Prevention of Chronic Non-Communicable Diseases: Quo Vadis? A New Example from Zagreb

    Authors

    Abstract

    The central event of the World Heart Day 2015 in Croatia was an open public-health initiative screening for leading cardiovascular risk factors in the city of Zagreb. Individuals with very high risk factor prevalence were accepted into the “Guardians of the Heart” program that assessed cardiovascular risk and offered advice on health. The goal of this article is to report on these results and demonstrate the significance of detecting specific risk factors in individuals with high cardiovascular risk. After an announcement in the media, participants voluntarily applied for free assessment of cardiovascular risk factors during the public event. For interested citizens, health professionals determined the body-mass index (BMI), measured blood pressure (BP), and determined glucose levels and total cholesterol from capillary blood. The first 100 participants with extremely high prevalence of individual risk factors were invited to further detailed evaluation and cardiovascular risk assessment at the Institute for Cardiovascular Prevention and Rehabilitation in Zagreb. The results of both actions are presented here. The open public-health action was attended by 308 participants, of whom 59.7% were women and 40.3% men. The average age was 68.8±13.2 years of age. Elevated BP (92.5%) and BMI (46.5% overweight, 25.7% obese) were the most common risk factors. Highly elevated total cholesterol levels were registered in 11.8% participants, and highly elevated glucose levels in the capillary blood in 4.1%. Of the 100 participants invited to detailed cardiovascular risk assessment, 77% responded, of whom 75.2% were women and 24.7% men. Increased BP levels were found in 90.9% of these respondents; dyslipidemia in 85.7%, increased waist size in 84.4%, and 78.9% had elevated BMI. We performed an additional analysis on the results of 30 participants with existing hypertension and dyslipidemia and found elevated risk factors, including elevated BMI (80.0%), waist size (76.7%), urate levels (23.3%), C-reactive protein (16.7%), creatinine (10.0%), and blood glucose levels (10.0%). The most common risk factors in the participants of this public-health action were arterial hypertension and increased BMI. In participants with existing hypertension and dyslipidemia we noted a dismissive approach to these risk factors, both in the sense of non-treatment

