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European Perspectives in Cardiology
Centres of Excellence: The Russian Cardiology
Research and Production Complex, Moscow,
Russian Federation
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Pioneering ew Treatments and Providing High-Quality Clinical
Care for the Most Severe and Complicated Cardiovascular Diseases
Eugene Chazov, MD, general director of the Russian Cardiology Research and
Production Complex, Moscow, Russian Federation, talks to Mark icholls about how
the Cardiocentre has responded to reduce the high mortality rate attributable to
ischaemic heart disease in Russia.
T
he Russian Cardiology Research and Production
Complex of the Medical High Technology Agency, a
federal state institution, functions as the leading national
research centre in Russia, in both applied clinical and fundamental cardiology, through its Cardiocentre.
A dynamic organisation, the Cardiocentre in Moscow
has a staff of 500 highly skilled scientists and cardiologists
who have consistently proved that they can pioneer and
develop new treatments for cardiac disease. Yet they face a
mounting challenge as the incidence of cardiovascular
disease in Russia continues to rise and remains by far the
leading cause of death in the country (see Box).
Cardiocentre general director, Eugene Chazov, MD, who
with US cardiologist Bernard Lown, MD, founded the
organisation International Physicians for the Prevention of
Nuclear War, which was awarded the Nobel Peace Prize in
1985, says, “Such a high rate of cardiovascular mortality is
due to the socioeconomic crisis that has taken place in
Russia in the 1990s. This is why we are facing, as a priority,
the challenge to improve the situation and see the decline
in the prevalence of cardiac diseases as well as the death
rate.” The Cardiocentre coordinates the national research
programme, which enables it to pioneer new treatments
and develop and manufacture new drugs. As a specialised
therapeutic and preventive medical institution, it can also
offer high-quality clinical care for the most severe and
Cardiovascular Disease in Russia
● Seven million Russians have ischaemic heart disease,
the equivalent of 62 per 1000 of the adult population.
● About 40 million Russians have arterial hypertension.
● More than 600 000 new patients are diagnosed with
ischaemic heart disease every year.
Data for Ischaemic Heart Disease in 2005
● Annual rate of 520 new cases per 100 000 population.
● The leading cause of death, resulting in 626 000
deaths: 27.2% of the total mortality rate.
On other pages...
Practice of Cardiology 2008: Serbia
Milan Nedeljkovic, MD, PhD, FESC, FACC, professor of internal medicine
and cardiology at the Clinical Centre of Serbia, Belgrade, Serbia, talks to
Jennifer Taylor, BSc, about current practice of cardiology in Serbia and
ways in which it could be improved.
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medical preparations developed in the Cardiocentre, has a
manufacturing capacity of up to 30 million ampoules, 100
million capsules, 80 million tablets, and 3 million suppositories a year.
Professor Chazov has overall responsibility for the
Cardiocentre and supervises investigations into ischaemic
heart disease. Vladimir N. Smirnov, MD, and Vsevolod A.
Tkachuk, MD, oversee the area of molecular–genetic
research and cell cardiology, whereas Mikhail Ruda, MD,
PhD, takes responsibility for studies in the field of acute
coronary syndrome.
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Top, Coronary angiography and stenting operation. Bottom,
Coronary care unit, with Dr Iskander Mukhamedzyanov and
nurse Helena Palashina on duty. Photographs courtesy of the
Russian Cardiology Research and Production Complex, Moscow,
Russian Federation. Copyright © 2008, Russian Cardiology
Research and Production Complex.
complicated cardiovascular diseases, and different regions
of the Russian Federation, including Moscow, refer cases
there.
The Cardiocentre dates back to 1945 when the Institute
of Experimental and Clinical Therapy came into existence.
From 1948, it was led by A.L. Myasnikov, MD, a Russian
professor of cardiology who would later receive the prize
of the International Society of Cardiology “Golden
Stethoscope” for his outstanding contribution to cardiology.
In 1967, the institute’s name changed to the A.L. Myasnikov
Research Institute of Cardiology. It saw another reorganisation in 1975 when it became the Cardiology Research
Centre of the USSR Academy of Medical Sciences, with
Professor Chazov appointed as director. By 1981, the
Centre included 3 institutes: the Myasnikov Research
Institute of Clinical Cardiology, the Institute of Experimental
Cardiology, and the Institute of Preventive Cardiology. On
March 20, 1996, under a decree of the Russian
Government, its name changed to the Russian Cardiology
Research and Production Complex of the Russian Ministry
of Health. Since 2005, the Cardiocentre has existed as part
of the Federal Medical High Technology Agency. The
Russian Cardiology Research and Production Complex
now comprises the Institute of Clinical Cardiology, the
Institute of Experimental Cardiology, and the Experimental
(Pilot) Plant for the Production of Biomedical Preparations.
