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State Program ''Early Detection and Prevention of Diseases - Ischemic Heart Disease Management Survey''

Role of the Primary health care in the management of CVD risk in patients with identified diseases as well as in high risk individuals is crucial. Cardiovascular risk management embraces risk assessment, patient awareness, promotion of implementation of recommendations regarding life style modification and cardio-protective medication by the adequate algorithm.

By the data of State program "Management of Ischemic Heart Disease" main disadvantage of the management of cardiovascular diseases is ignorance of recommended diagnostic and therapeutic algorithms. Explanation for it by the health professionals is inaccessibility to certain health services for most of patients due to low income. We suggested it is associated with need for additional training of medical professionals.

It must be emphasized, that lipid profile is totally neglected in CVD risk assessment. Knowledge of lipids measurements inclusion necessity in patient's investigation plan is not reflected in medical records and certainly it could not be explained by the low paying capacity of patient.
It has been shown that:

  • Diagnosis is formulated by ICD- 10 only in 44 % of cases.
  • Qualitative indicators of personal cardio-vascular risk assessment
    Anthropometric data in 39% (not completed)
    Smoking status in 51%
    Fasting glucose is measured in 63% in patients older 40 years during last 3 years.
    Lipid profile was assessed in 0.5% of mails older 40y and females older 50 y.
    Microalbiminuria was never tested
    Cardiovascular risk was not estimated.
Qualitative indicators of disease management:

  • Arterial hypertension
No information about drug dose titration

No information about target BP level

By present algorithms every patient with manifested Ischemic heart disease should regularly take aspirin in absence of precise contraindications.
Every patient with history of TEA or stroke should regularly take aspirin
Medication with ACE inhibitors is considered in post-MI patients. It must be prescribed early in disease course and remain along the life to prevent LV dysfunction.

Beta –blockers are recommended in all patients with IHD, LV dysfunction, particularly after acute coronary event. Side effect monitoring should be considered.

Anticoagulants are recommended in patients with history of TEA or stroke and atrial fibrillation. However, monitoring of coagulation is strongly recommended.
Prolonged anti lipid treatment ( Statins) is recommended in all patients with IHD.

  • Qualitative indicators of IHD management:
Aspirin was prescribed in 43% of IHD patients. Motivation for decision to not prescribe Aspirin was not argued in medical records.

Beta blockers were used in 30% of patients (only in two of them it was motivated by history bronchial spasm and patients self decision.

ACE inhibitors were used in 36 % of patients. Reason for denial is not argued.

Fasting glucose was measured in 51% of patients with IHD

  • Qualitative indicators of HF management:
EF was assessed in 12% of patients

Creatinine was measured in 0.5% 0f patients

  • Qualitative indicators of management of Dislipidemias:
Only in 9% of patients anti lipid treatment was prescribed without plan of monitoring and indication of target level.

During last decades invasive coronary interventions (PCI and CABG surgery) are broadly used in treatment of IHD. It is performed to reduce or eliminate the symptoms of coronary artery disease and in some cases to reduce death. In number of IHD management guidelines indications for PCI and CABG surgery are formulated. In scope of our program it has been shown that above mentioned recommendations for indications of PCI and CABG are not considered when planning treatment strategy and as a result patients fail to receive adequate treatment.

By the data of WHO the Healthy Life Expectancy (HALE) is 58.2 years and markedly less than in South- eastern countries (Bulgaria 63.4, Croatia 64.0, Slovenia 66.9). Prevalence of arterial hypertension and primary hypertension particularly exhibits tendency of aggressive rise and it situation becomes critical in Georgia. Considering the priority of hypertension as a risk factor of all vascular accidents (myocardial infarction, stroke, sudden death) it becomes clear that Georgian population risks may be dramatically high.

