Management of patients with hypertension and chronic kidney disease referred to Hypertension Excellence Centres among 27 countries. On behalf of the European Society of Hypertension Working Group on Hypertension and the Kidney.

Objective Real-life management of patients with hypertension and chronic kidney disease (CKD) among European Society of Hypertension Excellence Centres (ESH-ECs) is unclear : we aimed to investigate it. Methods A survey was conducted in 2023. The questionnaire contained 64 questions asking ESH-ECs representatives to estimate how patients with CKD are managed. Results Overall, 88 ESH-ECS representatives from 27 countries participated. According to the responders, renin-angiotensin system (RAS) blockers, calcium-channel blockers and thiazides were often added when these medications were lacking in CKD patients, but physicians were more prone to initiate RAS blockers (90% [interquartile range: 70-95%]) than MRA (20% [10-30%]), SGLT2i (30% [20-50%]) or (GLP1-RA (10% [5-15%]). Despite treatment optimisation, 30% of responders indicated that hypertension remained uncontrolled (30% (15-40%) vs 18% [10%-25%]) in CKD and CKD patients, respectively). Hyperkalemia was the most frequent barrier to initiate RAS blockers, and dosage reduction was considered in 45% of responders when kalaemia was 5.5-5.9 mmol/L. Conclusions RAS blockers are initiated in most ESH-ECS in CKD patients, but MRA and SGLT2i initiations are less frequent. Hyperkalemia was the main barrier for initiation or adequate dosing of RAS blockade, and RAS blockers' dosage reduction was the usual management.

What is the context? Hypertension is a strong independent risk factor for development of chronic kidney disease (CKD) and progression of CKD to ESKD. Improved adherence to the guidelines in the treatment of CKD is believed to provide further reduction of cardiorenal events. European Society of Hypertension Excellence Centres (ESH-ECs) have been developed in Europe to provide excellency regarding management of patients with hypertension and implement guidelines. Numerous deficits regarding general practitioner CKD screening, use of nephroprotective drugs and referral to nephrologists prior to referral to ESH-ECs have been reported. In contrast, real-life management of these patients among ESH-ECs is unknown. Before implementation of strategies to improve guideline adherence in Europe, we aimed to investigate how patients with CKD are managed among the ESH-ECs.What is the study about? In this study, a survey was conducted in 2023 by the ESH to assess management of CKD patients referred to ESH-ECs. The questionnaire contained 64 questions asking ESH-ECs representatives to estimate how patients with CKD are managed among their centres.What are the results? RAAS blockers are initiated in 90% of ESH-ECs in CKD patients, but the initiation of MRA and SGLT2i is less frequently done. Hyperkalemia is the main barrier for initiation or adequate dosing of RAAS blockade, and its most reported management was RAAS blockers dosage reduction. These findings will be crucial to implement strategies in order to improve management of patients with CKD and guideline adherence among ESH-ECs.

Screening and management of hypertensive patients with chronic kidney disease referred to Hypertension Excellence Centres among 27 countries. A pilot survey based on questionnaire.

OBJECTIVE: Real-life management of hypertensive patients with chronic kidney disease (CKD) is unclear. METHODS: A survey was conducted in 2023 by the European Society of Hypertension (ESH) to assess management of CKD patients referred to ESH-Hypertension Excellence Centres (ESH-ECs) at first referral visit. The questionnaire contained 64 questions with which ESH-ECs representatives were asked to estimate preexisting CKD management quality. RESULTS: Overall, 88 ESH-ECs from 27 countries participated (fully completed surveys: 66/88 [75.0%]). ESH-ECs reported that 28% (median, interquartile range: 15-50%) had preexisting CKD, with 10% of them (5-30%) previously referred to a nephrologist, while 30% (15-40%) had resistant hypertension. The reported rate of previous recent (<6 months) estimated glomerular filtration rate (eGFR) and urine albumin-creatinine ratio (UACR) testing were 80% (50-95%) and 30% (15-50%), respectively. The reported use of renin-angiotensin system blockers was 80% (70-90%). When a nephrologist was part of the ESH-EC teams the reported rates SGLT2 inhibitors (27.5% [20-40%] vs. 15% [10-25], P = 0.003), GLP1-RA (10% [10-20%] vs. 5% [5-10%], P = 0.003) and mineralocorticoid receptor antagonists (20% [10-30%] vs. 15% [10-20%], P = 0.05) use were greater as compared to ESH-ECs without nephrologist participation. The rate of reported resistant hypertension, recent eGFR and UACR results and management of CKD patients prior to referral varied widely across countries. CONCLUSIONS: Our estimation indicates deficits regarding CKD screening, use of nephroprotective drugs and referral to nephrologists before referral to ESH-ECs but results varied widely across countries. This information can be used to build specific programs to improve care in hypertensives with CKD.

