CONCOMITANT CARDIOVASCULAR DISEASES AND ANTIHYPERTENSIVE TREATMENT IN OUTPATIENT PRACTICE (BY THE RECVASA REGISTRY DATA)

Aim. To study a pattern of concomitant cardiovascular diseases (CVDs) and to estimate particularities and quality of medical antihypertensive therapy in hypertensive patients in real outpatient practice with a help of the Registry in Ryazan region.Material and methods. A total of 3690 patients with hypertension, ischemic heart disease, chronic heart failure and atrial fibrillation, who had attended general practitioners and cardiologists of 3 outpatient clinics in Ryazan city, were enrolled in the outpatient Registry of cardiovascular diseases (RECVASA). The diagnosis of hypertension was recorded in 3648 of 3690 (98.9%) outpatient charts, 28.1% of the subjects were men and 71.9% - women.Results. A total of 2907 (79.7%) of 3648 patients had combination of hypertension with other CVDs. Combination of 3-4 cardiovascular diagnoses was registered in 63.8% of the cases. 11.5% and 9.5% of the patients had a history of myocardial infarction and cerebral stroke, respectively. Diagnosis of hypertension was verified in 448 of 450 randomized hypertensive patients (99.6%). The incidence of prescription of one and two antihypertensive drugs (AHDs) was 25% and 39%, respectively, of 3 AHDs – 21%, 4 and more – 2%. AHDs were not prescribed in 13% of hypertensive patients. The mean number of prescribed AHDs was 1.73. The mean incidence rate of target blood pressure achievement was 26.1%. We have noted insufficient ACE inhibitors/angiotensin receptor blockers (ARB) and beta-blockers prescription in different concomitant CVDs. Patients with 3-4 cardiovascular diagnoses were more often prescribed combined antihypertensive treatment. Prescription of ACE inhibitors/ARB, beta-blockers and thiazide diuretics combination was preferable in 74.1% of the cases, when taking into account absolute and relative contraindications for betablockers use – in 64.0%. 15.2% of the hypertensive patients used reimbursed drugs for CVDs at the moment of the Registry enrollment as compared with 39.2% in previous years (p<0.05).Conclusion. The RECVASA study data allowed revealing high incidence of concomitant CVDs in hypertensive patients, insufficient use of combined antihypertensive treatment, including AHDs with proved favorable influence on prognosis. Achievement of concordance of medical treatment to national and international guidelines, taking into account concomitant CVDs, and optimization of patients’ coverage with reimbursed drugs are the main reserves for antihypertensive treatment quality improvement

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

ANALYSIS OF THE PRACTICE OF COMBINATIONAL ANTIHYPERTENSION THERAPY BY THE DATA FROM TWO OUTPATIENT REGISTRIES

Aim. To investigate on the ways antihypertension drugs (AD) prescription, including, firstly, combinational therapy, in real conditions, by the data from two outpatient registries done in district polyclinics of Ryazan city (RECVASA) and in specialized scientific center in Moscow (PROFILE).Material and methods. To the RECVAZA registry, 3690 patients were included, with cardiovascular diseases, and in 3648 (98,9%) arterial hypertension was diagnosed. Among 1531 patient’s data included into PROFILE registry during August 2011 —August 2015, hypertension was diagnosed in 1230 (80,3%). Mean age of RECVASA and PROFILE patients was 66,3±12,8 и 63,7±11,4, respectively. In overall data, males and females ratio were 28% and 72%, respectively, in RECVASA, and 54% and 46%, resp., in PROFILE.Results. In comparative analysis of the registries, it was found that RECVASA patients were older, and women predominated (72%). Hypertension was diagnosed in almost 100%, was more severe and more comorbid. By the number of prescribed AD, both registries were almost identical: every third patient was prescribed 2 drugs, every fourth — 3, every fifth was taking 1 drug. Fixed combinations of AD were used in 15%, in both registries. The target blood pressure profile was reached in 26,1% of hypertension patients in RECVASA and in 37,6% in PROFILE; in hypertension of 3rd degree — in 21,9% and 34,2% cases, respectively.Conclusion. In generally analogical approaches to AD, matching with current clinical guidelines, final result of treatment in terms of reached target blood pressure values, was significantly better in specialized cardiological center. This, probably, reflects better adherence to therapy in PROFILE patients

QUALITY ASSESSMENT OF ANTIHYPERTENSIVE THERAPY IN PATIENTS WITH ARTERIAL HYPERTENSION WITHOUT CONCOMITANT CARDIOVASCULAR DISEASES AS A PART OF OUTPATIENT RECVASA REGISTER