By the surveys conducted in Georgia main defects of hypertension management are: low patient adherence to treatment, interruptive treatment, frequent change of drugs due to low therapeutic efficacy, high level of anxiety and depression in population, financial challenges and etc. Rise of communication between doctor and patient is the prior objective. Confidence to doctor and respectively rise of treatment motivation will be realized by adequate behavioral model of doctor- sufficient competence, ability to understand all problems of patient, adequate style of giving information and etc.

Ministry of Health made steps in direction of development and implementation of clinical practice guidelines. In 2006 was worked out non-communicable disease – CVD national guidelines. Three main factors provided success of implementation process are : adapted guidelines and protocols, motivated doctor and adhered patient. Against of it three main resistances: non-adapted protocol, non-motivated doctor and non aware patient .Implementation process required use of instruments of practice assessment for evaluation of doctor's strategy for management of present clinical case. It should be considered while updating guidelines.
Important issues:

  • Ignorance of estimation of patient's personal CVD risk in clinical practice
  • Failure of primary and secondary prevention of diseases and first of all preventive medication.
  • Neglect of drug dose titration, management of side effects and principals of treatment optimization
  • Investigated persons distribution by places of residence and sex
 
Female
Male
All
Tbilisi
185
115
300
Batumi
65
85
150
All
250
200
450


 
 AH ( > 140/90 mm.Hg)
 Waist circumference
female > 88cm. male. > 102cm.
Tbilisi
Female
(n = 185)
Male
(n = 115)
Female
(n = 185)
Male
(n = 115)
 
87 – 47,027%
68 – 59,13%
142 – 76,76%
81 – 70,43%
Batumi
Female
(n = 65)
Male
(n = 85)
Female
(n = 65)
Male
(n = 85)
 
32 – 49,23% 
53 – 62,35% 
55 – 84,62% 
61 – 71,76% 
All
119 – 47,6%
121 – 60,5 %
197 – 78,8%
142 - 71%
  • Percentage of patients with AH- 53,33% ( 240 persons).
  • In Tbilisi it was 51,67%(155persons), in Batumi 56,67% (85 persons)
  • Overweight were 339 persons – 75,33%, in Tbilisi overweight were 223-74,33%, in Batumi 116 persons – 77,33%.
    In individuals with arterial hypertension increased total cholesterol T. CHOL
    (> 160 mg / dl) were identified in 138 cases - 57.5% - including 85 women - 97.7% - in., men of 53 - 77.94% - in Tbilisi..
  • In persons without Hypertension elevated total cholesterol
    (> 180 mg / dl) were seen in 99 cases -68.3% - including women - 74 - 75.51% .In Males 25 cases - 53.19%.
  • In Batumi in persons with Arterial hypertension elevated total cholesterol (> 160 mg / dl) were identified in 74 cases - 87.05% - including 28 women - 87.5% , in men of 46 - 86.79% .
  • In persons without AH elevated total cholesterol (> 180 mg / dl) were seen in 34 cases -68.3% - including women - 18 - 54.55% - , and 16 men - 50%.
  • Increased HDL CHOL (>130 mg/dl) were identified in Tbilisi in 115 persons-38,33%, women 83- 44,86%, men – 32-27,83%
  • In Batumi increased HDL CHOL (>130 mg/dl) were identified in 39 persons-26%, women 19 – 29,23%, men – 20 -23,53%.
  • Total increased HDL-CHOL (> 130 mgdl) were seen in 154 cases - 34.22%.
  • Elevated triglycerides - TG in the blood (> 200 mg / dl) were identified in 81 cases - 27% - in Tbilisi, the same figure was increased in 33 cases - 22% of the total population in Batumi.
  • Elevated triglycerides have been viewed in 114 cases, which amounted to a total of 25.33% ..
  • Another indicator of dislipidemia impaired HDL cholesterol HDL-CHOL was identified in 10 cases -3.33% - (for women in 3 cases, and the men of the7 cases), in Batumi these figures were higher - 64 -42,67%(women 26 - 40% - of the men of 38 - 44.71%,
  • Total impaired HDL cholesterol HDL-CHOL revealed in 74 cases - 16,44%
09.12.2011
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