Cohort Profile: the European Unified Registries On Heart care Evaluation and Randomised Trials (EuroHeart) - Acute Coronary Syndrome and Percutaneous Coronary Intervention.

AIMS: The European Unified Registries On Heart care Evaluation And Randomized Trials (EuroHeart) aims to improve the quality of care and clinical outcomes for patients with cardiovascular disease. The collaboration of acute coronary syndrome/percutaneous coronary intervention (ACS/PCI) registries is operational in seven vanguard European Society of Cardiology member countries. METHODS AND RESULTS: Adults admitted to hospitals with ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) are included, and individual patient-level data collected and aligned according to the internationally agreed EuroHeart data standards for ACS/PCI. The registries provide up to 155 variables spanning patient demographics and clinical characteristics, in-hospital care, in-hospital outcomes, and discharge medications. After performing statistical analyses on patient data, participating countries transfer aggregated data to EuroHeart for international reporting.Between 1st January 2022 and 31st December 2022, 40 021 admissions (STEMI 46.7%, NSTEMI 53.3%) were recorded from 192 hospitals in the seven vanguard countries: Estonia, Hungary, Iceland, Portugal, Romania, Singapore, and Sweden. The mean age for the cohort was 67.9 (standard deviation 12.6) years, and it included 12 628 (31.6%) women. CONCLUSION: The EuroHeart collaboration of ACS/PCI registries prospectively collects and analyses individual data for ACS and PCI at a national level, after which aggregated results are transferred to the EuroHeart Data Science Centre. The collaboration will expand to other countries and provide continuous insights into the provision of clinical care and outcomes for patients with ACS and undergoing PCI. It will serve as a unique international platform for quality improvement, observational research, and registry-based clinical trials.

Frequency of office blood pressure measurements and the seasonal variability of blood pressure: results of the Hungarian Hypertension Registry.

PURPOSE: Hypertension is a major public health problem, thus, its timely and appropriate diagnosis and management are crucial for reducing cardiovascular morbidity and mortality. The aim of the new Hungarian Hypertension Registry is to evaluate the blood pressure measurement practices of general practitioners (GPs), internists and cardiologists in outpatient clinics, as well as to assess the seasonal variability of blood pressure. MATERIALS AND METHODS: Omron M3 IT devices were used during four-month periods between October 2018 and April 2023 in GP practices and in hypertension clinics. The blood pressure data were then transmitted online from the monitors' cuffs to a central database using the Medistance system of Omron. RESULTS: Family physicians (n = 2491), and internists/cardiologists (n = 477) participated in the study. A total of 4804 821 blood pressure measurements were taken during 10 four-month evaluation periods. In the ten periods, the daily average number of measurements was between 3.0 and 5.6. Following ESH diagnostic criteria, the proportion of subjects in optimal, normal and high-normal blood pressure categories were 14, 13.4 and 16.7%, respectively. Altogether 56% of the measurements belonged to stage 1, stage 2 or stage 3 hypertension categories (31.6, 17.1 and 7.4%, respectively). On average, a difference of 5/2 mmHg was observed between winter and summer data in systolic and diastolic blood pressures, respectively. The average systolic blood pressure values were higher in GP practices with more than 2000 patients than in the ones with less than 1500 patients (141.86 mmHg versus 140.02 mmHg, p < 0.05). CONCLUSION: In conclusion, the low daily average number of blood pressure measurements indicates a limited blood pressure screening awareness/capacity in the case of Hungarian family physicians. In GP practices with more patients, blood pressure is usually less well-controlled. These results suggest that the further promotion of home blood pressure monitoring is necessary.

What is the background?The standard method for the diagnosis of hypertension and for the control of treatment efficacy in hypertensive patients is office blood pressure measurement.Until now we had no real-life data on the blood pressure measurement practices of general practitioners (GPs), internists and cardiologists.Although seasonal differences in blood pressure values are well known, we had no data on the extent of these changes.What is new?In this real-world, nationwide observational study we were able to measure the frequency of blood pressure measurements in the daily practice of GPs, internists and cardiologists in Hungary, which was found to be very low compared to the number of patients they treat. In practices with more patients, blood pressure is generally less well-controlled.We could also detect a significant seasonal variation in systolic and diastolic blood pressure values over the observed time periods.What is the impact?The low daily average number of blood pressure measurements indicates a limited blood pressure screening awareness/capacity in the case of Hungarian family physicians, supporting the further promotion of home blood pressure measurement.The marked seasonal blood pressure changes demonstrated by our study require attention and the individual adjustment of treatment in different seasons.

