Željko Reiner

Open image in new window European Guidelines on Cardiovascular Disease Prevention in Clinical Practice (Version 2012)

Atherosclerotic cardiovascular disease (CVD) is a chronic disorder developing insidiously thoughout life and usually progressing to an advanced stage by the time symptoms occur. It remains the major cause of premature death in Europe, even though CVD mortality has fallen considerably over recent decades in many European countries. It is estimated that .80% of all CVD mortality now occurs in developing countries. CVD causes mass disability: within the coming decades the disability-adjusted life years (DALYs) estimate is expected to rise from a loss of 85 million DALYs in 1990 to a loss of x02150 million DALYs globally in 2020, thereby remaining the leading somatic cause of loss of productivity.

Treatment and secondary prevention of ischemic coronary events in Croatia (TASPIC-CRO study)

Aims The objective of this study is to determine the status of major risk factors for coronary heart disease in patients with established coronary heart disease in Croatia and whether the Joint European Societies’ recommendations on coronary heart disease prevention are being followed in Croatia and whether secondary prevention practices have improved between 1998 and 2003. Methods Five surveys were undertaken in 35 centres covering the geographical area of the whole of Croatia between 1 June, 1998 and 31 March, 2003. Consecutive patients of both sexes were identified after coronary-bypass grafting or a percutaneous transluminal coronary angioplasty or a hospital admission with acute myocardial infarction or ischaemia. Data collection was based on a review of medical records and the methodology used was similar to the one used in the EUROASPIRE study. Results Fifteen thousand, five hundred and twenty patients were enrolled (64.6% men); 35% of patients smoked cigarettes, 66% had raised blood pressure, 69% elevated serum total cholesterol, 69% elevated serum low-density lipoprotein (LDL) cholesterol, 42% low high-density lipoprotein (HDL) cholesterol, 37% elevated triglycerides, 30% diabetes and 34% family history of coronary heart disease. More men were smokers and had low HDL cholesterol, but more women had elevated total and LDL cholesterol, hypertension and diabetes. More men had Q wave acute myocardial infarction, but more women had angina. Over 5 years, the prevalence of hypercholesterolemia decreased substantially from 82.7 to 65%. Eighty-three percent of patients received aspirin and this percentage did not change during the study. The use of diuretics, calcium antagonists and nitrates did not change either. The reported use of statins, angiotensin-converting enzyme inhibitors and beta-blockers increased significantly. Conclusion This survey shows a high prevalence of modifiable risk factors in Croatian patients with coronary heart disease. Although the higher use of statins, angiotensin-converting enzyme inhibitors and beta-blockers is encouraging, the fact that most coronary heart disease patients are still not achieving the recommended goals remains a concern. There is real potential to reduce the very high coronary heart disease morbidity and mortality in Croatia.

Effects of Rice Policosanol on Serum Lipoproteins, Homocysteine, Fibrinogen and C-Reactive Protein in Hypercholesterolaemic Patients

AbstractBackground: Policosanol is an agent that includes mixtures of aliphatic primary alcohols extracted primarily from sugar-cane wax. This mixture has been shown to lower total and low-density lipoprotein (LDL) cholesterol in animal models, healthy volunteers and hypercholesterolaemic patients.n Patients and methods: This study investigated the efficacy and tolerability of rice policosanol (Oryza sp.) 10 mg/day in 70 hypercholesterolaemic patients of both sexes aged 20–78 years in a randomised, double-blind, crossover, placebo-controlled, single-centre trial. After an 8-week run-in period during which patients were placed on therapeutic lifestyle changes, in particular a cholesterol-lowering diet, they were randomly assigned to receive rice policosanol 10mg tablets or placebo tablets once daily with the evening meal for 8 weeks. During the next 8 weeks those patients who received policosanol during the first 8 weeks received placebo, and those who received placebo during the first 8 weeks, received policosanol. Total, LDL, high-density lipoprotein (HDL), HDL2 and HDL3 cholesterol, triglycerides, oxidised LDL (ox-LDL), apoproteins (Apos) AI and B, lipoprotein (a) [Lp(a)], fibrinogen, homocysteine and C-reactive protein (CRP) levels were measured.n Results: Rice policosanol significantly reduced plasma total cholesterol from 7.37 ±1.42 mmol/L to 6.99 ± 1.33 mmol/L (p = 0.007) and increased Apo AI from 1.49 ± 0.39 mmol/L to 1.58 ± 0.38 mmol/L (p = 0.037) but did not change plasma triglycerides, HDL, HDL2, HDL3 and LDL cholesterol, ox-LDL, Lp(a), Apo B, fibrinogen, homocysteine or CRP levels.n Conclusion: Rice policosanol 10 mg/day moderately decreased plasma total cholesterol and increased Apo AI. Rice policosanol was also well tolerated, with no drug-related effects on safety parameters such as serum aminotransferases and creatine phosphokinase detected or found on physical examination.