    Keywords

    cardiovascular risk factor, screening, World Heart Day

    DOI

    https://doi.org/10.15836/ccar.2015.274

    Full Text

    ## Introduction Among European Union member states, Croatia is in the group of countries with very high risk of cardiovascular diseases (CVD). Although every second death in Croatia is caused by CVD, the good news is that the mortality rate from CVD has gradually dropped over the last ten years in Croatia ( 1 , 2 ), thanks to timely, high-quality, and evidence-based treatment of coronary heart disease (CHD) and preventive and public-health initiatives. The goal of World Heart Day, held on September 29, is to educate the general population on the importance of cardiovascular health, risk factors, and CVD prevention. The World Heart Day has a different slogan and topic every year, reflecting a key heart-related health issue. For 2015, the World Heart Federation chose the slogan “Healthy heart choices for everyone, everywhere”, calling attention to the need to change existing habits and form new ones to create a healthy environment in the home or workplace. The success of the public-health initiative on World Heart Day depends on the efforts of local national organizations in arranging the event ( 3 ). The central event of World Heart Day in Croatia in 2015 was the systematic screening for leading risk factors for CVD (high blood pressure, lipid disorders, obesity, and diabetes) that took place in Zagreb, the capital city. Under the sponsorship of the City of Zagreb and the University of Zagreb School of Medicine, the action was organized by the foundation Croatian Heart House and the Croatian Cardiac Society in cooperation with the Croatian Association of Cardiology Nurses. Participants who were found to have extremely high cardiovascular risk values were included into the “Guardians of the Heart” program started in September, 2015 by the Foundation Croatian Heart House to promote cardiovascular health through early CVD detection and improvement in length and quality of life. After proper preparation, the program consisted of detailed screening for modifiable and unmodifiable risk factors, cardiovascular risk assessment, and issuing health recommendations by a team of health professionals with years of experiences in therapeutic education of cardiovascular patients. The aim of this article is to report the results of the systematic screening for cardiovascular risk in the city of Zagreb and establish the significance of detecting specific risk factors in persons with high cardiovascular risk. ## Patients and Methods After announcements in the media, participants voluntarily applied for free assessment of cardiovascular risk factors during the public event on the Petar Preradović Square in Zagreb. Interested persons had their body-mass index (BMI) measured in an organized fashion by health professionals. Automatic blood pressure monitors were used to measure blood pressure (BP). Glucose and total cholesterol were determined from capillary blood using test strips. Participants were allowed to choose which cardiovascular risk factors they wanted to measure and were offered advice from health professionals as well as printed materials on CVD prevention. The first 100 participants with extremely high incidence of specific risk factors, especially those with high total cholesterol levels (≥7.0 mmol/L) due to suspected familial hypercholesterolemia, those with stage III arterial hypertension (systolic BP >180 mmHg or diastolic BP >110 mmHg), or with high glucose values (>11.1 mmol/L), received a free invitation to participate in a targeted public-health action. The invitation listed the date when they could receive a detailed evaluation of cardiovascular risk factors at the Institute for Cardiovascular Prevention and Rehabilitation in Zagreb. Participants have been advised to abstain from eating eight hours prior to having their blood drawn (except water). The evaluation included taking demographic data, BMI and waist size measurement, measuring BP and heart rate, and taking a detailed history on smoking and arterial hypertension (AH), CHD, dyslipidemia, diabetes, and previous drug treatments. All participants had a blood sample taken from a vein using the standard procedure in a biochemical laboratory, to determine total cholesterol values, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, blood triglycerides, glucose levels, C-reactive protein (CRP) levels, and creatinine, potassium, and urate levels. Based on the results, a cardiologist assessed the cardiovascular risk and advised on further tests and/or treatment. All participants received a written assessment with the results of all the measurements and recommendations for health improvement as well as further contact with a family medicine physician. The results are shown separately for the two groups of participants. First are the results of the open public-health screening for cardiovascular risk factors, followed by the results of the targeted cardiovascular risk assessment in the secondary healthcare institution. Frequency data are presented as absolute numbers and relative frequencies, according to gender. Continuous data are presented as minimal and maximal values and arithmetic means. The public-health action on the Petar Preradović Square in Zagreb had 308 participants, of whom 184 (59.7%) were women and 124 (40.3%) men. The average age was 68.8±13.2 years of age (data known for 302 participants, 181 women and 121 men). The men were on average three years older than the women (71.7±12.2 versus 68.5±13.8). The youngest female participant was 7 years of age, and the oldest was 92 years old. In men, the youngest participant was 13, and the oldest was 93 years old. BP measurement was the most chosen risk factor measurement among the participants. Specifically, BP was checked in 285 participants (92.5%), of whom 177 (62.1%) were women and 108 (37.9%) were men. Elevated BP values (systolic pressure >140 and/or diastolic >90 mmHg) were identified in 230 (80.7%) participants, of whom 90 were men and 140 women. Considering the results of the measurements, 83,3% of male and 79.1% of female participants, had elevated BP values. Stage III AH was found in 48 (15.6%) participants with BP, of whom 20 (16.1%) were men and 28 (15.2%) were women. Capillary blood glucose levels were measured in 245 participants, of which 10 (4.1%) had values above 11.1 mmol/L that indicate diabetes. Total cholesterol in fingerstick capillary specimens was measured in 119 participants, of which 14 (11.8%) had values ≥7.0 mmol/L, and in 12 (10.1%) total cholesterol was not measurable. BMI values were measured in 121 participants, least commonly of all risk