Incidence and predictors of heart failure with improved ejection fraction category in a HFrEF patient population.

AIMS: The aim of the study was to assess the incidence and predictive factors of the development of heart failure with improved ejection fraction (HFimpEF) category during a 1 year follow-up period in a heart failure with reduced ejection fraction (HFrEF) patient population managed in a heart failure outpatient clinic. METHODS AND RESULTS: The study evaluated data from patients enrolled in the Hungarian Heart Failure Registry (HHFR). The incidence and predictive factors of the development of the HFimpEF category after 1 year follow-up were assessed in the group of patients who had HFrEF at baseline. We evaluated the incidence and predictors of the development of HFimpEF after a 1 year follow-up in relation to time since diagnosis of HFrEF in patients diagnosed within 3 months, between 3 months and 1 year, and beyond 1 year. The predictive factors of the development of HFimpEF were analysed using univariate and multivariate logistic regression analysis. Of the 833 HFrEF patients enrolled in the HHFR, the development of HFimpEF was observed in 162 patients (19.5%) during 1 year follow-up. In the whole patient population, independent predictors of the development of HFimpEF were female gender [odds ratio (OR): 1.73; 95% confidence interval (CI): 1.01-2.96; P < 0.05], non-ischaemic aetiology (OR: 1.95; 95% CI: 1.15-3.30; P < 0.05), and left ventricular end-diastolic diameter (LVEDD) <60 mm (OR: 2.04; 95% CI: 1.18-3.51; P < 0.05). The 1 year incidence of HFimpEF decreased in relation to time since diagnosis of HFrEF. The incidence of HFimpEF was 27.1% in patients diagnosed within 3 months, 18.4% in patients diagnosed between 3 months and 1 year, and 12.2% in patients diagnosed beyond 1 year. Non-ischaemic aetiology (OR: 4.76; 95% CI: 1.83-12.4; P < 0.01) and QRS width (OR: 0.81; 95% CI: 0.71-0.94; P < 0.01) for patients diagnosed within 3 months, LVEDD (OR: 0.54; 95% CI: 0.32-0.90; P < 0.05) and left atrial diameter ≤45 mm (OR: 5.44; 95% CI: 1.45-20.4; P < 0.05) for patients diagnosed between 3 months and 1 year, and LVEDD < 67 mm (OR: 2.71; 95% CI: 1.07-6.88; P < 0.05) for patients diagnosed beyond 1 year were found to be independent predictive factors. CONCLUSIONS: In our study, in this HFrEF patient population managed in a heart failure outpatient clinic, the 1 year incidence of HFimpEF was found to be ~20%. The 1 year incidence of HFimpEF decreased in relation to time since diagnosis of HFrEF. The most important predictors of the development of HFimpEF were female sex, non-ischaemic aetiology, narrower QRS width, and smaller diameter of the left ventricle and left atrium.

2023 ESH Guidelines for the management of arterial hypertension The Task Force for the management of arterial hypertension of the European Society of Hypertension: Endorsed by the International Society of Hypertension (ISH) and the European Renal Association (ERA).

DOCUMENT REVIEWERS: Luis Alcocer (Mexico), Christina Antza (Greece), Mustafa Arici (Turkey), Eduardo Barbosa (Brazil), Adel Berbari (Lebanon), Luís Bronze (Portugal), John Chalmers (Australia), Tine De Backer (Belgium), Alejandro de la Sierra (Spain), Kyriakos Dimitriadis (Greece), Dorota Drozdz (Poland), Béatrice Duly-Bouhanick (France), Brent M. Egan (USA), Serap Erdine (Turkey), Claudio Ferri (Italy), Slavomira Filipova (Slovak Republic), Anthony Heagerty (UK), Michael Hecht Olsen (Denmark), Dagmara Hering (Poland), Sang Hyun Ihm (South Korea), Uday Jadhav (India), Manolis Kallistratos (Greece), Kazuomi Kario (Japan), Vasilios Kotsis (Greece), Adi Leiba (Israel), Patricio López-Jaramillo (Colombia), Hans-Peter Marti (Norway), Terry McCormack (UK), Paolo Mulatero (Italy), Dike B. Ojji (Nigeria), Sungha Park (South Korea), Priit Pauklin (Estonia), Sabine Perl (Austria), Arman Postadzhian (Bulgaria), Aleksander Prejbisz (Poland), Venkata Ram (India), Ramiro Sanchez (Argentina), Markus Schlaich (Australia), Alta Schutte (Australia), Cristina Sierra (Spain), Sekib Sokolovic (Bosnia and Herzegovina), Jonas Spaak (Sweden), Dimitrios Terentes-Printzios (Greece), Bruno Trimarco (Italy), Thomas Unger (The Netherlands), Bert-Jan van den Born (The Netherlands), Anna Vachulova (Slovak Republic), Agostino Virdis (Italy), Jiguang Wang (China), Ulrich Wenzel (Germany), Paul Whelton (USA), Jiri Widimsky (Czech Republic), Jacek Wolf (Poland), Grégoire Wuerzner (Switzerland), Eugene Yang (USA), Yuqing Zhang (China).

