World Heart Day has been celebrated since 2000 on the last Sunday in September. The goal of this initiative is to inform the population about the leading cause of death in the world, which claims 17.3 million lives every year. At the Institute for Cardiovascular Prevention and Rehabilitation in Zagreb, World Heart Day has been celebrated since 2000. Each year, the leading topic changes to reflect a key theme in cardiac health. The topic for 2014 was the creation of an environment beneficial for cardiac health as it pertains to the prevention of cardiovascular diseases (CVD) through lifestyle modifications and treatment of existing diseases and risk factors for CVD such as arterial hypertension, hyperlipidemia, diabetes, smoking, etc. The World Heart Federation believes that 80% of untimely deaths due to CVD could be avoided if the four leading risk factors are modified and controlled – smoking, unhealthy diet, lack of physical activity, and increased alcohol consumption. The success of the World Heart Day depends on the engagement of the participating organizations, with the goal of increasing the awareness of CVD, the leading cause of death in the world.

The CVD group represents the leading diseases of the Western world. That trend has been slowly but steadily reduced owing to the public health initiatives and the awareness of the population about the dangers of those diseases, which are in most cases asymptomatic until the moment of manifested damage.

In Croatia, one in two people die of CVD. This places us in the bottom half, if not the bottom quarter of EU member countries regarding this statistic. At the same time, Croatia is doing better regarding CVD compared with non-member states. The good news is that CVD mortality rate in Croatia is slowly but noticeably decreasing, while still retaining the leading position. (1-3)

As a part of a public health initiative on the occasion of 2014 World Heart Day, the Croatian Heart House and the City of Zagreb – the City Health Center at the Institute for Cardiovascular Prevention and Rehabilitation in Zagreb – organized preventive cardiovascular examinations for the persons between the ages of 40 and 60 that had not had a cardiac examination before. This year we focused on the variable risk factors: body mass index (BMI), arterial hypertension, dyslipidemia, and diabetes. (4) These four risk factors were chosen due to the possible early non-pharmacological approach in the form of lifestyle changes. All of those factors, combined or occurring individually, pose a health risk. Having in mind the prevalence of acute myocardial infarction in the age group between 40 and 60, we chose to conduct the public health action in that age group. We wanted to identify the most common risk factors and through this determine the next course of our action.

Arterial hypertension (AH) is the most important risk factor which not only contributes to many CVDs and related conditions, but to cerebrovascular diseases and renal diseases. Hyperlipidemia (HLP) often occurs together with other risk factors, and the cardiovascular risk it brings is high even if other risks factors are not pronounced. Treatment of HLP today is ubiquitous. When considering the treatment of HLP, the question is not how aggressive to be, but what are the lowest lipid values we are striving towards. Patient obesity represents a higher CVD risk factor than those similar to them, but with a normal BMI. This does not refer “just” to obesity but to a whole range of related diseases and risks. The relative CVD risk factor is higher for patients with diabetes as compared to the general population by a factor of 2 or 4. (5-8)

Our methodology has already been described in the published report from the 10^th Congress of Croatian Cardiac Society. (4) In short, the participants registered in advance by telephone after having been notified of the initiative in local printed and electronic media in Zagreb. The calls were answered by a nurse who noted all the participants age 40 to 60 who had not by that time had a cardiac examination. All of the participants were reminded of the importance of early morning arrival and fasting. Upon their arrival at the institution, measurements were made of their weight and height, and BMI was calculated. The fasting values of lipids and glucose were measured on a sample of their venous blood. The 12-leed ECG and blood pressure have been done. A cardiologist or an internist went over these results and the cardiovascular risk was estimated. Finally, they were given further instructions for necessary non-pharmacological and pharmacological treatment and possible further treatment.

A total of 91 participants were examined, out of which two thirds were women (64% women 58/91; 36% men 33/91). The majority (93%, 85/91; 58%, women 53/91; 35%, men 32/91) of the participants were in the age group 40-65, 6% of the participants were older than 65, and 1 participant was younger than 40.

Dyslipidemia was registered in 55% of the participants (50/91; 32/91 combined, 18/91 “single lipid”), 14% of whom were already aware of dyslipidemia.