factors evaluated. BMI distribution is shown in Figure 1 . Being overweight was more common in men than in women (57.9% versus 30.2%). Obesity was found less commonly in men than in women (18.4% versus 44.2%). Body-mass distribution according to gender in the participants of the open public-health initiative on the Petar Preradović Square in Zagreb. ## Results of the targeted public-health evaluation of cardiovascular risk factors Of the 100 participants invited for further targeted cardiovascular risk evaluation in a secondary healthcare institution due to extremely high incidence of particular risk factors, 77 (77.0%) responded to the invitation, of whom 58 (75.3%) were women and 19 (24.7%) were men. The average age of these respondents was the same (70.7±9.2 for women versus 70.7±9.8 for men). The youngest female participant was 26, and the oldest was 89 years of age. The youngest male participant was 43, and the oldest 86 years of age. BMI distribution is shown in detail in Figure 2 . The percentage of participants with normal BMI was not associated with gender (5/19; 26.3% in men versus 16/58; 27.6% in women). Body-mass index according to gender in participants of the targeted public-health evaluation of cardiovascular risk factors at the Institute for Cardiovascular Prevention and Rehabilitation in Zagreb. Waist size was normal in just 13.8% (8/58) women and 21.1% (4/19) men. Average waist size values were similar regardless of gender (98.8 cm in women versus 99.9 cm in men). Elevated BP was found in 90.9% of participants (52/58; 89.7% in women versus 18/19; 94.7% in men), mostly stage I and II AH. AH stage III was found in only 9.6% (5/52) of female participants. Isolated systolic hypertension was found only in 5.8% (3/52) women. Of the participants with increased AP, as many as 87.1% (61/70) were already aware of their AH (48/52; 92.3% of women versus 13/18; 72.2% men). Of these, 67% were already receiving antihypertensive treatment, but only 6 participants had optimal BP values. Analyzing the association between AH and BMI, we found that 58% of participants with AH were also obese. Heart rate frequencies were normal in most participants (average frequency 71/min in men versus 74/min in women), and elevated heart rates were found in only 2 (3.4%) participants. Three (3/77; 3.9%) participants have had previous myocardial infarction (2/58; 3.4% women versus 1/19; 5.3% men). Medical history positive for cigarette smoking was found in only 2 (2.6%) participants, one man and one woman. Positive medical history for dyslipidemia was found in 51 (66.2%) participants (11; 57.9% men versus 45; 77.6% women). However, laboratory findings showed dyslipidemia in as many as 85.7% (66/77) participants, namely in all of the men and 81.0% (47/58) women. Total cholesterol levels above 7.0 mmol/L were found in 11 participants (10 women and 1 man). The man in this group stood out because of his extraordinarily high lipid values (total cholesterol 9.8 mmol/L, triglycerides 8.3 mmol/L, while LDL levels were not established because of extremely lipemic serum). A total of 10 (13.0%) participants had a history of diabetes, of whom 8 (13.8%) were women and 2 (10.5%) men. Half of these diabetics (4 women and 1 man) had blood glucose levels above 7.8 mmol/L, indicative of unregulated diabetes. The prevalence of increased creatinine, urate, and CRP levels in participant groups according to gender is shown in Table 1 . All participants with increased creatinine values were additionally assessed for glomerular filtration rates using the Modification of Diet in Renal Disease equation. All 4 men with increased creatinine had moderately lowered glomerular filtration rates (stage III of chronic kidney disease), as did the 3 women with increased creatinine levels. One participant had a severely lowered glomerular filtration rate (stage IV of chronic kidney disease). Potassium values were not elevated in any participants. We performed an additional assessment of cardiovascular risk in 30 participants that had already been previously diagnosed with both AH and dyslipidemia (25/58; 43.1% women and 5/19; 26.3% men), shown in Table 2 . As many as 80% of these participants were overweight or obese, and 76.7% had increased waist size. Increased urate values were found in 23.3%, increased CRP in 16.7%, increased blood glucose in 10.0%, and increased creatinine values in 10.0% of these participants. *BMI: Body-mass index; CRP: C-reactive protein. ## Discussion Cardiovascular diseases are characterized by a lack of specific symptoms until manifest damage occurs. Long-term outcomes in this disease group are determined by the presence of cardiovascular risk factors, of which the modifiable ones are the most important. Data on the high prevalence of cardiovascular risk factors found in the 308 participants of the first, and the more detailed assessments on the 77 participants of the second public-health action are cause for concern. These results further clarify the causes of high cardiovascular morbidity and mortality in the Republic of Croatia and indicate a need for more targeted public-health initiatives in patients with elevated BMI, dyslipidemia, or AH. Despite advances in treatment, AH is still the most common CVD and an important risk factor that contributes to many complications. It requires optimal treatment with both a pharmacological and non-pharmacological approach. Dyslipidemia is, like AH, a significant risk factor on its own. When treating dyslipidemia, the aim is to lower blood cholesterol, LDL-cholesterol, and triglyceride as much as possible to achieve the best reduction in CVD risk. For an individual, obesity represents a higher risk of CVD in comparison with a person with normal BMI and is the most common consequence of insufficient physical activity. Obesity is not “just” being overweight, representing rather a whole spectrum of cardiometabolic diseases and risks related to obesity. ( 4 - 7 ) Obesity is one of the main CVD risk factors and has, along with AH, become the focus of this article. Obesity leads to cardiovascular risk in several ways. Increased BMI is associated with changes in myocyte metabolism, atherosclerotic plaque, arterial rigidity, AH, kidney disease, heart failure, dyslipidemia, insulin resistance, etc. ( 8 - 11 ) The correlation tables between BMI, dyslipidemia, and AH clearly show that increased BMI coexists with dyslipidemia and/or AH, but the absence of these is no guarantee that they will not develop within a short period of time and eventually lead to one or more manifested CVD. The data gathered as part of the public-health initiative on World Heart Day in 2015 in the city of Zagreb indicate a high prevalence of unregulated