Mortality on DOACs Versus on Vitamin K Antagonists in Atrial Fibrillation: Analysis of the Hungarian Health Insurance Fund Database.

PURPOSE: Limited real-world data are available on the survival of patients treated with vitamin K antagonists (VKAs) versus with direct oral anticoagulants (DOACs) for nonvalvular atrial fibrillation (AF). In this nationwide registry, we analyzed the mortality risk of patients with nonvalvular AF taking DOACs versus VKAs, with a special attention to the early treatment period. METHODS: The Hungarian National Health Insurance Fund (NHIF) database was searched to identify patients treated with VKA or DOAC as a thromboembolic prophylaxis for nonvalvular AF between 2011 and 2016. The overall and the early (0-3, 4-6, and 7-12 months) mortality risks with the 2 types of anticoagulation were compared. A total of 144,394 patients with AF treated with either a VKA (n = 129,925) or a DOAC (n = 14,469) were enrolled. FINDINGS: A 28% improvement in 3-year survival with DOAC treatment compared with VKA treatment was shown. Mortality reduction with DOACs was consistent across different subgroups. However, younger patients (30-59 years old) initiated on DOAC therapy had the greatest RRR (53%) in mortality. Furthermore, DOAC treatment also yielded a benefit of greater magnitude (HR = 0.55; 95% CI, 0.40-0.77, P = 0.001) in the lower (0-1) CHA2DS2-VASc score segment and in those with fewer (0-1) bleeding risk factors (HR = 0.50, CI 0.34-0.73, P = 0.001). The RRR in mortality with DOACs was 33% within the first 3 months, and 6% in the second year. IMPLICATIONS: Thromboembolic prophylaxis with DOACs in this study yielded significantly lower mortality compared with VKA treatment in patients with nonvalvular AF. The largest benefit was shown in the early period after treatment initiation, as well as in younger patients, those with a lower CHA2DS2-VASc score, and those with fewer bleeding risk factors.

Ankle Brachial Index is a strong predictor of mortality in hypertensive patients: results of a five-year follow-up study.

BACKGROUND: In the hypertensive population, the peripheral arterial disease (PAD) is considered one of the target organ damages. Ankle Brachial Index (ABI) measurement represents the widely accepted clinical method that may objectively detect the presence of PAD. The study aimed to assess how PAD revealed by ABI predicts mortality in patients with hypertension. METHODS: In the follow-up time (5 years period) of the Hungarian ERV Study, a large scale, multicenter observational study, recruiting hypertensive subjects between 50-75 years, the association of PAD with the survival time was analysed. Several multivariate, interval-censored survival models were developed to assess this association. RESULTS: Among the 21892 enrolled hypertensive patients, the prevalence of PAD (ABI≤0.9) was 14.4%. The crude death rate was 5.44% (1190 cases) over the available observational period. In multivariate models male sex, myocardial infarction in patients' history, diabetes, renal failure, PAD and cardiovascular risk (SCORE risk) were significantly associated with mortality. Lower ABI showed a continuous, close to linear association with worse survival. PAD was predictive for mortality risk in all SCORE patient groups. CONCLUSIONS: Low ABI is a strong predictor of mortality in hypertensive patients between the age 50-75, even after adjustment for several potential confounders. The association is linear, with no apparent cut-off, suggesting that ABI should be handled as a continuous variable. The detection of PAD in hypertensives may contribute to the determination of total cardiovascular risk in hypertensive population.

High Level of Unwarranted Clinical Variation in the Use of Lower Extremity Revascularisation Procedures in Hungary (2013-2017).

