Identification and management of patients with hypertension in the polyclinic system of the Russian Federation.

BACKGROUND: Cardiovascular diseases, including hypertension and type 2 diabetes mellitus, are the major determinants of poor health in the Russian Federation. METHODS: This study assessed the feasibility of establishing a program to identify and manage hypertension and associated cardiovascular risk factors in an outpatient clinic within the Russian polyclinic system. In urban polyclinic in Kazan, Tatarstan, which is responsible for 77,000 covered lives, we enrolled 192 patients with hypertension of whom 68 had type 2 diabetes mellitus screened from various clinics within the polyclinic. After collection of baseline data, patients were treated for hypertension and those risk factors amenable to pharmaceutic intervention and counseled on those that required behavior modification. RESULTS: Baseline blood pressure was 173.9+/-20.7/104.2+/-15.3 mm Hg in those with hypertension only (n=124) and 172.9+/-26.0/97.9+/-16.4 mm Hg in those with both hypertension and type 2 diabetes mellitus. More than 80% of the entire group had a body mass index >25 kg/m2 and left ventricular hypertrophy. Nearly 70% had total cholesterol >5.2 mmol/L. Of the diabetics, more than 50% had glycosylated hemoglobin (HbA1c)>or=8%. Less than 10% of this self-selected population smoked. Blood pressure decreased modestly, but significantly, in both groups of patients. There were no significant changes in obesity, cholesterol, smoking, or HbA1c in the diabetics. CONCLUSIONS: Identification, recruitment, management, and follow-up of patients with chronic disorders is feasible within the Russian polyclinic system. However, to have a more profound effect on risk factor profiles, a wider effort is needed than one restricted to the clinic itself.

Pharmacokinetic factors in the adverse cardiovascular effects of antipsychotic drugs.

Antipsychotics may cause serious adverse cardiovascular effects, including prolonged QT interval and sudden death. This review considers antipsychotic-induced cardiovascular events from three perspectives: high-risk drugs, high-risk individuals and high-risk drug interactions. Pharmacokinetic drug interactions involving the cytochrome P450 (CYP) enzymatic pathway and pharmacodynamic interactions leading to direct cardiotoxic effects are discussed. Original reports on antipsychotic-induced drug interactions are reviewed, with consideration of management guidelines. The literature was reviewed from 1 January 1966 to 1 February 2002. The literature search revealed only 12 original articles published on antipsychotic drug interactions leading to cardiovascular adverse events. Only 4 of the 12 reports were prospective studies; the remainder were either retrospective or anecdotal.Although poor study designs preclude a definitive statement, it appears that pharmacokinetic interactions primarily involved the CYP2D6 and CYP3A4 enzymatic pathways. Those involving the CYP2D6 isozyme included interactions with tricyclic antidepressants, selective serotonergic reuptake inhibitors and beta-blockers. Among these drug interactions, tricyclic antidepressants were most likely to reach clinical significance because of their limited therapeutic index. Drug interactions related to the CYP3A4 pathway were generally less severe, and involved high-potency antipsychotics coadministered with inhibitors such as clarithromycin. Strategies are discussed for the management of adverse cardiovascular events related to antipsychotic drug interactions, including the use of an algorithm. Large, randomised, placebo-controlled studies with strict inclusion criteria are needed to determine the role that antipsychotics play in QT prolongation and sudden death.

The Russian health care system today: can American-Russian CME programs help?

The health of the Russian people has deteriorated dramatically since the fall of communism, due particularly to cardiovascular disease. The Eurasian Medical Education Program was developed in response to provide continuing medical education for Russian physicians. Programs are directed mainly toward primary care physicians and focus on outpatient management of diseases that cause high rates of mortality and morbidity. This experience provides an opportunity to assess the structure and functioning of the Russian health care system and emphasizes the importance of general internal medicine training in detection, management, and prevention of disease complications.

Global health assistance: a new perspective.

Health care priorities for many emerging economies have undergone a dramatic transition in the recent past because of the rise in chronic illness, increased longevity, and lessened infant mortality. Two additional major societal forces, democratization and the information revolution, will alter the nature of global health assistance. Because of democratization, governments will feel increasing pressure to provide adequate health care. Because of the information revolution, all practitioners will know what is available. The convergence of these three forces will create an enormous financial burden for emerging economies. Adapting to these new realities will be the challenge to donor organizations. What is likely to emerge as a critical health care problem around the world is the need to balance priorities between acute care and prevention or modification of chronic disease. These efforts will be directed at different populations, one manifestly ill and one potentially so, and each will need to be recognized politically as having valid claims on governmental resources. External support will need to include demonstration within the recipient communities that data collection permits an accurate identification of disease burden, that risk factor modification ameliorates the impact of disease, that continuity of care is essential to long term outcomes, and that therapy of developed disease can be rationally carried out utilizing evidence based medicine to insure efficiency and appropriateness.