risk factors in 308 participants, mostly between 60 and 79 years of age. In the first group of participants, who had no preparation before taking part in the action on the Petar Preradović Square and could select which risk factors they wanted to check, among traditional modifiable risk factors most common were elevated BP (92.5% of the participants) and increased BMI (46.5% was overweight, 25.7% was obese). Significantly elevated total cholesterol values were found in 11.8% of the participants, and very high glucose levels in capillary blood in 4.1%. Special invitations were given to the above participants to attend an additional screening and cardiovascular risk assessment process. In the 77 participants who responded to the invitation, we found a high prevalence of risk factors, which confirms optimally set values for cardiovascular risk assessment outside of family medicine practice and the regular health care system. Elevated BP values were found in 90.9%, dyslipidemia in 85.7%, and increased waist size in 84.4% of the participants. More than three quarters (78.9%) were overweight or obese, which is similar to last-year’s results which included participants from younger age groups ( 12 ). Regarding awareness of the significance of changeable cardiovascular risk factors, we performed an additional analysis on participants with previously-diagnosed AH and dyslipidemia. We found that increased BMI was the most prevalent risk factor in this group of participants and was associated with increased waist size as well as incidence of AH and dyslipidemia. We found that persons with known risk factors adhere to treatment and healthy lifestyle measures only poorly, both in reaching target risk factor levels and in preventing complications. CRP values are a well-studied variable in the context of atherosclerosis and CHD. Urate values and creatinine, with its “accelerated atherosclerosis” in renal insufficiency, both have a role in determining cardiovascular risk ( 13 - 20 ). However, to properly interpret the significance of CRP, creatinine, and urate values in an individual when assessing cardiovascular risk, an expert opinion is still required. A single accidentally determined CRP and/or creatinine and/or urate value alone tells us much less when there is no medical history data available from a proper medical exam. As a result of our research, we can conclude that in order to screen the general population for increased traditional modifiable risk factors at a public-health gathering (action), it is enough to determine BMI and measure waist size and BP values. However, more detailed insight into the presence of risk factors still requires “classic” laboratory tests for fasting serum lipid and glucose values according to standard procedures. Regarding “newer” risk factors and/or indirect indicators of cardiovascular risk and morbidity in the form of CRP, creatinine, and urates, the interpretation of these values requires a medical examination that can include further tests with a 12-lead electrocardiogram. The above is supported by a Dutch study that found similar results at the primary healthcare level in the sense that detecting individual risk factors was important for everyone, but a more exhaustive approach that includes an expert opinion should be available for those with moderate or increased cardiovascular risk ( 21 ). It should also be noted that screening for just a single risk factor can burden the healthcare system and cause undue fear in the patient due to the possibility of false-positive results. A positive aspect of our data is that there were only two smokers among the 77 persons that responded to the invitation for targeted assessment, which we hypothesize is due to the higher average age of the participants in comparison with past initiatives. Gathering data on the prevalence and alterations in individual risk factors plays a role in predicting possible manifestations of CVD in a given population. Thus, due to a high incidence of risk factors and presence of CVD, the question that presents itself is: Cardiovascular disease prevention, quo vadis? An adequate reply based on the results of this study would be – to one or more clinically manifesting or asymptomatic entities in the CVD spectrum. According to epidemiological data from the City of Zagreb Register of Acute Coronary Syndrome, the first manifestation of CHD is acute myocardial infarction, and, despite more successful hospital treatment, half of these patients die before reaching the hospital. In the 20 th century, authors noted that the first presentation of CHD is myocardial infarction, roughly equally in women and in men. Newer publications list myocardial infarction, sudden cardiac death, and abdominal aortic aneurysm as the first manifestations of CVD in men, whereas in women the first place is held by cerebrovascular events followed by heart failure as a clinical entity. Stable angina is less common, but equally prevalent in men and women ( 22 - 25 ). We are also aware of the limitations of our study, primarily in that the way participants were selected undoubtedly influenced the results. Since this was an organized public-health initiative of the open type, persons from all age groups could participate as well as choose which risk factor they wanted to be tested for. Furthermore, finding one or more risk factors in 308 participants could mean that the participants did not consider them as important or were already aware of the risk factors; this could also at least partly explain the response rate of 77% to the invitation for detailed cardiovascular risk assessment. ## Conclusion We confirmed the already established issues of the general population in the city of Zagreb, namely increased body-mass index and AH. We noticed a dismissive approach to those issues in patients previously diagnosed with AH and dyslipidemia, both in the sense of a failure to treat these diseases and in suboptimal drug treatment. A dismissive approach was also evident in the approach to corrective measures for unhealthy lifestyle habits in persons with AH and dyslipidemia who had increased BMI and waist size. The data indicate a need for a continuous and firmer approach to modifiable risk factors. Further education of the public is required on the importance of healthy diet, regular exercise, the deleterious effect of excess body weight, and also on the need for adherence to recommended treatment and achieving target AP and lipid values. Public-health initiatives such as this should be more common; however, at-risk participants still require the expert opinions of a team of experienced health professionals and continuous work on the prevention of cardiovascular diseases.