OBJECTIVE: Assessment of variations in the use of lower extremity open vascular surgical procedures (LEOPEN) and lower extremity endovascular procedures (LEENDO) across small geographic areas in Hungary from 2013 to 2017. Introduction of a new metric giving a rough estimate of unwarranted clinical variation in revascularisation practice. METHODS: Spatial variation (at local administrative unit level) of referral for LEOPEN and LEENDO was evaluated through a retrospective analysis using healthcare administrative data of all beneficiaries in Hungary. The same assessment was performed for percutaneous coronary intervention in acute myocardial infarction (PCIAMI). The latter was considered a reasonable comparator (similar at risk population, well organised, guideline driven patient pathways, small room for referral discretion). Consequently, the ratio of spatial variations of LEOPEN and LEENDO to PCIAMI (as a reference) are thought to reflect unwarranted clinical variation. RESULTS: A total of 109 882 procedures were identified in the database (LEOPEN, LEENDO, PCIAMI) affecting 85 083 patients. While estimates of spatial variations for LEOPEN and LEENDO turned out to be high (systematic component of variation [SCV] 0.09 and 0.21, respectively), PCIAMI showed a low SCV value of 0.02. Consequently, the ratios of SCVs were SCV/SCVref = 4.67 (LEOPEN) and SCV/SCVref = 10.3 (LEENDO), indicating high levels of unwarranted clinical variation. CONCLUSION: The analysis showed that patients living in different locations of Hungary face very different odds of having lower extremity revascularisation procedures (open or endovascular). This spatial variation is thought to be related mainly to the failure in vascular service organisation. The newly introduced numerical estimate of unwarranted clinical variation may support within, and also between, system comparisons.

Spatial analysis of factors impacting lower limb major amputation rates in Hungary: Is geography partially destiny?

Background: Lower limb major amputations represent a substantial public health burden in Hungary, where previous research revealed markedly high rates with significant spatial variations. Therefore, we aimed to assess to what extent healthcare and socio-economic factors in the local environment explain the regional disparity. Patients and methods: In a retrospective cohort analysis, based on the healthcare administrative data of the Hungarian population, lower limb major amputations were identified from 1st of January 2017 to 31st of December 2019. The permanent residence of the amputees on the local administrative level (197 geographic units) was used to identify potential healthcare (outpatient care, revascularisation activity) and socio-economic (educational attainment, local infrastructure and services, income and employment) determinants of amputations. Spatial effects were modelled using the spatial Durbin error regression model. Results: 10,209 patients underwent 11,649 lower limb major amputations in the observational period. In our spatial analysis, outpatient care was not associated with local amputation rates. However, revascularisation activity in a geographic unit entailed an increased rate of amputations, while revascularisations in the neighbouring areas were associated with a lower rate of amputations, resulting in an overall neutral effect (ß=-0.002, 95% CI: -0.05 - 0.04, p=0.96). The local socio-economic environment had a significant direct inverse association with amputations (ß=-7.45, 95% CI: -10.50 - -4.42, p<0.0001) . Our spatial model showed better performance than the traditional statistical modelling (ordinary least squares regression), explaining 37% of the variation in amputations rates. Conclusions: Regional environmental factors explain a substantial portion of spatial disparities in amputation practice. While the socio-economic environment shows a significant inverse relationship with the regional amputation rates, the impact of the local healthcare-related factors (outpatient care, revascularisation activity) is not straightforward. Unravelling the impact of the location on amputation practice requires complex spatial modelling, which may guide efficient healthcare policy decisions.

Aspects of antithrombotic and anticoagulant therapies in patients undergoing endovascular procedures for lower extremity arterial disease. / Az alsó végtagi endovascularis veroér-beavatkozások során alkalmazott antithromboticus, antikoaguláns terápia szempontjai.