Increased values of blood pressure (Figure 1) were registered in 45% (42/91, women 23, men 18) of the participants, one half of whom had been diagnosed with arterial hypertension (21/91, women 15, men 6).

Only one quarter of the participants (26%) had a normal BMI value (24/91, women 17, men 7). A total of 43% participants (39/91, women 28, men 11) were overweight, and 31% (28/91, women 13, men 15) were obese (Figure 2).

Slightly more than one half of the participants with a normal body mass index (58%, 14/24; women 11, men 3) had normal values of arterial pressure and were not hypertonic (Figure 3), similar to the participants (Figure 4) who had BMI over 25 (57%, 38/67; women 26, men 12). A majority of the participants with normal BMI (7/10, 70%) who were previously diagnosed with AH had increased values of blood pressure (Figure 3). Inadequately regulated values of arterial pressure were even more common with hypertensive participants with increased BMI (Figure 4).

An increased value of blood glucose was noted with 2% of the participants (two participants) who had previously been diagnosed with glucose intolerance.

ECG of 90 of the participants showed sinus rhythm; only one showed atrial fibrillation which was newly discovered and of unknown duration. In the group of patients with AH we noted two descriptions of left ventricle hypertrophy, one left anterior hemiblock, one atrial fibrillation and one supraventricular extrasystole. In the group of patients without AH, of note were only one supraventricular extrasystole and one patient with a description of anterior hemiblock and flow obstruction of the right bundle.

The results of the public health initiative show a high prevalence of risk factors among the participants of initiative conducted on the occasion of World Heart Day 2014 in Zagreb. Three quarters of the participants of the action were overweight or obese, one half had increased values of blood pressure and dyslipidemia. These results raise the question of AH identification in men and increased body mass index in women. The common denominator is widespread awareness of the damaging effect of these risk factors, as well as increased engagement of the general practitioners who still represent the front lines in this fight. The same stands for the discouraging numbers that are proof of weak regulation of AH.

Considering the prevalence of increased BMI, the results are very discouraging. According to the available data, more than half of the population of North America and Europe has an increased BMI, whereas in Croatia the number is around one quarter of the population. (9) Obesity is one of the main risk factors for CVD and has unfortunately become the focus of this paper. The genesis of CV risk factors related to obesity is varied. Increased BMI is linked to changes in myocite metabolism, atherosclerosis plaque, increased rigidity of the arterial vessels, AH, renal disease, hart failure, hyperlipidemia, insulin resistance, etc. The recent “obesity paradox” must not be an obstacle for a more aggressive approach to this widespread public health problem. Lifestyle changes which should also include physical activity, are a way towards a decrease of obesity prevalence. BMI value of <25 kg/m² is associated with various beneficial effects for the health of an individual. (5, 10-13) Lack of physical activity in and of itself is a CVD risk factor and is associated with the general increased mortality rate. Regular exercise contributes towards lower incidence of CVD and mortality rate caused by CVD, and also has a beneficial effect on the clinical outcome in patients with diagnosed coronary heart disease (CHD). Despite the clear beneficial effects of the reduction of body weight and regular physical exercise, the number of people practicing this lifestyle is, however, still low. (14)

Hyperlipidemia is an important risk factor for CHD and for other forms of peripheral atherosclerosis, in the form of the involvement of the carotid arteries, peripheral arterial vessels, diabetes, etc. In the context of primary prevention it is very important to estimate the degree of risk. In case of hyperlipidemia, with or without hypolipemics, it is very important to encourage the patient in achieving and maintaining the adequate body weight. (7, 15)

According to available data, 45% of the population of Croatia suffers from arterial hypertension. This disease is also a high and important risk factor for the development of CVD which directly contributes to the CHD, stroke, heart failure, damage or failure of renal function, and disease of peripheral blood vessels. It requires optimal treatment and both a pharmacological and non-pharmacological approach. Changes in the neohumoral and endocrinological level in the context of physical activity are positive and beneficial in view of lower (improved) values of blood pressure. (8, 16)

The data acquired indicate the need to encourage lifestyle changes and a more aggressive and continuous approach towards the variable risk factors for CVD. Considering the results of this public health initiative, it is clear that there is a need for more frequent similar initiatives in order to detect the leading risk factors in Croatia and identify the most common risk factor so as properly prioritize our efforts.