    Cardiologia Croatica
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    Prevention of Chronic Non-Communicable Diseases: Quo Vadis? A New Example from Zagreb

    Research Article
    Issue11-12
    Published
    Pages274-282
    PDF via DOIhttps://doi.org/10.15836/ccar.2015.274
    cardiovascular risk factor
    screening
    World Heart Day

    Authors

    Mario IvanušaORCIDCroatia
    Vedrana Škerk*ORCIDCroatia
    Marija HeinrichORCIDCroatia
    Nada HrstićORCIDCroatia
    Goran KrstačićORCIDCroatia
    Ivana Portolan PajićORCIDCroatia

    Abstract

    The central event of the World Heart Day 2015 in Croatia was an open public-health initiative screening for leading cardiovascular risk factors in the city of Zagreb. Individuals with very high risk factor prevalence were accepted into the “Guardians of the Heart” program that assessed cardiovascular risk and offered advice on health. The goal of this article is to report on these results and demonstrate the significance of detecting specific risk factors in individuals with high cardiovascular risk. After an announcement in the media, participants voluntarily applied for free assessment of cardiovascular risk factors during the public event. For interested citizens, health professionals determined the body-mass index (BMI), measured blood pressure (BP), and determined glucose levels and total cholesterol from capillary blood. The first 100 participants with extremely high prevalence of individual risk factors were invited to further detailed evaluation and cardiovascular risk assessment at the Institute for Cardiovascular Prevention and Rehabilitation in Zagreb. The results of both actions are presented here. The open public-health action was attended by 308 participants, of whom 59.7% were women and 40.3% men. The average age was 68.8±13.2 years of age. Elevated BP (92.5%) and BMI (46.5% overweight, 25.7% obese) were the most common risk factors. Highly elevated total cholesterol levels were registered in 11.8% participants, and highly elevated glucose levels in the capillary blood in 4.1%. Of the 100 participants invited to detailed cardiovascular risk assessment, 77% responded, of whom 75.2% were women and 24.7% men. Increased BP levels were found in 90.9% of these respondents; dyslipidemia in 85.7%, increased waist size in 84.4%, and 78.9% had elevated BMI. We performed an additional analysis on the results of 30 participants with existing hypertension and dyslipidemia and found elevated risk factors, including elevated BMI (80.0%), waist size (76.7%), urate levels (23.3%), C-reactive protein (16.7%), creatinine (10.0%), and blood glucose levels (10.0%). The most common risk factors in the participants of this public-health action were arterial hypertension and increased BMI. In participants with existing hypertension and dyslipidemia we noted a dismissive approach to these risk factors, both in the sense of non-treatment