The Pilot Plant, a state pharmaceutical enterprise producing
“The Balance of Work at the Cardiocentre Is Split,
With 60% of the Activities Devoted to Research and
40% to Delivery of Highly Qualified Medical Care”
Professors of the various divisions at the Cardiocentre
include Irina Chazova, MD, PhD (hypertension), Valery
Kukharchuk, MD (atherosclerosis), Yuri Belenkov, MD,
PhD (heart failure), R.S. Akchurin, MD (cardiovascular
surgery), Yu Karpov, MD (angiology), S. Golitsyn, MD,
and L.V. Rozenshtraukh, MD (arrhythmology), S.A.
Boytsov, MD (aging problems in cardiovascular pathology), A.N. Rogoza, MD (the development of diagnostic
instruments), V.N. Titov, MD (biochemistry), and V.P.
Masenko, MD (immunology).
More than 500 members of staff participate in research
and specialised medical services; these staff members include
209 cardiologists and 277 biologists, biochemists, biophysicists, and specialists in genetics. Among these specialists, 6
have memberships in the Russian Academy of Sciences, 9
have memberships in the Russian Academy of Medical
Science, 71 have doctorates of science, and 217 have PhDs.
Professor Chazov says, “Every year, more than 6000
patients receive treatment in our clinic and 20 000 patients
receive outpatient treatment in our outpatient department.
Annually, over 500 coronary artery bypass surgeries and
complex combined operations on blood vessels and valves
of the heart are performed and more than 1000 endovascular
interventions on coronary arteries and endocardial interventions in arrhythmias are made by our specialists.”
Previous patients have included former prime minister Victor
S. Chernomyrdin and former president Boris Yeltsyn; both
had open heart surgery. The Cardiocentre has 350 beds for
in-hospital patients, and the clinical departments take part
in a range of Russian and international multicentre clinical
trials of drugs for the treatment of heart diseases.
The early construction of the modern centre and its
equipment received financing through the “peoples’ funds”
collected in 1971 from the “Communist subbotnik.” This
saw the entire working population of the country remit
their salaries for work on 1 Saturday (normally a day off),
raising $110 million for such public projects. Today, the
scientists and clinicians of the Cardiocentre carry out
research on up to 70 various topics, with many supported
by Russian and international grants. Studies proceed in
cooperation with institutes and universities from France,
Canada, Australia, the United States, and Great Britain.
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“[Research] Activities Are Aimed at the Development
of ew Methods for Prevention, Diagnosis, and
Treatment of Heart and Blood Vessel Diseases”
The Cardiocentre serves as national coordinator for
research in cardiology and organises the nationwide system
of cardiological care in all the major cities of Russia.
Professor Chazov says, “This system allows us to effectively study the prevalence and structure of cardiovascular
diseases, to optimise their prevention and treatment, and to
conduct basic and applied research.”
Scientists from the Cardiocentre have made a number of
significant discoveries over the years, such as intracoronary thrombolytic fibrinolysis, which saw Professor
Chazov pioneer the administration of fibrinolysin in
patients with myocardial infarction.1 At the end of the
1970s, scientists explored the regulation of the force of
myocardial contraction by creatine2—work that earned the
State Prize. In 1991, another breakthrough occurred that
involved the self-regulation of the arterial lumen according
to blood flow rate and viscosity. Professor Chazov says that
researchers at the Cardiocentre have developed a wide range
of effective drugs, with many successfully introduced into
national clinical practice, including thrombolytics, recombinant prourokinase, and antiarrhythmic drugs.
A major project undertaken for 40 years with pathologists from Sweden and Czechoslovakia revealed that in
cities across Russia, the incidence of atherosclerosis had
increased,3 and the Cardiocentre has also participated in the
Russian space programme through astronaut investigator
Oleg Atkov, MD, who carried out work onboard Salyut-7
for 237 days, conducting ultrasound examinations of astronauts.4 Professor Chazov explains, “He has tested new
medical equipment specially designed for long-term space
flights and intended for studies of adaptation processes of
the human body to prolonged weightlessness.”
