SECONDARY PREVENTION OF CORONARY HEART DISEASE IN PRIMARY HEALTH CARE Introduction Cardiovascular disease

Signifi cant increasing in mortality from coronary heart disease (CHD) has seen in Bosnia and Herzegovina in the past decade. Little is known about current secondary preventive practices and treatments among patients with CHD in primary health care. Th e aims of this study were to evaluate the components of secondary prevention for CHD and to detect possible gender diff erences. Th is trial included  patients, aged - years, with established CHD from Family Medicine Teaching Center Tuzla. We evaluated components of secondary prevention (serum total cholesterol and blood pressure levels, smoking habits, body mass index, using aspirin, ACE inhibitors and lipid lowering drugs) in all participants. Results showed that signifi cantly more men than women had diagnosis of CHD. / (,) patients had myocardial infarction, with signifi cantly higher number of men than women, but more women had angina only. Mean systolic blood pressure was ,±, and diastolic ,±, mmHg; mean total cholesterol level was ,±, mmol/l; mean BMI was ,±, kg/m2. Blood pressure was managed according to guidelines in  (,), and lipid concentrations in  (,) patients. / (,) patients took aspirin, only / (,) patients took lipid lowering therapy, and / (,) patients with heart failure took ACE inhibitors. / (,) patients were current smokers, only / (,) patients had healthy body mass index, while / () patients were obese. Results of this study show a suboptimal secondary prevention in primary health care, which indicate more eff ective public health messages and changes in the healthcare system that promotes preventive strategies.


Introduction
Cardiovascular disease is leading cause of death in industrial countries all over the world and represents a continuing crisis of epidemic proportions.Signifi cant increasing of mortality from cardiovacular disease has seen in central and eastern europian countries, which is related to tranzitional changes in sphera of economic and political relations, as well as to total tranzitional changes which have happened in the past decade in central and eastern Europe.Conflict in Bosnia and Herzegovina (-) as well as the period after that, have resulted in many social and psychological breakdowns in people who lived through it.Migrations, political and economic instability in the country, increasing of mental health disorders, smoking and alcohol consumption, and unhealthy diet had negative eff ects on people health.Th ese current and past adverse situations have resulted in increasing prevalence of cardiovascular disease, especially coronary heart disease.According to the limited statistical data, we can conclude that cardiovascular disease is leading cause of morbidity and mortality in our country, for men, as well for women, causing   deaths of total mortality.In addition, because of inadequate health culture in community (high prevalence of smoking, alcohol consumption, obesity, physical inactivity, unhealthy diet and obesity) we can expect a further trend in increasing of cardiovascular morbidity and mortality ().Numerous studies had shown that eff ective secondary prevention can reduce the risk for subsequent coronary events or death in patients with pre-exiting coronary heart disease (,).Optimal secondary prevention includes controlled blood pressure </ mmHg, serum total cholesterol level <, mmol/l, prophylactic use of antiplatelet agents and lipid lowering therapy, and interventions to change behavior and modify lifestyles (smoking cessation, regular physical activity, moderate alcohol consumption, healthy diet and weight reduction in overweight and obese).Th e integral part of primary care physicians for patient's health is prevention of disease and health promotion.Most people with coronary heart disease come in primary care offi ce with aim that primary healthcare professionals be a persons who will suggest and give advice regarding to regular using antihypertensive medications, antiplatelets agents, lipid lowering therapy, as well as lifestyle modifi cations, so family physicians and general practitioners have been encouraged to target them for secondary prevention.However, many investigations have shown that secondary prevention of coronary heart disease is suboptimal (,,).Little is known about current secondary preven-tive practices and treatment among patients in primary health care.That´s why we studied secondary preventive treatment among patients with coronary heart disease in primary care, so that we could assess our current secondary preventive practices.

Methods
We included  randomly selected patients aged - years from Family Medicine Teaching Center Tuzla.Every consecutive patient with established coronary heart disease, who came in family physician offi ce for examination during the period September-November , was included in this study.Notes from medical records were reviewed to ensure that patients were documented by hospital or cardiologist letter as having coronary heart disease.We had placed a limit of  patients for data collection.All patients gave informed consent to the study before attending the clinical assessment.Main outcome measures were components of secondary prevention for coronary heart disease: blood pressure and cholesterol management, body mass index, non-smoking, and using of aspirin and lipid lowering therapy.According to the Th ird Joint European Societies Recommendations on Prevention of Coronary Heart Disease in Clinical Practice criteria used to defi ne appropriate secondary prevention were blood pressure </ mmHg, total cholesterol level <, mmol/l; normal body mass index below  kg/m², not currently smoking and using prophylactic medications (aspirin and lipid lowering therapy) ().Blood pressure was measured in sitting position after rest for fi ve minutes, using standarized equipment and technic.After measuring body weight and body height, we calculated the body mass index in all patients.According to the guidelines patients were overweight if their body mass index was > kg/m² or obese if body mass index was ≥ kg/m² ().We collected data on aspirin, ACE inhibitors and lipid lowering medications use from medical records, and smoking status by questionnaire ().All patients were referal to laboratory for measurement of total cholesterol concentration from venous blood sample after fasting for twelve hours at least.Serum total cholesterol concentration was measured by biochemical analyzer Lysa  plus using standarized method.According to the guidelines, the blood cholesterol goals were a total cholesterol level below , mmol/l for patients with coronary heart disease ().We used standard statistical methods for analysis.male and female.We expressed effect size as the difference between groups with a  confi dence interval.