    Full Text

    ## Introduction Among European Union member states, Croatia is in the group of countries with very high risk of cardiovascular diseases (CVD). Although every second death in Croatia is caused by CVD, the good news is that the mortality rate from CVD has gradually dropped over the last ten years in Croatia ( 1 , 2 ), thanks to timely, high-quality, and evidence-based treatment of coronary heart disease (CHD) and preventive and public-health initiatives. The goal of World Heart Day, held on September 29, is to educate the general population on the importance of cardiovascular health, risk factors, and CVD prevention. The World Heart Day has a different slogan and topic every year, reflecting a key heart-related health issue. For 2015, the World Heart Federation chose the slogan “Healthy heart choices for everyone, everywhere”, calling attention to the need to change existing habits and form new ones to create a healthy environment in the home or workplace. The success of the public-health initiative on World Heart Day depends on the efforts of local national organizations in arranging the event ( 3 ). The central event of World Heart Day in Croatia in 2015 was the systematic screening for leading risk factors for CVD (high blood pressure, lipid disorders, obesity, and diabetes) that took place in Zagreb, the capital city. Under the sponsorship of the City of Zagreb and the University of Zagreb School of Medicine, the action was organized by the foundation Croatian Heart House and the Croatian Cardiac Society in cooperation with the Croatian Association of Cardiology Nurses. Participants who were found to have extremely high cardiovascular risk values were included into the “Guardians of the Heart” program started in September, 2015 by the Foundation Croatian Heart House to promote cardiovascular health through early CVD detection and improvement in length and quality of life. After proper preparation, the program consisted of detailed screening for modifiable and unmodifiable risk factors, cardiovascular risk assessment, and issuing health recommendations by a team of health professionals with years of experiences in therapeutic education of cardiovascular patients. The aim of this article is to report the results of the systematic screening for cardiovascular risk in the city of Zagreb and establish the significance of detecting specific risk factors in persons with high cardiovascular risk. ## Patients and Methods After announcements in the media, participants voluntarily applied for free assessment of cardiovascular risk factors during the public event on the Petar Preradović Square in Zagreb. Interested persons had their body-mass index (BMI) measured in an organized fashion by health professionals. Automatic blood pressure monitors were used to measure blood pressure (BP). Glucose and total cholesterol were determined from capillary blood using test strips. Participants were allowed to choose which cardiovascular risk factors they wanted to measure and were offered advice from health professionals as well as printed materials on CVD prevention. The first 100 participants with extremely high incidence of specific risk factors, especially those with high total cholesterol levels (≥7.0 mmol/L) due to suspected familial hypercholesterolemia, those with stage III arterial hypertension (systolic BP >180 mmHg or diastolic BP >110 mmHg), or with high glucose values (>11.1 mmol/L), received a free invitation to participate in a targeted public-health action. The invitation listed the date when they could receive a detailed evaluation of cardiovascular risk factors at the Institute for Cardiovascular Prevention and Rehabilitation in Zagreb. Participants have been advised to abstain from eating eight hours prior to having their blood drawn (except water). The evaluation included taking demographic data, BMI and waist size measurement, measuring BP and heart rate, and taking a detailed history on smoking and arterial hypertension (AH), CHD, dyslipidemia, diabetes, and previous drug treatments. All participants had a blood sample taken from a vein using the standard procedure in a biochemical laboratory, to determine total cholesterol values, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, blood triglycerides, glucose levels, C-reactive protein (CRP) levels, and creatinine, potassium, and urate levels. Based on the results, a cardiologist assessed the cardiovascular risk and advised on further tests and/or treatment. All participants received a written assessment with the results of all the measurements and recommendations for health improvement as well as further contact with a family medicine physician. The results are shown separately for the two groups of participants. First are the results of the open public-health screening for cardiovascular risk factors, followed by the results of the targeted cardiovascular risk assessment in the secondary healthcare institution. Frequency data are presented as absolute numbers and relative frequencies, according to gender. Continuous data are presented as minimal and maximal values and arithmetic means. The public-health action on the Petar Preradović Square in Zagreb had 308 participants, of whom 184 (59.7%) were women and 124 (40.3%) men. The average age was 68.8±13.2 years of age (data known for 302 participants, 181 women and 121 men). The men were on average three years older than the women (71.7±12.2 versus 68.5±13.8). The youngest female participant was 7 years of age, and the oldest was 92 years old. In men, the youngest participant was 13, and the oldest was 93 years old. BP measurement was the most chosen risk factor measurement among the participants. Specifically, BP was checked in 285 participants (92.5%), of whom 177 (62.1%) were women and 108 (37.9%) were men. Elevated BP values (systolic pressure >140 and/or diastolic >90 mmHg) were identified in 230 (80.7%) participants, of whom 90 were men and 140 women. Considering the results of the measurements, 83,3% of male and 79.1% of female participants, had elevated BP values. Stage III AH was found in 48 (15.6%) participants with BP, of whom 20 (16.1%) were men and 28 (15.2%) were women. Capillary blood glucose levels were measured in 245 participants, of which 10 (4.1%) had values above 11.1 mmol/L that indicate diabetes. Total cholesterol in fingerstick capillary specimens was measured in 119 participants, of which 14 (11.8%) had values ≥7.0 mmol/L, and in 12 (10.1%) total cholesterol was not measurable. BMI values were measured in 121 participants, least commonly of all risk factors evaluated. BMI distribution is shown in Figure 1 . Being overweight was more