The perception and knowledge of cardiovascular risk factors among medical students

Aim To assess perceptions, knowledge, and awareness of cardiovascular disease (CVD) risk factors among medical students (freshmen and graduating students). Methods A descriptive cross-sectional survey based on an anonymous self-administered questionnaire was conducted in 2008 on 443 medical students – 228 freshmen on their enrollment day and 214 students on the day of their final exam at the University of Zagreb School of Medicine, Croatia. Results The perception and knowledge of some CVD risk factors, eg, dyslipidemia, arterial hypertension, and metabolic syndrome as well as of lipid-lowering therapy important for CVD prevention was significantly better among graduating students but was still not sufficient. Only 66% of graduating students reported that they would prescribe lipid-lowering therapy to high risk patients. Disappointingly, many graduating students were smoking (30.4%) and had low-awareness of obesity as an important CVD risk factor. Conclusion These results suggest an urgent need to improve medical students’ knowledge of obesity and low physical activity as important CVD risk factors and of the methods for increasing low high-density lipoprotein-cholesterol and for smoking cessation. All this provides a rationale for modifying the university core curriculum to include more information concerning these issues.

Simplifying the audit of risk factor recording and control: A report from an international study in 11 countries

Background To simplify the assessment of the recording and control of coronary heart disease risk factors in different countries and regions. Design The SUrvey of Risk Factors (SURF) is an international clinical audit. Methods Data on consecutive patients with established coronary heart disease from countries in Europe, Asia and the Middle East were collected on a one-page collection sheet or electronically during routine clinic visits. Information on demographics, diagnostic category, risk factors, physical and laboratory measurements, and medications were included and key variables summarized in a Cardiovascular Health Index Score. Results Coronary heart disease patients (Nu2009=u200910,186; 29% women) were enrolled from 79 centres in 11 countries. Recording of risk factors varied considerably: smoking was recorded in over 98% of subjects, while about 20% lacked data on laboratory measurements relevant to cardiovascular disease risk. Sixteen per cent of participants reported smoking, 29% were obese, and 46% had abdominal obesity. Sixty per cent of participants had blood pressure <140/90u2009mmHg (140/80u2009mmHg for diabetics), 48% had HbA1c<7%, 30% had low-density lipoprotein <1.8u2009mmol/l and 17% had a good cardiovascular health index score. There were substantial regional variations. Less than 3% of patients attended cardiac rehabilitation in Asia or the Middle East, compared with 45% in Europe. In Asia, 15% of patients had low-density lipoprotein cholesterol <1.8u2009mmol/l compared with 33% in Europe and 36% in the Middle East. Variations in medications were noted, with lower use of statins in Asia. Conclusions SURF proved to be practical in daily practice. Results indicated poor control of risk factors with substantial variation between countries, calling for development and implementation of clinical standards of secondary prevention of coronary heart disease.

Guidelines, position papers and critical reviews: differences and similarities.

In the European Journal of Preventive Cardiology more and more position papers and expert consensus papers are published as well as critical reviews. The same is true for the other journals of the European Society of Cardiology (ESC) family, particularly for the European Heart Journal, where all ESC Guidelines are published. A great number of guidelines, position papers and critical reviews have been issued in other different scientific medical journals around the world as well, particularly during the last decades. When searching PubMed under ‘guidelines’ one can find 221,633 papers with the intensity of publication varying from only four in the year 1960 up to 17,625 in the year 2011. One can find also 91,016 ‘critical reviews’, 11,976 ‘position papers’ and 4287 ‘expert consensus papers’. However, many experts are not quite sure what the differences are between these different types of manuscript. This editorial is aimed at providing a brief insight into their differences and similarities. Although focusing only on publications developed/written by the ESC and its entities such as the European Association for Cardiovascular Prevention and Rehabilitation (EACPR), most of this editorial can be applied to the publications of all other scientific societies in medicine as well. Guidelines are official publications of the ESC which are produced by the task forces supervised, reviewed and approved by the ESC Committee for Practice Guidelines (CPG). ESC entities (Associations, Working Groups, Councils, etc.) do not produce their own guidelines but can produce position papers and expert consensus documents in the name of their entity or group of authors. Guidelines are produced to present all the relevant and best available up-todate evidence on a particular broad clinical issue with the aim to help clinicians in their everyday clinical practice when they have to weigh the benefits and risks of a diagnostic and/or therapeutic procedure. According to this they provide well-balanced information reflecting established evidence-based knowledge on a specific subject and systematically developed recommendations for diagnosis and treatment for practitioners. However, it has to be stressed that applying them in everyday practice always requires careful judgement of individual cases. Considering all this, guidelines are also aimed to be used to develop standards to assess the best clinical practice. The methodological standards for issuing good quality and trustworthy guidelines were well defined more than a decade ago and ESC Guidelines follow the high quality criteria for the development of guidelines which can be found at www.escardio.org/knowledge/ guidelines/rules. Since the guidelines should not only represent the views of one or two specific groups of experts in selected topics, the task forces have to be composed of a diverse expertise to represent the multidisciplinary views and give an objective evaluation of the particular broad subject at hand. The guidelines’ recommendations must be graded according to four different classes (I, IIa, IIb and III) and linked to their levels of evidence (A, B and C), but some guidelines might have in addition also another type of grading such as GRADE (strong or weak recommendation), which could be more suitable for a particular topic and which has the advantage of distinguishing quality of evidence and strength of recommendation. For instance, this latter type of grading was used in the recently published 2012 joint Guidelines on cardiovascular disease prevention in clinical practice, illustrating that strong evidence does not automatically lead to a strong recommendation. Although the implementation of the guidelines’ recommendations should be an integral part of the guidelines’ development process, the adherence to guidelines is often far from optimal due to many barriers which have not substantially changed during the last decade. Some of the ESC Guidelines are produced solely by the ESC and some are produced in partnership with another societies, such as the Guidelines for