Aim. To assess the quality of arterial hypertension (HT) pharmacotherapy within the outpatient register RECVASA, emphasizing whether the choice of antihypertensive drugs (AHD) is in line with current clinical guidelines.Material and methods. Patients with HT without ischemic heart disease, chronic heart failure and atrial fibrillation (n=741) were selected from all patients (n=3690) included into the register. Among concomitant diseases were revealed the following: bronchial asthma and/or chronic obstructive pulmonary disease (COPD) – in 42 (5.7%) patients; obesity – in 93 patients, impaired glucose tolerance – in 9 patients, and diabetes mellitus – 84 patients. Prescription of AHD, their number and class were recorded at every next visit to doctor. Accuracy of AHD choice, compliance with current clinical guidelines, and other considerations were assessed through the example of beta-blockers (BBs).Results. AHD were prescribed to 641 patients, and in 13.5% of patients did not receive any AHD. 49.7% of patients received ACE inhibitors, 38.5% – diuretics, 32.5% – BBs. BBs were prescribed to the third part of patients with diabetes and obesity. Furthermore a quarter patients with COPD and the third part of patients with bronchial asthma received BBs. BBs in combination with thiazide diuretics were prescribed to 12 (41.4%) patients with diabetes mellitus and to 13 (40.6%) patients with obesity.Conclusion. Doctors do not always make AHD choice according to current clinical guidelines. Compliance of AHD choice with current clinical guidelines should be an element of treatment quality assessment.</p

COMBINED ANTIHYPERTENSIVE THERAPY IN REAL CLINICAL PRACTICE. FOCUS ON FIXED COMBINATIONS OF ANTIHYPERTENSIVE DRUGS (According to the Data of Outpatient Registries RECVASA and PROFILE)

On Behalf of the Working Groups of the Registries PROFILE and REСVASA. Working Group of the PROFILE Registry: Akimova A.V., Voronina V.P., Dmitrieva N.A., Zakharova A.V., Zakharova N.A., Zagrebelnyy A.V., Kutishenko N.P., Lerman O.V., Lukina Yu.V., Tolpygina S.N., Martsevich S.Y.Working Group of the RECVASA Registry: Vorobyev A.N., Zagrebelnyy A.V., Kozminsky A.N., Lukina Yu.V., Loukianov M.M., Moseichuk K.A., Nikulina N.N., Pereverzeva K.G., Pravkina E.A., Boytsov S.A., Martsevich S.Yu., Yakushin S.S.Aim. To assess the frequency of prescription of different combinations of the main groups of antihypertensive drugs (AHD) and their fixed combinations to patients with arterial hypertension by physicians according to two outpatient registries.Material and methods. Hypertension was diagnosed in 3648 (98.9%) patients of the RECVASA registry and in 1230 patients of the PROFILE registry (80.3%). Data on doctor’s prescriptions reflected in the outpatient charts of patients of the both registries were analyzed. The following information of the prescribed antihypertensive therapy was studied in details: AHD, including fixed and free combinations, original and generic AHD. Data on the achievement/non-achievement of target blood pressure (BP) level in patients with hypertension were also analyzed.Results. Women were predominated among hypertensive patients of the RECVASA registry, (71.9%). The ratio of men and women was close to 1:1 in the PROFILE registry. Patients of the registry RECVASA were older: the average age was 66.2±12.8 years compared to 63.7±11.4 years in patients of the PROFILE registry, respectively. The majority of patients in the RECVASA registry (61.4%) had hypertension of the 3rd degree, patients of the PROFILE registry revealed mostly hypertension of the 2 degree (53.3%). Fixed combinations were prescribed to 14% of patients in the registry of RECVASA and to 16% of patients in the PROFILE registry. Doctors of the PROFILE registry often prescribed original AHD; 75% of patients from RECVASA registry received generics. The most popular combinations in both registries were combinations of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers with thiazide/thiazide-like diuretics. The target level of BP was more often achieved in the patients of the PROFILE registry: 37.6% vs 26.1% in the RECVASA registry.Conclusion. The results of the analysis of the presented registries demonstrate the low frequency of prescribing fixed combinations in real clinical practice, the inertness of physicians in achieving the target BP levels and the low efficiency of antihypertensive therapy

OUTPATIENT REGISTRY OF CARDIOVASCULAR DISEASES (RECVASA): PROSPECTIVE FOLLOW-UP DATA, ESTIMATION OF RISKS AND OUTCOMES IN PATIENTS WITH ATRIAL FIBRILLATION