common in men than in women (57.9% versus 30.2%). Obesity was found less commonly in men than in women (18.4% versus 44.2%). Body-mass distribution according to gender in the participants of the open public-health initiative on the Petar Preradović Square in Zagreb. ## Results of the targeted public-health evaluation of cardiovascular risk factors Of the 100 participants invited for further targeted cardiovascular risk evaluation in a secondary healthcare institution due to extremely high incidence of particular risk factors, 77 (77.0%) responded to the invitation, of whom 58 (75.3%) were women and 19 (24.7%) were men. The average age of these respondents was the same (70.7±9.2 for women versus 70.7±9.8 for men). The youngest female participant was 26, and the oldest was 89 years of age. The youngest male participant was 43, and the oldest 86 years of age. BMI distribution is shown in detail in Figure 2 . The percentage of participants with normal BMI was not associated with gender (5/19; 26.3% in men versus 16/58; 27.6% in women). Body-mass index according to gender in participants of the targeted public-health evaluation of cardiovascular risk factors at the Institute for Cardiovascular Prevention and Rehabilitation in Zagreb. Waist size was normal in just 13.8% (8/58) women and 21.1% (4/19) men. Average waist size values were similar regardless of gender (98.8 cm in women versus 99.9 cm in men). Elevated BP was found in 90.9% of participants (52/58; 89.7% in women versus 18/19; 94.7% in men), mostly stage I and II AH. AH stage III was found in only 9.6% (5/52) of female participants. Isolated systolic hypertension was found only in 5.8% (3/52) women. Of the participants with increased AP, as many as 87.1% (61/70) were already aware of their AH (48/52; 92.3% of women versus 13/18; 72.2% men). Of these, 67% were already receiving antihypertensive treatment, but only 6 participants had optimal BP values. Analyzing the association between AH and BMI, we found that 58% of participants with AH were also obese. Heart rate frequencies were normal in most participants (average frequency 71/min in men versus 74/min in women), and elevated heart rates were found in only 2 (3.4%) participants. Three (3/77; 3.9%) participants have had previous myocardial infarction (2/58; 3.4% women versus 1/19; 5.3% men). Medical history positive for cigarette smoking was found in only 2 (2.6%) participants, one man and one woman. Positive medical history for dyslipidemia was found in 51 (66.2%) participants (11; 57.9% men versus 45; 77.6% women). However, laboratory findings showed dyslipidemia in as many as 85.7% (66/77) participants, namely in all of the men and 81.0% (47/58) women. Total cholesterol levels above 7.0 mmol/L were found in 11 participants (10 women and 1 man). The man in this group stood out because of his extraordinarily high lipid values (total cholesterol 9.8 mmol/L, triglycerides 8.3 mmol/L, while LDL levels were not established because of extremely lipemic serum). A total of 10 (13.0%) participants had a history of diabetes, of whom 8 (13.8%) were women and 2 (10.5%) men. Half of these diabetics (4 women and 1 man) had blood glucose levels above 7.8 mmol/L, indicative of unregulated diabetes. The prevalence of increased creatinine, urate, and CRP levels in participant groups according to gender is shown in Table 1 . All participants with increased creatinine values were additionally assessed for glomerular filtration rates using the Modification of Diet in Renal Disease equation. All 4 men with increased creatinine had moderately lowered glomerular filtration rates (stage III of chronic kidney disease), as did the 3 women with increased creatinine levels. One participant had a severely lowered glomerular filtration rate (stage IV of chronic kidney disease). Potassium values were not elevated in any participants. We performed an additional assessment of cardiovascular risk in 30 participants that had already been previously diagnosed with both AH and dyslipidemia (25/58; 43.1% women and 5/19; 26.3% men), shown in Table 2 . As many as 80% of these participants were overweight or obese, and 76.7% had increased waist size. Increased urate values were found in 23.3%, increased CRP in 16.7%, increased blood glucose in 10.0%, and increased creatinine values in 10.0% of these participants. *BMI: Body-mass index; CRP: C-reactive protein. ## Discussion Cardiovascular diseases are characterized by a lack of specific symptoms until manifest damage occurs. Long-term outcomes in this disease group are determined by the presence of cardiovascular risk factors, of which the modifiable ones are the most important. Data on the high prevalence of cardiovascular risk factors found in the 308 participants of the first, and the more detailed assessments on the 77 participants of the second public-health action are cause for concern. These results further clarify the causes of high cardiovascular morbidity and mortality in the Republic of Croatia and indicate a need for more targeted public-health initiatives in patients with elevated BMI, dyslipidemia, or AH. Despite advances in treatment, AH is still the most common CVD and an important risk factor that contributes to many complications. It requires optimal treatment with both a pharmacological and non-pharmacological approach. Dyslipidemia is, like AH, a significant risk factor on its own. When treating dyslipidemia, the aim is to lower blood cholesterol, LDL-cholesterol, and triglyceride as much as possible to achieve the best reduction in CVD risk. For an individual, obesity represents a higher risk of CVD in comparison with a person with normal BMI and is the most common consequence of insufficient physical activity. Obesity is not “just” being overweight, representing rather a whole spectrum of cardiometabolic diseases and risks related to obesity. ( 4 - 7 ) Obesity is one of the main CVD risk factors and has, along with AH, become the focus of this article. Obesity leads to cardiovascular risk in several ways. Increased BMI is associated with changes in myocyte metabolism, atherosclerotic plaque, arterial rigidity, AH, kidney disease, heart failure, dyslipidemia, insulin resistance, etc. ( 8 - 11 ) The correlation tables between BMI, dyslipidemia, and AH clearly show that increased BMI coexists with dyslipidemia and/or AH, but the absence of these is no guarantee that they will not develop within a short period of time and eventually lead to one or more manifested CVD. The data gathered as part of the public-health initiative on World Heart Day in 2015 in the city of Zagreb indicate a high prevalence of unregulated risk factors in 308 participants, mostly