TY - THES A1 - Wagner, Martin T1 - Chronic Kidney Disease as an Important Co-morbid Condition in Coronary Heart Disease Patients T1 - Chronische Nierenerkrankung als bedeutender Risikofaktor bei Patienten mit koronarer Herzkrankheit N2 - In patients with coronary heart disease (CHD) the control of the modifiable “traditional” cardiovascular risk factors such as hypertension, dyslipidemia, diabetes, achieving/maintaining normal body weight and smoking cessation is of major importance to improve prognosis. Guideline recommendations for secondary CHD prevention include specific treatment targets for blood pressure, lipid levels, and markers of glucose metabolism for both younger and older patients. Chronic kidney disease (CKD) has been identified as a “non-traditional” risk factor for worse outcome in CHD patients, as it is associated with a markedly increased risk for subsequent CV events and mortality. The specific objectives of the current thesis-project are to investigate (a) the quality of care in a recent sample of German CHD patients and to investigate variation of risk factor control between younger and elder patients (≤70 versus >70 years), (b) to analyze the prevalence of CKD across Europe in stable CHD patients in the outpatient setting and during a hospital stay for CHD, (c) to investigate the level of awareness of CKD in German CHD patients and their treating physicians. Data from the European-wide EUROASPIRE IV study were used that include data on 7998 CHD patients in the ambulatory setting (study visit) and during a hospital stay for CHD (index). The German EUROASPIRE IV study center in Würzburg recruited 536 patients in 2012-2013. Risk factor control was compared against the current recommendations of the European Society of Cardiology. CKD was described by stages of glomerular filtration rate (eGFR) and albuminuria. German patients were asked in an additional kidney specific module whether they have ever been told by a physician about renal impairment. The fact that CKD or acute kidney injury (AKI) was mentioned in prominent parts of the hospital discharge letter as well as correct ICD-coding of CKD or AKI served as a proxy for physician’s awareness of CKD. The majority of German CHD patients was treated with the recommended drug therapies including e.g. β-blockers, anti-platelets and statins. However, treatment targets for blood pressure and LDL-cholesterol levels were not achieved in many patients (45% and 53%, respectively) and glycemic control in diabetic CHD patients with HbA1-levels <7% was insufficient (61%). A minority of patients reported on current smoking (10%), but unhealthy life-styles e.g. overweight/obesity (85%/37%) were frequent. Patterns of care differed between younger and older CHD patients while older patients were less likely to receive the recommended medical CHD-therapy, were more likely to have uncontrolled blood pressure and also to be diabetic. However, a greater proportion of diabetic patients >70 years was achieving the HbA1c target, and less elder patients were current smokers or were obese. About 17% of patients on average had CKD (eGFR< 60 ml/min/1.73m²) in the entire European sample at the study visit, and an additional 10% had albuminuria despite preserved eGFR, with considerable variation among countries. Impaired kidney function was observed in every fifth patient admitted for CHD in the entire European dataset of the EUROASPIRE IV study. Of the German CHD patients with CKD at the study visit, only a third were aware of their renal impairment. A minority of these patients was being seen by nephrologists, however, with a higher likelihood of CKD awareness and specialist care in more advanced stages of CKD. About a third of patients admitted for CHD showed either CKD or AKI during the hospital stay, but the discharge letter mentioned chronic or acute kidney disease only in every fifth of these patients. In contrast, correct ICD coding of CKD or AKI was more complete, but