Aim. To evaluate outcomes and risk of their occurrence in patients with atrial fibrillation (AF) within 12 months of follow-up in actual outpatient practice.Material and methods. A total of 3690 patients with AF, arterial hypertension (HT), ischemic heart disease (IHD) and chronic heart failure (CHF) consulted by general practitioners and cardiologists of three outpatient clinics of Ryazan, were enrolled into the outpatient REgistry of CardioVAScular diseAses (RECVASA). 530 of 3690 (14.4%) patients had the diagnosis of "atrial fibrillation" in their outpatient charts. Estimation of the end points within 12 months after inclusion into the registry was performed based on the data received from the contacts with patients or a documented fact of death.Results. 39 (7.4%) patients had died during this period [30 (76.9%) of them due to cardiovascular causes], 18 (3.4%) – had undergone stroke, 3 (0.6%) – myocardial infarction, 2 (0.4%) patients had cardiovascular surgery. There were 63 hospitalizations due to cardiovascular diseases (CVD). AF did not lead to significant increase in cardiovascular death risk [odds ratio (OR)=1.31, p=0.21] and stroke risk (OR=1.64, р=0.09) within 12 months after inclusion into the registry, but the risk of hospitalization due to CVD was significantly higher(OR=2.88, р=0.0001). Permanent AF significantly increased the risk of stroke (OR=2.07, р=0.04). Such factors as diabetes, prior stroke, systolic blood pressure (SBP)&lt;110 mm Hg and heart rate (HR)≥90 bpm significantly increased all-cause death risk (OR=2.49, р=0.008; OR=2.46, р=0.01; OR=7.6, р=0.003; OR=15.3, р=0.01, respectively). Patients treated with ACE inhibitors or angiotensin receptor blockers (ARB) had lower all-cause and cardiovascular death risks: OR=0.38, р=0.01 and OR=0.25, р=0.02, respectively. Other drugs revealed no significant influence on prognosis.Conclusion. According to the outpatient registry RECVASA data such factors as permanent type of AF, diabetes mellitus, prior stroke, SBP&lt;110 mm Hg and HR≥90 bpm, ACE inhibitors/ARB prescription significantly influenced prognosis in patients with AF. Estimating outcomes in AF patients, combination with HT, IHD, CHF and non-cardiac comorbidities must be taken into account as well as peculiarities of these diseases drug treatment

DIAGNOSTICS, TREATMENT, ASSOCIATED CARDIOVASCULAR AND CONCOMITANT NON-CARDIAC DISEASES IN PATIENTS WITH DIAGNOSIS OF “ATRIAL FIBRILLATION” IN REAL OUTPATIENT PRACTICE (ACCORDING TO DATA OF REGISTRY OF CARDIOVASCULAR DISEASES, RECVASA)

Aim. To study the structure of risk factors and associated cardiovascular and concomitant non-cardiac diseases in patients with atrial fibrillation (AF) on the base of the data of registry, and to estimate diagnostics and treatment quality in real outpatient practice in the Ryazan region with high cardiovascular mortality rate.Material and methods. A total of 3690 patients with AF, arterial hypertension (HT), ischemic heart disease (IHD) and chronic heart failure (CHF) consulted by general practitioners and cardiologists in three outpatient clinics of Ryazan, were enrolled into the outpatient REgistry of CardioVAScular diseAses (RECVASA). 530 of 3690 (14.4%) patients had the "atrial fibrillation" diagnosis in their outpatient charts: 175 (33.0%) men, 355 (67.0%) women, and mean age – 72.3±10.1 years.Results. Permanent, paroxysmal or persistent forms of AF were indicated in outpatient charts of 43.2%, 26.4% and 24.7% of 530 AF patients, respectively, and 5.7% of outpatient charts did not specify AF form. All the AF patients had associated cardiovascular diseases (HT and/or IHD and/or CHF). The history of myocardial infarction, stroke and diabetes was revealed in 20.2%, 14.9% and 21.1% of patients, respectively. Revealed level of diagnostics did not satisfy adequate standard of examination with such cardiac pathology. Prescription of necessary drugs of some groups was insufficient, although indications existed. At the time of being included into the registry only 15.2% of AF patients received cardio-vascular drugs at a privileged price compared to 39.2% in the preceding years (p&lt;0.05). AF diagnosis was confirmed in 84.2% of 76 randomly selected patients at its validation.Conclusion. The RECVASA research revealed high incidence of cardiac comorbidity in patients with the AF, underestimation of cardiovascular risk factors, insufficient use of diagnostic tests and prescription of some drug groups recommended by national and international guidelines.</p

OUTPATIENT REGISTRY OF CARDIOVASCULAR DISEASES (RECVASA): PROSPECTIVE FOLLOW-UP DATA, ESTIMATION OF RISKS AND OUTCOMES IN PATIENTS WITH ATRIAL FIBRILLATION