Összefoglaló. A népesség öregedése, a meghatározó cardiovascularis rizikótényezok - mint a cukorbetegség - egyre nagyobb arányú elofordulása, a csökkeno akut cardiovascularis halálozás az alsó végtagi veroérszukület növekvo megjelenésével jár. Ezzel együtt szaporodnak a beavatkozást igénylo, jelentos életminoség-romlást, illetve végtag-veszélyeztetettséget okozó, súlyosabb esetek. Ilyenkor az alsó végtagi revascularisatio szüksége merül fel, ami az utóbbi évtizedben az endovascularis beavatkozások számának növekedéséhez vezetett. A beavatkozások technikai sikere mellett újabb szukületek, elzáródások veszélyével kell számolni. Ennek hátterében az atherosclerosis progressziója mellett a beavatkozáshoz kötheto, kontrollált érfalsérülés indukálta vascularis remodelling (neointima-hyperplasia), valamint thromboticus tényezok állnak. Az ér-nyitvamaradás hosszú távú biztosításának feltétele a fenti folyamatok megelozésére alkalmazott optimális gyógyszeres kezelés. Ennek biztosítása elengedhetetlen a beavatkozást megelozoen, periprocedurálisan, majd az érintett betegkör hosszú távú gondozása során. A gyógyszeres terápiás lehetoségek közül az antithromboticus, antikoaguláns terápiának kiemelt jelentosége van. Az ezen hatású gyógyszerek alkalmazását igen nehézzé teszi (i) a thromboticus elzáródás kiújulása és a potenciális vérzés közötti dinamikusan változó egyensúly bizonytalansága, (ii) az egyéb társbetegségek kapcsán felmerülo terápiás szempontok egyideju érvényesítése, valamint (iii) a napi ellátásban támpontot adó tudományos bizonyítékok relatív hiánya. Az összefoglaló tanulmány a fenti gyógyszerterápiás terület legújabb eredményeit kísérli meg elemezni. Orv Hetil. 2022; 163(3): 98-108. Summary. The aging of the population, the increasing prevalence of important risk factors of atherosclerosis, like diabetes, and the declining mortality of acute cardiovascular conditions lead to increased peripheral arterial disease incidence. At the same time, cases showing a severe decline in quality of life or danger of limb loss get more prevalent that demands vascular interventions. In such cases, revascularization is recommended, and consequently, in the last decade, an expansion in endovascular procedures can be seen. Considering these procedures, besides a technical success, the risk of new stenosis or occlusion may be imminent. This may be accounted for the progression of atherosclerosis and the controlled vascular injury caused by the procedure itself that induces vascular remodeling (neointima hyperplasia) and thrombotic hyperactivity. The long-term vascular patency is closely associated with the success of an optimal medical treatment strategy. Its effect is considered essential prior to the endovascular procedure, perioperatively, and in the phase of long-term follow-up of the affected patients. In this scenario, antithrombotic and anticoagulant therapy regimes bear particular relevance. The use of this kind of drugs is challenged by (i) the uncertainty of dynamic changes of balance between the thrombotic reocclusion and the risk of bleeding, (ii) the interplay of treatment strategy related to concomitant diseases, (iii) the relative lack of high-level scientific pieces of evidence guiding daily routine. The narrative review makes an effort to provide new findings and an analysis of this therapeutic field. Orv Hetil. 2022; 163(3): 98-108.

May Measurement Month 2019: an analysis of blood pressure screening results from Hungary.

Cardiovascular diseases are not only the leading causes of mortality in Hungary but also the mortality rate is twice as high as the European Union average, so screening programmes identifying subjects with elevated blood pressure (BP) are of utmost importance. May Measurement Month (MMM) is an annual global initiative that began in 2017 aimed at raising awareness of high BP. Hungary joined the 3rd campaign of MMM in 2019 and an overview of the results are presented in this paper. An opportunistic cross-sectional survey of participants aged ≥18 years was carried out in May 2019. Hypertension was defined as systolic BP ≥140 mmHg and diastolic BP ≥90 mmHg or treatment for hypertension, statistical analysis followed the standard MMM protocol. In Hungary, 55 sites were set up in primary and secondary care facilities, in pharmacies, and in malls across all regions, in both cities and villages. Out of 2766 individuals screened, 1286 participants (46.5%) had hypertension. Out of 1869 participants not on antihypertensive medication, 389 (20.8%) had elevated BP. In the case of treated individuals (n = 897), 420 (46.8%) had uncontrolled hypertension. Almost every 2nd subject of the screened cohort had hypertension (treated and controlled, treated and uncontrolled, or untreated). In the untreated cohort, every 5th subject had elevated BP, whilst among patients on antihypertensive medication, every second had uncontrolled BP. By identifying almost one-third of the whole screened cohort with the possibility of newly diagnosed or uncontrolled hypertension, our results confirm the importance of BP screening campaigns.

Optimal use of lipid-lowering therapy after acute coronary syndromes: A Position Paper endorsed by the International Lipid Expert Panel (ILEP).

Atherosclerotic cardiovascular disease (ASCVD) and consequent acute coronary syndromes (ACS) are substantial contributors to morbidity and mortality across Europe. Much of these diseases burden is modifiable, in particular by lipid-lowering therapy (LLT). Current guidelines are based on the sound premise that with respect to low density lipoprotein cholesterol (LDL-C), "lower is better for longer", and the recent data have strongly emphasized the need of also "the earlier the better". In addition to statins, which have been available for several decades, the availability of ezetimibe and inhibitors of proprotein convertase subtilisin/kexin type 9 (PCSK9) are additional very effective approach to LLT, especially for those at very high and extremely high cardiovascular risk. LLT is initiated as a response to an individual's calculated risk of future ASCVD and is intensified over time in order to meet treatment goals. However, in real-life clinical practice goals are not met in a substantial proportion of patients. This Position Paper complements existing guidelines on the management of lipids in patients following ACS. Bearing in mind the very high risk of further events in ACS, we propose practical solutions focusing on immediate combination therapy in strict clinical scenarios, to improve access and adherence to LLT in these patients. We also define an 'Extremely High Risk' group of individuals following ACS, completing the attempt made in the recent European guidelines, and suggest mechanisms to urgently address lipid-medicated cardiovascular risk in these patients.

