЫ В КАРДИОЛОГИИ. ОСНОВНЫЕ ПРАВИЛА ПРОВЕДЕНИЯ И РЕАЛЬНЫЕ ВОЗМОЖНОСТИ

The article presents the main goals, tasks, principles, and methodological aspects of the cardiology register development. The authors describe the main types of registers, provide the examples, and specify the key principles of the register development and maintenance. In addition, they discuss the role of both long- and short-term registers in solving a wide range of important research tasks, particularly in the areas of effectiveness and safety of cardiovascular pharmacotherapy and the survival prognosis for specific nosological forms. The task-specific limitations of registers are also discussed.

THE LIS STUDY (LYUBERTSY STUDY ON MORTALITY RATE IN PATIENTS AFTER ACUTE MYOCARDIAL INFARCTION). EVALUATION OF DRUG THERAPY. PART 2. INFLUENCE OF PREVIOUS DRUG TREATMENT ON LONG-TERM LIFE PROGNOSIS

Aim. To evaluate drug therapy received by patients who had survived acute myocardial infarction (AMI) in the framework of the AMI register (the “LIS” study) and estimate this therapy influence on long-term outcomes of the disease. Material and methods. The total of 961 patients of 1133 enrolled in the “LIS” study , were discharged from hospital. 191 patients had died during follow-up. 632 patients (who had survived and consented to visit out-patient clinic) underwent repeated examination (median of follow-up 1.6 [1.0; 2.4] years). Data about treatment before and during AMI were received from patient’s charts; data about treatment after AMI were obtained from out-patient medical records. Results. Before reference AMI only a small number of the patients received the main drug groups (antiplatelet agents, β-blockers, ACE inhibitors, statins), at that ACE inhibitors were prescribed more often than the others. Use of β-blockers and ACE inhibitors before reference AMI significantly improved long-term life prognosis [relative risk (RR) 0.70 and 0.66, respectively]. Rate of the main drug groups prescribed in hospital was rather high with the exception of thrombolytics (less than 10%). Thrombolytics, β-blockers and antiplatelet agents prescribed in hospital significantly improved long-term life prognosis of patients (RR 0.42, 0.65 and 0.58 respectively). At the second visit (according to data of out-patient medical records) rate of antiplatelet agents, ACE inhibitors, β-blockers and statins prescription exceeded 60%. Conclusion. Very low prevalence of adequate drug therapy preceding AMI determines high mortality rate among survived acute stage of myocardial infarction patients in long-term period.