Results
Th is trial included  patients mean aged , ± , years with established coronary heart disease;  men (,) and  women (,).Table .compares the characteristics of male and female patients with coronary heart disease.Signifi cantly more men than women had diagnosis of CHD (P=,).Diagnosis of myocardial infarction (with or without angina) had  (,) patients;  (,) men and  (,) women.Significantly more men had diagnosis of myocardial infarction comparing with women (P=,), but significantly more women than men had angina only (P=,)).Th is diagnosis was present in  (,) patients;  (,) men and  (,) women.Complications, as coronary artery bypass grafting had  (,) patients and percutaneous transluminal coronary angioplasty had  (,) patients.Of all  patients, heart failure was present in  (,) patients;  (,) men and  (,) women.We didn't fi nd a significant difference in number of patients with complications related to gender. (,) patients had diabetes;  (,) men and  (,) women. (,) patients were current smokers;  (,) men and  (,) women.Uncontrolled blood pressure was present in  (,) patients;  (,) men and  (,) women.Of all  patients,  (,) had unhealthy body mass index and signifi cantly more women were obese than men (P=,).Table .shows mean blood pressure and total cholesterol level, smoking status and body mass index in patients with coronary heart disease.Mean blood pressure was ,  ± , mmHg for systolic, and , ± , mmHg for diastolic blood pressure; mean total cholesterol level was ,±, mmol/l, and mean body mass index was , ± ,.There were no significant differences in mean blood pressure, total cholesterol level, smoking status and body mass index between men and women.Table .shows achieved optimal secondary prevention in patients with coronary hearth disease.Adequate blood pressure </ mmHg had  (,) patients;  (,) men and  (,) women.Serum total cholesterol level , mmol/l had only  (,) patients;  (,) men and  (,) women.Of all  patients with coronary heart disease,  (,) patients didn't smoke;  (,) men and  (,) women.Only  (,) patients had body mass index below  kg/m²;  (,) men and  (,) women.Antiplatelet agents were taken by  (,) patients;  (,) men and  (,) women, while only  (,) patients used OLIVERA BATIĆMUJANOVIĆ ET AL.: SECONDARY PREVENTION OF CORONARY HEART DISEASE IN PRIMARY HEALTH CARE lipid lowering therapy;  (,) men and  (,) women.Of all  patients with heart failure,  (,) patients took ACE inhibitors;  (,) men and  (,) women.We didn't find any gender differences in medical and lifestyle components for optimal secondary prevention of coronary heart disease.

Discussion
The overall objective of coronary heart disease prevention is to reduce the risks for subsequent coronary events, and thereby reduce premature disability, mortality and to prolong survival.Opportunities for family physicians and general practitioners to undertake preventive activities for coronary heart disease and other cardiovascular diseases in clinical practice are possible, but it is not optimal realized in our country.We have attempted to measure the use of secondary prevention in Family Teaching Center Tuzla.It is well known that treatment with aspirin and lipid lowering therapy can reduce cardiovascular events in patients with coronary heart disease.Aspirin is available for the most of patients, and that's the reason why more than two third of patients in our study use that medication.In contrast, lipid management was largely neglected comparing with other studies, despite the eff orts of family physi-cians who advocate cholesterol lowering for patients with coronary hearth disease (,).Lipid lowering therapy (preference is given to statins) is very expensive, and many patients, because of their limited financial resources, were not be able to buy it.Th at's why only about  of all patients in study used that medication and only , patients with coronary heart disease had recommended total cholesterol level below , mmol/l.In addition, high blood pressure remains poor managed in spite of availability most of antihypertensive medications.Findings from our study showed that only , patients have adequate blood pressure managing </ mmHg, and for example, in EUROASPIRE II study  patients had controlled blood pressure ().Lifestyle changes can modify coronary heart disease ().Our results showed that , patients with coronary heart disease smoked, which is similar to other studies which analyzed secondary prevention in primary care (,).Numerous prospective investigations demonstrated substantial decrease in coronary heart disease mortality for former smokers compared with continuing smokers.Persons with diagnosis of coronary heart disease have expirience as much as a  reduction in risk of reinfarction, sudden cardiac death, and total mortality if they quit smoking after the initial heart infarction ().In our study male patients showed higher levels of

Conclusion
Results of this study show a suboptimal secondary prevention in primary health care, with a high prevalence of modifi able risk factors, unhealthy lifestyles, and inadequate use of prophylactic drug therapies.We need more effective public health messages, changes in the healthcare system that promotes preventive strategies, and more effective methods to educate healthcare providers.General practitioners and primary care teams should aim to identify all people with established cardiovascular disease and off er them comprehensive advice and appropriate treatment to reduce their risks.Th is will require important changes in clinical practice and primary health care system.
blood pressure and total cholesterol level, but in general, a gender-equal level of blood pressure control, lipid control and access to prophylactic drug treatment has been established for patients in secondary prevention of coronary heart disease in primary health care, which is similar to recent study from Sweden which investigated gender diff erences in secondary prevention of coronary heart disease ().Weight loss in patients with coronary heart disease reduced coronary risk independently and by improving lipid profi le, blood pressure and glucose tolerance.Most patients in our study, nearly half of them were overweight, with  patients who were obese.These findings put considerable capacity for secondary prevention through lifestyle modifi cations.
OLIVERA BATIĆMUJANOVIĆ ET AL.: SECONDARY PREVENTION OF CORONARY HEART DISEASE IN PRIMARY HEALTH CARE Th e hi-square test with signifi cance P<. and independent samples t-test respectively were used for comparing proportions and means between   BOSNIAN JOURNAL OF BASIC MEDICAL SCIENCES 2006; 6 (2): 37-41