Cilostazol improves the quality of life and lower-limb functional capacity also in diabetic patients / A cilostazol diabeteses betegekben is javítja az életminoséget és az alsó végtagi funkcionális kapacitást.

INTRODUCTION: Intermittent claudication has a significant negative impact on the patients' quality of life. Revascularization procedures and noninvasive medical therapies can improve walking capacity. Cilostazol has IA recommendation for the treatment of intermittent claudication. AIM: The aim of this study was to evaluate the effect of a three-month cilostazol treatment on the health-related quality of life and on the lower-limb functional capacity in diabetic (DM) and non-diabetic patients (NDM) with intermittent claudication in the clinical practice. METHOD: The study was a multicenter, non-interventional trial; 812 patients with peripheral artery disease (Fontaine II stage, mean age: 67.17 years, male/female: 58.25/41.75%, 318 diabetics) were enrolled, who received cilostazol (50 or 100 mg twice a day) for 3 months. The quality of life was evaluated with the EQ-5D-3L questionnaire, the functional capacity with the WELCH questionnaire. Walking distances, ankle-brachial index were measured at baseline and after 3 months. RESULTS: Upon conclusion of the study, the EQ-5D index improved both in non-diabetic and diabetic patients (baseline: NDM -0.45 ± 0.22, DM -0.48 ± 0.23, 3rd month: -0,24 ± 0.18, -0,27 ± 0.19; respectively; p<0.0001) and there was a significant increase in the WELCH score as well (baseline: NDM 20 ± 14, DM 18 ± 14; 3rd month: 33 ± 19, 29 ± 16, respectively; p<0.0001). Both pain-free and maximal walking distance increased by 59.2% (median: 50.0%), 46.58 (median: 40.51%) in NDM and 42.85% (median: 43.33%), 41.61% (median: 34.68%) in DM patients, respectively (p<0.001). CONCLUSIONS: Three months of cilostazol treatment improved the quality of life and lower-limb functional capacity in diabetic and non-diabetic claudicant patients. The WELCH questionnaire is a useful tool in clinical practice for the evaluation of intermittent claudication treatment. Orv Hetil. 2020; 161(38): 1637-1645.

A summary of data of screening of the lower limb peripheral arterial diseases in the region of Northern Hungary / Tapasztalataink az alsó végtagi perifériás artériás érbetegség szurésérol az Észak-Magyarország régióban

INTRODUCTION: The screening tool for diagnosing lower extremity arterial disease (LEAD) is the assessment of the ankle-brachial index (ABI). In patients at risk for LEAD, the purpose of screening is to avoid major adverse limb events, such as amputation. However, resting ABI can easily produce a false negative result. AIM: In light of this, our goal was to test the usefulness of an easily performed, fast and cost-effective screening method and to determine the proportion of subjects without definitive diagnoses among patients screened in general practice (with special attention to groups having negative ABI with symptoms and patients with non-compressible arteries). METHOD: 680 patients were screened from the region of Northern Hungary. We used the Edinburgh Questionnaire, recorded medical histories, major risk factors, current complaints, and medication. Physical examinations were performed, including ABI testing. RESULTS: 34% complained about lower extremity claudication; 23% had abnormal ABI values; 14% of the patients within the normal ABI range had complaints of dysbasia; 12% were in the non-compressible artery group. The ABI-negative symptomatic group's risk factor profile showed a close similarity to the clear LEAD-positive and non-compressible artery groups. CONCLUSION: The percentage of LEAD could be higher than the number of patients diagnosed by ABI screening. Nearly a quarter of the population fell into the non-compressible artery and ABI-negative symptomatic groups. When screening purposely for LEAD, these patients deserve special attention due to the insufficient selectivity and sensitivity of measurements. If there is a high clinical suspicion of LEAD in spite of normal ABI values, further assessment may be considered. Orv Hetil. 2020; 161(33): 1381-1389.

Regional variation of lower limb major amputations on different geographic scales - a Hungarian nationwide study over 13 years.

Background: The incidence of lower limb major amputations is an important healthcare quality indicator, as it reflects all efforts aimed to prevent limb loss. Analysis of within-country regional variations in incidence may reveal the sources of disparities in care. Materials and methods: Based on the data of the Hungarian healthcare beneficiary population from 2004 to 2016, the incidence of lower limb major amputations and its spatial variations was determined regionally on four levels of geographic resolution. Variability and autocorrelation were quantified on different resolutions. Results: A total of 56,468 lower limb major amputation procedures were identified in 49,528 patients over the observation period. Marked regional variations were detected at all geographic scale levels. In the case of county-level and local administrative level, the systematic component of variation was 0.03 and 0.09, respectively. Only half of the variation at local administrative level was explained by county. Conclusions: Lower limb major amputations show marked regional variations on the different geographic levels of resolution. The more granular the assessment, the higher the regional variation was. Assumingly, this observation is partially a mathematical necessity but may also be related to the different characteristics of care at a given level of spatial aggregation. The decomposition of the variance of amputation rates indicates that the potential explanatory factors contributing to spatial variability are multiple and may be interpreted on different levels of geographic resolution. Addressing the unwarranted variations and resolving the issues that contribute to high lower limb major amputation rates needs further explorative analysis.