still suboptimal. In summary, quality of secondary prevention in German CHD patients indicates considerably room for improvement, with life-style modifications may become an even greater factor in prevention campaigns than medical treatment into certain target ranges. Preventive therapies should also consider different needs in older individuals acknowledging physical and mental potential, other comorbidities and drug-interactions with co-medication. CKD is common in CHD patients, not only in the elderly. Since CHD and CKD affect each other and impact on worse prognosis of each other, raising the awareness of CKD among patients and physicians and considering CKD in medical therapy may improve prognosis and slow disease progression of CHD as well as CKD. N2 - Bei Patienten mit koronarer Herzkrankheit (KHK) ist die Behandlung der „klassischen“ kardiovaskulären Risikofaktoren wie Bluthochdruck, Hypercholesterinämie, Diabetes, ein normales Körpergewicht sowie der Nikotinverzicht von Bedeutung, um die Prognose zu verbessern. Leitlinien empfehlen in der Sekundärprävention spezifische Behandlungsziele für Bluthochdruck, Hypercholesterinämie und Diabetes. Die chronische Niereninsuffizienz (NI) stellt einen „nicht-klassischen“ Risikofaktor für eine schlechtere Prognose bei KHK-Patienten dar und ist assoziiert mit einem erhöhten Risiko für eine Progression der KHK und kardiovaskuläre Mortalität. Die Studienziele der vorgelegten Arbeit beinhalten (a) die Umsetzung der KHK-Leitlinien in einem deutschen Kollektiv von Patienten inklusive der Unterschiede in der Versorgung zwischen Jüngeren und älteren Patienten (≤70 / >70 Jahre). Zudem (b) wird die Prävalenz der NI in stabilen ambulanten Verhältnissen und ebenso während eines Krankenhausaufenthaltes aufgrund eines KHK-Ereignisses in 24 Europäischen Ländern inklusive Deutschland untersucht. Schließlich (c) wird am deutschen Studienzentrum das Bewusstsein („Awareness“) für Nierenerkrankungen sowohl bei den Patienten als auch den behandelnden Ärzten analysiert. Es wurden die Daten der europaweiten EUROASPIRE IV Studie verwendet, für die zwischen 2012 und 2013 insgesamt 7998 KHK Patienten rekrutiert wurden. Sie enthält Informationen aus einem ambulanten Studienbesuch und aus einem Krankenhausaufenthalt aufgrund eines KHK-Ereignisses (Index). Am deutschen Studienzentrum in Würzburg wurden 536 Patienten eingeschlossen und die Qualität der Risikofaktorkontrolle nach den Empfehlungen der Europäischen Gesellschaft für Kardiologie untersucht. Chronische NI wurde in Stadien eingeteilt anhand von glomerulärer Filtrationsrate (eGFR) und Albuminurie. Zudem Am deutschen EUROASPIRE IV Studienzentrum wurden die Patienten zudem in einem zusätzlichen „Nieren-spezifischen Modul“ befragt, ob sie jemals von einem Arzt hinsichtlich einer Nierenerkrankung aufgeklärt wurden. Um das Bewusstsein für Nierenerkrankungen bei Ärzten einzuschätzen, wurde untersucht, ob akute oder chronische Nierenfunktionseinschränkungen im Arztbrief des Index-Aufenthaltes erwähnt wurden, und ob Nierenerkrankungen adäquat ICD-codiert waren. Die Mehrheit der deutschen KHK-Patienten wurde mit den empfohlenen Präparaten β-Blocker, Aspirin und Statinen behandelt, allerdings wurden die Ziel-/Grenzwerte für Blutdruck und Cholesterin oftmals nicht erreicht (45% bzw. 53%), ebenso wie die Blutzuckerkontrolle bei diabetischen Patienten (39%). Nur wenige Patienten waren aktive Raucher (10%), aber viele waren übergewichtig (85%) oder adipös (37%). Ältere Patienten erhielten seltener die empfohlenen Präparate und waren häufiger hypertensiv oder Diabetiker. Allerdings zeigten sich diabetische Patienten >70 Jahre besser kontrolliert und ältere Patienten waren seltener Raucher oder übergewichtig. Im Durchschnitt hatten 17% der KHK Patienten – mit großer Variation innerhalb der teilnehmenden Staaten – im EUROASPIRE IV Gesamtkollektiv eine chronische NI (eGFR <60 ml/min/1.73m²) und zusätzliche 10% hatten Albuminurie bei erhaltener eGFR. Eine