Aim. To evaluate outcomes and risk of their occurrence in patients with atrial fibrillation (AF) within 12 months of follow-up in actual outpatient practice.Material and methods. A total of 3690 patients with AF, arterial hypertension (HT), ischemic heart disease (IHD) and chronic heart failure (CHF) consulted by general practitioners and cardiologists of three outpatient clinics of Ryazan, were enrolled into the outpatient REgistry of CardioVAScular diseAses (RECVASA). 530 of 3690 (14.4%) patients had the diagnosis of "atrial fibrillation" in their outpatient charts. Estimation of the end points within 12 months after inclusion into the registry was performed based on the data received from the contacts with patients or a documented fact of death.Results. 39 (7.4%) patients had died during this period [30 (76.9%) of them due to cardiovascular causes], 18 (3.4%) – had undergone stroke, 3 (0.6%) – myocardial infarction, 2 (0.4%) patients had cardiovascular surgery. There were 63 hospitalizations due to cardiovascular diseases (CVD). AF did not lead to significant increase in cardiovascular death risk [odds ratio (OR)=1.31, p=0.21] and stroke risk (OR=1.64, р=0.09) within 12 months after inclusion into the registry, but the risk of hospitalization due to CVD was significantly higher(OR=2.88, р=0.0001). Permanent AF significantly increased the risk of stroke (OR=2.07, р=0.04). Such factors as diabetes, prior stroke, systolic blood pressure (SBP)&lt;110 mm Hg and heart rate (HR)≥90 bpm significantly increased all-cause death risk (OR=2.49, р=0.008; OR=2.46, р=0.01; OR=7.6, р=0.003; OR=15.3, р=0.01, respectively). Patients treated with ACE inhibitors or angiotensin receptor blockers (ARB) had lower all-cause and cardiovascular death risks: OR=0.38, р=0.01 and OR=0.25, р=0.02, respectively. Other drugs revealed no significant influence on prognosis.Conclusion. According to the outpatient registry RECVASA data such factors as permanent type of AF, diabetes mellitus, prior stroke, SBP&lt;110 mm Hg and HR≥90 bpm, ACE inhibitors/ARB prescription significantly influenced prognosis in patients with AF. Estimating outcomes in AF patients, combination with HT, IHD, CHF and non-cardiac comorbidities must be taken into account as well as peculiarities of these diseases drug treatment.</p

Cardiovascular Diseases and Drug Treatment in Patients with the History of Cerebral Stroke: Data of the Outpatient Registry REGION

Aim. To evaluate the structure of combined cardiovascular diseases, drug treatment and observation of patients with a history of stroke in the framework of prospective outpatient registries. Material and methods. The study was conducted based on 3 outpatient clinics of Ryazan city. Patients with a history of acute cerebrovascular accident (ACVA) of any remoteness (AR) were included into ACVA-AR outpatient registry (n=511). Patients who had visited the outpatient clinics for the first time (FT) after cerebral stroke (n=475) were included into the ACVA-FT outpatient registry. The structure of the cardiovascular diseases (CVD), compliance with the clinical recommendations of the prescribed and received drug therapy were evaluated. The proportion of patients with dispensary observation for CVD, using preferential drug provision was determined. Results. A combination of 2 or more CVDs was found in 84.4% and 82.5% of cases, and severe cardiovascular multimorbidity (3-4 CVDs) – in 69% and 64% of cases, respectively, in ACVA-AR and ACVA-FT registers. Compliance with the clinical guidelines prescribed and received drug therapy was insufficient at the outpatient stage. Necessary prescription of drugs with a proven beneficial effect on the prognosis were observed significantly more frequent in the ACVA-FT registry, compared to the ACVA-AR registry at the enrolling stage of the study (p&lt;0.05): statins for stroke – 50.1% vs 25.2%; statins for coronary heart disease (CHD) – 47.2% vs 27.9%; antiplatelet agents for CHD without atrial fibrillation – 65.6% vs 54.3%; anticoagulants for atrial fibrillation – 17.7% vs 9.3%; beta-blockers for heart failure 43.5% vs 33.1%, respectively. After 2-3 years of the follow-up frequency of prognostically significant prescriptions in patients of the compared registries were not significantly different, except prescriptions for statin therapy (47.6% vs 21.3%, respectively). The prognostically significant prescriptions during the enrolling stage in ACVA-AR and ACVA-FT registries occurred in 44.4% and 54% of the total number of proper prescriptions, and in the long-term follow-up period – in 55% and 57%, respectively; and the dispensary observation coverage was only 35.0% and 31.8%, respectively. According to patient contact only 21-24% of patients used the system of preferential drug provision at the stage of inclusion into the registers, and after 2-3 years of follow-up – 1.5-2 times less (12-14%). Conclusion The results of the study REGION found the presence of cardiovascular multimorbidity in 83% of patients with a history of stroke, insufficient quality of prescribed drug therapy in the out-patient clinic, especially in the ACVA-AR registry. The quality of medical treatment of patients improved within 2-3-year follow-up after the reference visit to out-patient clinic, but not sufficiently. Increase in dispensary observation coverage and optimization of the system of preferential drug provision are also important reserves for improving the quality of treatment of patients with a history of stroke, as well as prevention of cardiovascular complications

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 &gt;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.</p