The combined effect of regular alcohol consumption and smoking on blood pressure and on the achievement of blood pressure target values in treated hypertensive patients / A rendszeres alkoholfogyasztás és a dohányzás hatása a vérnyomásra és a vérnyomáscélértékek elérési arányára kezelt hypertoniás betegekben

INTRODUCTION: The combined effect of alcohol consumption and smoking on hypertension in hypertensive patients is still not completely clear, although both are known to be cardiovascular risk factors. AIM: The aim of our study was to compare the blood pressure, the achievement of target blood pressure and heart rate of non-smokers and non-drinkers in the middle-aged hypertensive patients with those who smoke and drink regularly. METHOD: From the database of the Hungarian Hypertension Registry, 12 615 patients (6341 men and 6274 women) aged 45-64 years were included in the current analysis, who self-reported smoking habit and alcohol consumption. RESULTS: The mean age of the patients was 55.8 ± 5.7 years (males) and 56.1 ± 5.5 years (females). The percentage of regular smokers was 40.8% and 27.2% among men and women, respectively. 38.1% of males and 12.5% of females were regular alcohol drinkers. The ratio of patients reaching goal blood pressure values was higher in all investigated groups of females than males (p<0.001). Regular smokers and drinkers have lower percentage of reaching goal blood pressure values: 31.1% versus 46.6% in males (p<0.001) and 41.1% versus 49.8% in females (p<0.01), respectively. The average of pulse rate was higher in patients who are smokers and regular drinkers. CONCLUSION: Regular alcohol consumption and smoking decrease the chance of reaching blood pressure goal values in middle-aged, treated hypertensive patients. Orv Hetil. 2020; 161(30): 1252-1259.

Usefulness of a Novel Electrocardiographic Score to Estimate the Pre-Test Probability of Acute Pulmonary Embolism.

According to our experience the 12-lead electrocardiogram (ECG) may be used to estimate the pretest probability of acute pulmonary embolism (acPE). To this end, we devised a novel ECG score (nECGs) composed of 5 known ECG criteria, best characterizing the key pathogenetic steps of acPE. A retrospective derivation cohort including 136 patients with acPE and a prospective validation cohort including 149 consecutive patients were used to devise and validate the nECGs. The latter cohort consisted of 76 patients with acPE and 73 controls presenting with characteristic symptoms of acPE, in whom the work-up ruled out acPE. We compared the diagnostic value of our nECGs with those of another ECG score (Daniel-ECG-score) and of the best prediction rules (3 Wells score and 2 Geneva score variants). The sensitivity (98.7%), negative predictive value (98%), test accuracy (84.4%) and the negative likelihood ratio (LR) (0.019) of the nECGs were superior to those of all other investigated methods. There was no between-groups difference in the positive LR. The specificity (69%) of the nECGs was inferior to those of the Daniel-ECG-score and Wells scores and did not differ or was superior to those of the Geneva score variants. The positive predictive value (77.3%) of the nECGs was superior to those of the 2 Geneva scores and did not differ from those of the other methods. In conclusion, the nECGs due to its superior sensitivity, negative predictive value, test accuracy, and negative LR estimated the pretest probability of acPE better than the Daniel-ECG-score and the prediction rules.

The potentials and importance of imaging in large-vessel vasculitis / A nagyérvasculitisek képalkotó vizsgálatának lehetoségei és azok jelentosége

According to the nomenclature of the Chapel Hill Consensus Conference, giant-cell arteritis and Takayasu's arteritis belong to the group of large-vessel vasculitis. Recognition of these diseases is primarily based on the clinical assessment and the use of various vascular imaging modalities. With regard to the latter one, significant technological advances have been observed in recent years, which allow not only to make a diagnosis but also to evaluate the extent of the disease and the degree of vascular inflammation. In addition, subsequent complications of vascular inflammation can be examined. Ultrasound, computed tomography, magnetic resonance imaging, and positron-emission tomography represent imaging modalities that are essential for recognizing affected patients and planning effective treatment and follow-up. The review of this topic may be of interest to a number of medical specialties that are potentially involved in the care of these patients. Orv Hetil. 2020; 161(23): 939-950.