eingeschränkte Nierenfunktion zeigte sich auch in jedem fünften Patienten bei Krankenhausaufnahme für das Index Ereignis im EUROASPIRE IV Gesamtkollektiv. Von den deutschen Patienten mit chronischer NI gab nur ein Drittel an, von ihrer Nierenfunktionseinschränkung zu wissen. Nur wenige dieser Patienten wurden von einem Nephrologen behandelt, wobei Patienten mit fortgeschrittener NI sich sowohl häufiger ihrer NI bewusst waren als auch von Spezialisten behandelt wurden. Im Index-Krankenhausaufenthalt hatte ein Drittel der Patienten wenigstens einen Hinweis auf eine entweder chronisch oder akut eingeschränkte Nierenfunktion. Lediglich in einem Fünftel war diese Diagnose im Entlassungsbrief erwähnt, während die Codierung nach Entlassung zwar vollständiger, aber immer noch lückenhaft war. Die Qualität der Sekundärprävention in deutschen KHK-Patienten lässt weiterhin beträchtlichen Raum für Verbesserung. Hierbei erscheinen die Veränderung im Lebensstil weitaus zielführender zu sein als die medikamentöse Therapie in definierte Zielbereiche. Die medizinische Therapie und die Herangehensweise an Verhaltensänderungen muss insbesondere bei älteren Patienten an die besondere Bedürfnisse dieser Patientengruppe angepasst werden. Chronische NI ist häufig bei KHK Patienten anzutreffen, nicht nur bei älteren Studienteilnehmern. KHK und chronische NI beeinflussen sich und die Prognose des jeweils anderen gegenseitig, sodass eine Steigerung des Bewusstseins für Nierenerkrankungen sowohl bei Patienten als auch bei Ärzten, und die Anpassung der Behandlungsstrategie womöglich zu einer Verbesserung der Prognose und zur Verlangsamung des Fortschreitens beider Erkrankungen, KHK und NI führen. KW - koronare Herzerkrankung KW - Sekundärprävention KW - Chronische Nierenerkrankung KW - coronary heart disease KW - secondary prevention KW - chronic kidney disease Y1 - 2019 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-175498 ER - TY - JOUR A1 - Morbach, Caroline A1 - Wagner, Martin A1 - Güntner, Stefan A1 - Malsch, Carolin A1 - Oezkur, Mehmet A1 - Wood, David A1 - Kotseva, Kornelia A1 - Leyh, Rainer A1 - Ertl, Georg A1 - Karmann, Wolfgang A1 - Heuschmann, Peter U A1 - Störk, Stefan T1 - Heart failure in patients with coronary heart disease: Prevalence, characteristics and guideline implementation - Results from the German EuroAspire IV cohort JF - BMC Cardiovascular Disorders N2 - Background: Adherence to pharmacotherapeutic treatment guidelines in patients with heart failure (HF) is of major prognostic importance, but thorough implementation of guidelines in routine care remains insufficient. Our aim was to investigate prevalence and characteristics of HF in patients with coronary heart disease (CHD), and to assess the adherence to current HF guidelines in patients with HF stage C, thus identifying potential targets for the optimization of guideline implementation. Methods: Patients from the German sample of the European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EuroAspire) IV survey with a hospitalization for CHD within the previous six to 36 months providing valid data on echocardiography as well as on signs and symptoms of HF were categorized into stages of HF: A, prevalence of risk factors for developing HF; B, asymptomatic but with structural heart disease; C, symptomatic HF. A Guideline Adherence Indicator (GAI-3) was calculated for patients with reduced (≤40%) left ventricular ejection fraction (HFrEF) as number of drugs taken per number of drugs indicated; beta-blockers, angiotensin converting enzyme inhibitors/angiotensin receptor blockers, and mineralocorticoid receptor antagonists (MRA) were considered. Results: 509/536 patients entered analysis. HF stage A was prevalent in n = 20 (3.9%), stage B in n = 264 (51.9%), and stage C in n = 225 (44.2%) patients; 94/225 patients were diagnosed with HFrEF (42%). Stage C patients were older, had a longer duration of CHD, and a higher prevalence of arterial hypertension. Awareness