A number of studies on the morphological features of
pulmonary vessels in patients with different forms of pulmonary hypertension resulted from a Russian–American
collaboration in the field of pulmonary hypertension.5
Recent research includes studies of inflammation in
atherogenesis. Professor Chazov notes, “Based on the results
obtained, a new drug inhibiting migration of monocytes
and granulocytes in the arterial wall has been developed.”6
Researchers also isolated T-cadherin from the aorta, and
have shown that it specifically inhibits the migration of
endothelial cells and the formation of small vessels and
capillaries in vivo.7 Professor Chazov says, “The molecular mechanisms underlying the effects of urokinase on cell
migration and proliferation have been studied; cell receptors and intracellular signal pathways mediating these
effects of urokinase have been identified. Expressing
urokinase in ischaemic tissues was shown to stimulate
angiogenesis, which formed the basis for development of a
new gene therapy drug.”8 Another recent success is the
development of original plasmid vector for high-efficient
expression of transgenes in eukaryotic cells,9 and future
research is focused on new approaches to cellular therapy.
Circulation: European Perspectives
Circulation
Top, Enhanced external counterpulsation laboratory with Dr Sergei
Gabrusenko. Bottom, Microsurgical coronary artery bypass grafting performed by Dr Renat Akchurin, Dr Damir Galyautdinov,
and Dr Cirill Mershin. Photographs courtesy of the Russian
Cardiology Research and Production Complex, Moscow, Russian
Federation. Copyright © 2008, Russian Cardiology Research and
Production Complex.
The medical and basic research staff of the Cardiocentre
publish more than 300 articles in Russian and 30 articles in
the leading foreign journals every year. In addition, the
Cardiocentre publishes about 10 monographs. and staff
members are editors in chief of a number of journals.
Professor Chazov has received the Lenin Prize, state
prizes, and orders of 8 foreign states. A further 16 scientists
from the Cardiocentre have received state prizes of the
Soviet Union and the Russian Federation, and 4 scientists
have received prizes from the Russian government.
Cooperation With Centres in Other Countries
For centres to be successful, Professor Chazov emphasises
the importance of cooperation with centres of cardiology in
other countries. He points to the Treaty of Cooperation
signed between the Soviet Union and the United States in
1973 that led to a link between the Cardiocentre and the
National Heart, Lung, and Blood Institute in Bethesda for
25 years and a large number of symposiums and joint
research projects. Similar programmes exist in collaboration with the Baker Меdiса1 Research Institute,
Melbourne, Australia; the German Heart Centre, Munich,
Germany; and the Institut National de la Sante et de la
Recherche Medicale (INSERM) in France.
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References
1. Chazov EI, Matveeva LS, Mazaev AV, Sargin KE, Sadovskaia GV, Ruda
MI. Intracoronary administration of fibrinolysin in acute myocardial
infarct. Ter Arkh. 1976;48:8–19.
2. Saks VA, Rosenshtraukh LV, Smirnov VN, Chazov EI. Role of creatine
phosphokinase in cellular function and metabolism. Can J Physiol
Pharmacol. 1978;56:691–706.
3. Zdanov VS, Sternby NH, Vikhert AM, Galakhov IE. Development of
atherosclerosis over a 25-year period: an epidemiological autopsy study
in males of 11 towns. Int J Cardiol. 1999;68:91–106.
4. Gazenko OG, Schulzhenko EB, Grigoriev AI, Atkov OYu, Egorov AD.
Review of basic medical results of the Salyut-7—Soyuz-T 8-month
manned flight. Acta Astronaut. 1988:17:155–160.
5. Chazova I, Loyd JE, Zhdanov VS, Newman JH, Belenkov Y, Meyrick B.
Pulmonary artery adventitial changes and venous involvement in primary
pulmonary hypertension. Am J Pathol. 1995;146:389–397.
6. Chazov EI, Bespalova JD, Arefieva TI, Kukhtina NB, Sidorova MV,
Provatorov SI, Krasnikova TL. The peptide analogue of MCP-1 65-76
sequence is an inhibitor of inflammation. Can J Physiol Pharmacol.
2007;85:332–340.