Treatment of children with homozygous familial hypercholesterolaemia

Homozygous familial hypercholesterolaemia (HoFH) is a rare lipoprotein disorder characterized by extremely elevated low-density lipoprotein cholesterol (LDL-C) levels in blood and therefore an extremely increased risk for premature atherosclerosis with life-threatening cardiovascular diseases (CVDs), particularly acute myocardial infarction, at an early age. Aortic disease such as supra-aortic stenosis might also be a consequence of paediatric HoFH. HoFH in children is usually diagnosed based upon phenotypic criteria such as tendon xanthomas which during infancy are in flexures, usually those of the wrist and ankles, Achilles tendon thickening, xanthoma tuberosum, xanthomas in webbing of fingers and those in the buttocks and/or arcus cornealis, very high LDL-C, family history of elevated LDL-C or premature CVD and/or genetic testing, if available. Namely, identification of the causative mutation in the genes for LDL receptor, apolipoprotein B, proprotein convertase subtilisin/kexin type 9 (PCSK9) genes or STAP1 coding signal transducing adaptor family member 1 provides definitive diagnosis. According to the most recent Japanese guidelines for paediatric familial hypercholesterolaemia, two pathogenic mutations in causative genes are needed for diagnosis of HoFH. These guidelines also suggest for diagnosis of paediatric HoFH that, apart from existence of skin and/or tendon xanthomas, untreated LDL-C levels have to be approximately twice those of heterozygous familial hypercholesterolaemia (HeFH) parents. The prevalence of HoFH was for many years considered to be 1:1,000,000 in the general population but more recently it has been shown that, at least in Northern Europe, it is much higher – about 1:300,000. Since the exact data about the prevalence of not only HoFH but also HeFH are not known for all European countries, registries are being organized to obtain this information. The approach to HoFH children has to be slightly different from the one to HeFH paediatric patients despite the fact that HeFH children might have LDL-C in the range typical for HoFH, that is, 5–10mmol/l ( 400–500mg/dl). For HoFH children the treatment based only upon healthy lifestyle (diet, regular exercise, etc.) and statin therapy is virtually never enough. It has to be stressed that doses, especially in very small children, are totally arbitrary because, for obvious reasons, no trials, particularly no randomized placebocontrolled trials, in these children have been performed. The first trial on HoFH children (the mean age was 10.9 years) with a statin which was published most recently demonstrated that rosuvastatin 20mg/day alone or added to ezetimibe and/or apheresis is safe and that such a treatment can reduce LDL-C effectively. A recent meta-analysis of all trials with statin treatment of children aged 6–17 years with HeFH have demonstrated significant reductions and statins seem to be safe and well-tolerated in these patients. Nevertheless, even adding ezetemibe to the maximally tolerable statin doses is often not enough to decrease extremely elevated LDL-C to the required levels. Still, there are not many data on HoFH children younger than 6–8 years. It is very important since children with familial hypercholesterolaemia (both HeFH and HoFH) have greater mean carotid intima-media thickness (cIMT) values as compared with their unaffected siblings even at the age of 6–8 years and it is generally accepted that the measurement of cIMT and/or screening for atherosclerotic plaques by carotid artery ultrasound can add information beyond assessment of traditional risk factors, including elevated LDL-C, in asymptomatic adults at moderate CVD risk. It has also been shown that exposure to high LDL-C in childhood and adolescence predicts increased cIMT and decreased elasticity in young adulthood. It is quite clear that the treatment of paediatric HoFH patients has to start as early as possible, that

РЕКОМЕНДАЦИИ ЕОК/ЕОА ПО ДИАГНОСТИКЕ И ЛЕЧЕНИЮ ДИСЛИПИДЕМИЙ 2016

The Task Force for the Management of Dyslipidaemias of the European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS) Developed with the special contribution of the European Assocciation for Cardiovascular Prevention & Rehabilitation (EACPR)