between 60 and 79 years of age. In the first group of participants, who had no preparation before taking part in the action on the Petar Preradović Square and could select which risk factors they wanted to check, among traditional modifiable risk factors most common were elevated BP (92.5% of the participants) and increased BMI (46.5% was overweight, 25.7% was obese). Significantly elevated total cholesterol values were found in 11.8% of the participants, and very high glucose levels in capillary blood in 4.1%. Special invitations were given to the above participants to attend an additional screening and cardiovascular risk assessment process. In the 77 participants who responded to the invitation, we found a high prevalence of risk factors, which confirms optimally set values for cardiovascular risk assessment outside of family medicine practice and the regular health care system. Elevated BP values were found in 90.9%, dyslipidemia in 85.7%, and increased waist size in 84.4% of the participants. More than three quarters (78.9%) were overweight or obese, which is similar to last-year’s results which included participants from younger age groups ( 12 ). Regarding awareness of the significance of changeable cardiovascular risk factors, we performed an additional analysis on participants with previously-diagnosed AH and dyslipidemia. We found that increased BMI was the most prevalent risk factor in this group of participants and was associated with increased waist size as well as incidence of AH and dyslipidemia. We found that persons with known risk factors adhere to treatment and healthy lifestyle measures only poorly, both in reaching target risk factor levels and in preventing complications. CRP values are a well-studied variable in the context of atherosclerosis and CHD. Urate values and creatinine, with its “accelerated atherosclerosis” in renal insufficiency, both have a role in determining cardiovascular risk ( 13 - 20 ). However, to properly interpret the significance of CRP, creatinine, and urate values in an individual when assessing cardiovascular risk, an expert opinion is still required. A single accidentally determined CRP and/or creatinine and/or urate value alone tells us much less when there is no medical history data available from a proper medical exam. As a result of our research, we can conclude that in order to screen the general population for increased traditional modifiable risk factors at a public-health gathering (action), it is enough to determine BMI and measure waist size and BP values. However, more detailed insight into the presence of risk factors still requires “classic” laboratory tests for fasting serum lipid and glucose values according to standard procedures. Regarding “newer” risk factors and/or indirect indicators of cardiovascular risk and morbidity in the form of CRP, creatinine, and urates, the interpretation of these values requires a medical examination that can include further tests with a 12-lead electrocardiogram. The above is supported by a Dutch study that found similar results at the primary healthcare level in the sense that detecting individual risk factors was important for everyone, but a more exhaustive approach that includes an expert opinion should be available for those with moderate or increased cardiovascular risk ( 21 ). It should also be noted that screening for just a single risk factor can burden the healthcare system and cause undue fear in the patient due to the possibility of false-positive results. A positive aspect of our data is that there were only two smokers among the 77 persons that responded to the invitation for targeted assessment, which we hypothesize is due to the higher average age of the participants in comparison with past initiatives. Gathering data on the prevalence and alterations in individual risk factors plays a role in predicting possible manifestations of CVD in a given population. Thus, due to a high incidence of risk factors and presence of CVD, the question that presents itself is: Cardiovascular disease prevention, quo vadis? An adequate reply based on the results of this study would be – to one or more clinically manifesting or asymptomatic entities in the CVD spectrum. According to epidemiological data from the City of Zagreb Register of Acute Coronary Syndrome, the first manifestation of CHD is acute myocardial infarction, and, despite more successful hospital treatment, half of these patients die before reaching the hospital. In the 20 th century, authors noted that the first presentation of CHD is myocardial infarction, roughly equally in women and in men. Newer publications list myocardial infarction, sudden cardiac death, and abdominal aortic aneurysm as the first manifestations of CVD in men, whereas in women the first place is held by cerebrovascular events followed by heart failure as a clinical entity. Stable angina is less common, but equally prevalent in men and women ( 22 - 25 ). We are also aware of the limitations of our study, primarily in that the way participants were selected undoubtedly influenced the results. Since this was an organized public-health initiative of the open type, persons from all age groups could participate as well as choose which risk factor they wanted to be tested for. Furthermore, finding one or more risk factors in 308 participants could mean that the participants did not consider them as important or were already aware of the risk factors; this could also at least partly explain the response rate of 77% to the invitation for detailed cardiovascular risk assessment. ## Conclusion We confirmed the already established issues of the general population in the city of Zagreb, namely increased body-mass index and AH. We noticed a dismissive approach to those issues in patients previously diagnosed with AH and dyslipidemia, both in the sense of a failure to treat these diseases and in suboptimal drug treatment. A dismissive approach was also evident in the approach to corrective measures for unhealthy lifestyle habits in persons with AH and dyslipidemia who had increased BMI and waist size. The data indicate a need for a continuous and firmer approach to modifiable risk factors. Further education of the public is required on the importance of healthy diet, regular exercise, the deleterious effect of excess body weight, and also on the need for adherence to recommended treatment and achieving target AP and lipid values. Public-health initiatives such as this should be more common; however, at-risk participants still require the expert opinions of a team of experienced health professionals and continuous work on the prevention of cardiovascular diseases.