7. Rubina K, Talovskaya E, Cherenkov V, Ivanov D, Stambolsky D,
Storozhevykh T, Pinelis V, Shevelev A, Parfyonova Ye, Resink T, Erne P,
Tkachuk V. LDL induces intracellular signalling and cell migration via
atypical LDL-binding protein T-cadherin. Mol Cell Biochem.
2005;273:33–41.
8. Traktuev DO, Tsokolaeva ZI, Shevelev AA, Talitskiy KA, Stepanova VV,
Johnstone BH, Rahmat-Zade TM, Kapustin AN, Tkachuk VA, March
KL, Parfyonova YeV. Urokinase gene transfer augments angiogenesis in
ischemic skeletal and myocardial muscle. Mol Ther. 2007;15:1939–1946.
9. Radukhina NV, Ilyinskaya OP, Rutkevich PN, Vlasik TN, Arefyeva TI,
Rybalkin IN, Peklo MM, Janushevskaja EV, Tararak EM. Stable transduction of murine bone marrow Lin− c-Kit+ subpopulation with HIVbased pseudoviral particles. Atherosclerosis. 2006;7:96.
Mark icholls is a freelance medical journalist.
Practice of Cardiology 2008: Serbia
“Complex Interventional Cardiology Is a Strength, but We Would
Rather Have More Developed Prevention”
Milan edeljkovic, MD, PhD, FESC, FACC, professor of internal medicine and
cardiology at the Clinical Centre of Serbia, Belgrade, Serbia, and vice president
of the Cardiology Society of Serbia for the region of Belgrade talks to
Jennifer Taylor, BSc, about current practice of cardiology in Serbia and
ways in which it could be improved.
D
emonstrators perform complex percutaneous coronary
intervention (PCI) procedures at the Belgrade Summit
of Interventional Cardiologists (http://www.uksrb.org/
basics_2008/index.html), also called BASICS+, which
takes place every April in Belgrade, Serbia. This year’s
meeting—the fourth of its kind—took place from April 16
to April 19, 2008, and hosted 400 attendees from about 40
international faculties, from countries including Serbia,
Bulgaria, Croatia, Greece, Russia, India, Italy, Belgium,
Germany, United Kingdom, France, Bosnia and
Hercegovina, Switzerland, Hungary, Netherlands, and
Spain. The bulk of the participants were interventional
cardiologists, but other cardiologists also came. “It’s a
really important meeting for us,” says Milan Nedeljkovic,
MD, PhD, FESC, FACC, professor of internal medicine and
cardiology at the Clinical Centre of Serbia, Belgrade, Serbia.
“This year, we were part of the European Board of
Accreditation in Cardiology Continuing Medical Education,
and we were granted with 24 points for this course.” He
adds, “The aim of this summit is, first, to have patients
with the most complex forms of coronary artery disease
treated in cooperation with the most prominent world
interventional cardiologists and, also, to share knowledge
with other interventional cardiologists about the newest
developments in this area.” The summit saw 37 patients
treated, with conditions ranging from congenital heart
diseases such as atrial septal defects to coronary artery
disease with implantation of stents. Summit attendees
could view live transmissions of the interventions in the
auditorium.
Professor Nedeljkovic, who also serves as general secretary of the Working Group on Interventional Cardiology
for the Cardiology Society of Serbia, identifies interventional cardiology as a big strength in Serbia.
“Interventional cardiology is very well organised in Serbia,
and the Working Group on Interventional Cardiology in
our national society is very well organised,” he says. “And,
to be honest, one of the main advantages may be that there
are not so many interventional cardiologists in Serbia, so,
when you have fewer people, you can organise them better.
There are 50 interventional cardiologists in Serbia; they are
a very compact group, and they are working together.
These cardiologists have good training, and many of them
have trained abroad. Thus, Serbian cardiologists can treat
the most severe cases and perform the most complex PCI
procedures, as they did at BASICS+.”
Just 20% of the Population Do ot Have Risk Factors
for Coronary Artery Disease
Professor Nedeljkovic maintains that Serbia needs to turn
its attention to prevention, and the summit reflects his concern. He explains, “The ‘plus’ [in BASICS+] means that not
only are there lectures on interventional cardiology given,
but the most recent updates in the whole field of cardiology
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July 1, 2008
One Cannot Always Treat All Patients According to
the Guidelines
Serbia has around 700 cardiologists, most of whom have
trained in their home country. They work at primary, secondary, and tertiary health centres. Most patients go to
primary and secondary health care, with the tertiary centres
reserved for diagnosing and treating the most difficult
cases. For this reason, primary health centres represent the
most common type, followed by secondary and then tertiary centres. The 3 tiers have different organisational
schemes for cardiology. Professor Nedeljkovic explains,
“You have a cardiology department only in tertiary centres.