of pre-diagnosed HF was low (19%). Overall GAI-3 of HFrEF patients was 96.4% with a trend towards lower GAI-3 in patients with lower LVEF due to less thorough MRA prescription. Conclusions: In our sample of CHD patients, prevalence of HF stage C was high and a sizable subgroup suffered from HFrEF. Overall, pharmacotherapy was fairly well implemented in HFrEF patients, although somewhat worse in patients with more reduced ejection fraction. Two major targets were identified possibly suited to further improve the implementation of HF guidelines: 1) increase patients´ awareness of diagnosis and importance of HF; and 2) disseminate knowledge about the importance of appropriately implementing the use of mineralocorticoid receptor antagonists. Trial registration: This is a cross-sectional analysis of a non-interventional study. Therefore, it was not registered as an interventional trial. KW - awareness KW - heart failure KW - pharmacotherapy KW - coronary artery disease KW - coronary heart disease KW - euroaspire KW - guideline adherence KW - guideline implementation KW - mineralocorticoid antagonist KW - preserved ejection fraction Y1 - 2017 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-157738 VL - 17 IS - 108 ER - TY - JOUR A1 - Wagner, Martin A1 - Wanner, Christoph A1 - Schich, Martin A1 - Kotseva, Kornelia A1 - Wood, David A1 - Hartmann, Katrin A1 - Fette, Georg A1 - Rücker, Viktoria A1 - Oezkur, Mehmet A1 - Störk, Stefan A1 - Heuschmann, Peter U. T1 - Patient’s and physician’s awareness of kidney disease in coronary heart disease patients – a cross-sectional analysis of the German subset of the EUROASPIRE IV survey JF - BMC Nephrology N2 - Background Chronic kidney disease (CKD) is a common comorbid condition in coronary heart disease (CHD). CKD predisposes the patient to acute kidney injury (AKI) during hospitalization. Data on awareness of kidney dysfunction among CHD patients and their treating physicians are lacking. In the current cross-sectional analysis of the German EUROASPIRE IV sample we aimed to investigate the physician’s awareness of kidney disease of patients hospitalized for CHD and also the patient’s awareness of CKD in a study visit following hospital discharge. Methods All serum creatinine (SCr) values measured during the hospital stay were used to describe impaired kidney function (eGFR\(_{CKD-EPI}\) < 60 ml/min/1.73m2) at admission, discharge and episodes of AKI (KDIGO definition). Information extracted from hospital discharge letters and correct ICD coding for kidney disease was studied as a surrogate of physician’s awareness of kidney disease. All patients were interrogated 0.5 to 3 years after hospital discharge, whether they had ever been told about kidney disease by a physician. Results Of the 536 patients, 32% had evidence for acute or chronic kidney disease during the index hospital stay. Either condition was mentioned in the discharge letter in 22%, and 72% were correctly coded according to ICD-10. At the study visit in the outpatient setting 35% had impaired kidney function. Of 158 patients with kidney disease, 54 (34%) were aware of CKD. Determinants of patient’s awareness were severity of CKD (OR\(_{eGFR}\) 0.94; 95%CI 0.92–0.96), obesity (OR 1.97; 1.07–3.64), history of heart failure (OR 1.99; 1.00–3.97), and mentioning of kidney disease in the index event’s hospital discharge letter (OR 5.51; 2.35–12.9). Conclusions Although CKD is frequent in CHD, only one third of patients is aware of this condition. Patient’s awareness was associated with kidney disease being mentioned in the hospital discharge letter. Future studies should examine how raising physician’s awareness for kidney dysfunction may improve patient’s awareness of CKD. KW - coronary heart disease KW - ICD-coding of CKD KW - chronic kidney disease KW - patients’ awareness KW - physicians’ awareness KW - EUROASPIRE survey Y1 - 2017 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-158387 VL - 18 IS - 321 ER -