At primary centres, you have just cardiologists, and they
don’t have departments. At secondary centres, you have
departments of internal medicine where the cardiologists
are involved, working together with other doctors or other
specialities from internal medicine. In secondary centres
you have catheterisation laboratories, but without cardiovascular surgery facilities, whereas in tertiary centres you
have them both in the same place. Patients pay 5% of the
overall price of implanted materials for example, stents.”
Serbia has national guidelines for ischaemic heart disease and for diabetes prevention, which Professor
Nedeljkovic identifies as important because of the overlap
between diabetes mellitus and coronary artery disease. For
other conditions, such as heart failure, cardiologists translate European Society of Cardiology guidelines into
Serbian—a process organised through the Cardiology
Society of Serbia.
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for other participants that are not so involved in interventional cardiology only, and this part is also dealing with
prevention.”
After looking at the statistics, one can easily see why
cardiology professionals should view prevention as a priority. Serbia has 7.9 million inhabitants, and ischaemic heart
disease represents the most common cardiovascular disease,
with a prevalence of 10 per 1000 in 2003. Professor
Nedeljkovic says the disease has a similar prevalence
today. He adds that more than a half of all deaths in Serbia
result from cardiovascular disease—a figure similar to (and
perhaps slightly higher than) those in the surrounding
countries. “As far as I know, in Europe we have the highest
prevalence of ischaemic heart disease after Russia and
Ukraine,” he says, adding that just 20% of the population
do not have risk factors for coronary artery disease.
In Serbia, an estimated 35% to 40% of the population
smoke, and 40% have hypertension. Obesity, defined as
body mass index over 30, has a prevalence of about 15%,
and diabetes mellitus has a prevalence of about 10.5 per
1000. Professor Nedeljkovic describes the prevalence of
smoking and obesity as evenly distributed between rural
and urban areas. But obesity has a higher prevalence in
northern parts of Serbia because of the diet, which includes
many fatty greasy foods in those regions. Smoking represents a problem area because a steadily increasing number
of women have taken up the habit.
Top, The Clinical Centre of Serbia. Bottom. Photograph from the
annual workshop, BASICS+2008 with Professor Carlo Di Mario
MD, PhD, FESC, FACC, president-elect of the European
Association for Percutaneous Coronary Interventions.
Photographs courtesy of Professor edeljkovic. Copyright ©
2008, Professor edeljkovic.
But one cannot always treat all patients according to the
guidelines, says Professor Nedeljkovic. “The best example
for that is the treatment of acute myocardial infarction. We
started a programme in October 2005 in the Clinical Centre
of Serbia, a programme of primary PCI. Primary PCI is
also available in some other centres in Serbia, such as in
Novi Sad and Niš and some other centres in Belgrade.
However, patients who are not near those centres cannot
receive primary PCI, and fibrinolysis could still be the
treatment of choice for them. PCI is available 24 hours a
day, 365 days a year, only at the Clinical Centre of Serbia.”
As a result, around half of patients receive primary PCI.
Serbia has 15 catheterisation laboratories, and Professor
Nedeljkovic says the country would benefit from a few
more. But some parts of Serbia lie at considerable distances
from these laboratories, which means that some patients
cannot transfer to other facilities for primary PCI.
Tertiary centres have the best equipment, as expected,
given that they deal with the patients who are most ill.
Cardiac resynchronisation therapy, for example, first came
into use at the Clinical Centre of Serbia and is now used in
4 centres in Serbia, 2 in Belgrade, 1 in Nis, and 1 in Novi
Sad, and people travel from across Serbia for it. Professor
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July 1, 2008
Nedeljkovic says, “Because it’s a highly sophisticated
treatment, I think that, as in all other countries, you cannot
perform the most sophisticated treatments in each hospital,
only in tertiary centres.” Most procedures can be performed
in Serbia, with the exception of heart transplantation, for
which patients must travel to other centres in Europe.
A Cardiac etwork Would Improve Follow-Up and
Monitoring of Patients
Follow-up and monitoring of patients represent an area that
Professor Nedeljkovic says could see some improvement,
and he believes that creating a cardiac network would help.
This network would include an electronic database of
patient information for the whole of Serbia that health professionals could always access. Although this remains just
an idea at the moment, he thinks it could provide the best
solution. He explains, “For example, if you perform, as we
do here, PCI for the patient, you don’t have to call the
patient to come for a visit. He can be tracked by his physician, and you can see the results of the examination. That
could be one idea, but we are really far from that.” The system would take some time to set up, not least because the
country lacks national registries, which would represent the
first step. So, for the time being, he says each institution
must take responsibility for organising its own monitoring.
Professor Nedeljkovic says, “In our centre, we have very
good follow-up of patients treated with PCI. They come for
a regular check-up, [and] we follow them up for 3 to 5
years. We have nurses who contact the patients, ask for their
current status, and, if something is wrong, suggest they
come for the examination.”
When it comes to tertiary centres, Professor
Nedeljkovic works at one of the leading clinical centres in
Serbia that, as such, offers the highest services to its
patients. But do others see this level of service replicated
throughout the country? Professor Nedeljkovic has regular
contact with the doctors from other institutions through his
role as vice president of the Cardiology Society of Serbia
for the region of Belgrade. He says, “Of course, since all
regions of the country are not on the same level of economic
development, so the clinical practice is similar and it’s
related to economic development. But I’m sure that our
doctors are doing the best that they can do to follow the
best clinical practice.”
Use of Angiotensin-Converting Enzyme Inhibitors for
Coronary Artery Disease Could See Improvements
Professor Nedeljkovic says, “According to the current
[European Society of Cardiology] guidelines, all patients
with established coronary artery disease should be on
angiotensin-converting enzyme inhibitors. And maybe we
should do more on promotion of angiotensin-converting
Editor: Thomas F. Lüscher, MD, FRCP, FACC
Managing Editor: Lindy van den Berghe, BMedSci, BM, BS
We welcome comments. E-mail [email protected]
enzyme inhibitors for coronary artery disease, even in
cases of absence of hypertension.”
We Have to Make Preventive Work More Popular and
More Effective
Professor Nedeljkovic says “The main thing that we have
to improve is prevention, not only of smoking, but prevention of other risk factors such as hypertension, obesity, and
diabetes.” Professor Nedeljkovic comments that his idea
for a cardiac network could also improve work in this area.
All cardiologists in Serbia would have access, and the database could specifically address the questions of risk factors
and the issues of prevention. He envisages teamwork by
cardiologists and family doctors, who would spend more
time with patients discussing risk factors and options for
prevention. These represent ideas for the future; at the
moment, separate national campaigns exist for the different
risk factors, such as smoking, but the country has no holistic approach. The government’s ministry of health runs
some of the campaigns, whereas professional institutions,
such as the Cardiology Society of Serbia and the Serbian
Heart Foundation, run others. The latter 2 organisations
participate actively in World Heart Day in September.
The Cardiology Society of Serbia has worked hard to
promote prevention, and it has formed branches in the
important regions of the country to support this aim. The
society also uses workshops, congresses, and similar activities to get primary care physicians involved in prevention,
mainly of ischaemic heart disease. These physicians seem
open to the idea, but Professor Nedeljkovic says that doctors
need more training in how to prevent disease, instead of
focusing on treatment. “We have to make preventive work
more popular and more effective,” he says. “We have to
involve more doctors—not only cardiologists, but also primary care physicians as well as secondary care physicians.”
Professor Nedeljkovic admits that motivation can present
a problem for doctors. “They are interested in prevention,
but it’s always a problem with preventive work because
you have to wait for a long time to see the results. For
example, if you give pills to lower blood pressure, in a
month you can see the beneficial effects of your treatment.
However, if you are making some campaign for smoking
cessation, you have to wait for a few years, and the adherence rate is very low, so that’s one of the reasons why there
is a lack of motivation for doctors.” But, he adds, “When
you talk to all of my colleagues, they would agree that prevention of cardiovascular disease is a very, very important
thing and that we have to work on it. I think also that prevention is the most troublesome thing, not only in Serbia,
but maybe even in the whole world.”
Jennifer Taylor is a freelance medical journalist.
The opinions expressed in Circulation: European
Perspectives in Cardiology are not necessarily those
of the editors or of the American Heart Association.
European Perspectives
Circulation. 2008;118:f1-f6
doi: 10.1161/CIRCULATIONAHA.108.189690
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