Lipid-Modifying Therapy and Attainment of Cholesterol Goals in Hungary: The Return on Expenditure Achieved for Lipid Therapy (REALITY) Study

György Paragh; Lászlo Márk; Károly Zámolyi; Gyula Pados; Péter Ofner


Clin Drug Invest. 2007;27(9):647-660. 

In This Article

Abstract and Introduction


Background and objective: Cardiovascular disease is a leading cause of death in Eastern Europe. Few studies on cholesterol goal achievement have been conducted in Hungarian clinical settings. This study set out to evaluate lipid-modifying therapy practices and their effects on total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) goal attainment in Hungarian patients with coronary heart disease (CHD), CHD risk equivalents, or =2 coronary risk factors.
Methods: This multicentre observational study involved patients receiving lipid-modifying therapy who were under the care of general practitioners (n = 300) or specialists (n = 140). Physician questionnaires were used to collect data on baseline patient characteristics, including laboratory parameters. Using validated cardiovascular risk assessment measures, patients were stratified into high-risk (10-year absolute coronary risk >20%; n = 367) and lower risk groups (n = 73). Cholesterol goals were TC <4.5 mmol/L (<175 mg/dL) and LDL-C <2.5 mmol/L (<100 mg/dL) for the high-risk group and TC <5.0 mmol/L (<193 mg/dL) and LDL-C <3.0 mmol/L (<117 mg/dL) for those at lower risk.
Results: Among 440 patients (n = 312 with CHD or CHD risk equivalents), 374 (85%) were initiated on HMG-CoA reductase inhibitors (statin monotherapy), 44 (10%) received fibric acid derivatives and 22 (5%) received combination regimens. Although >50% of patients needed >35% TC lowering to reach goal, <10% of patients received high or very high potency lipid-modifying regimens or combination regimens initially. A total of 116 (26.4%) patients achieved their TC goals after =1 year of treatment, including 27.9% of patients with CHD/risk equivalents and 22.7% of those with risk factors only. Sixty-six (15%) patients achieved goal on initial lipid-modifying regimens, while a further 50 (11.4%) achieved goal following treatment changes, including upward dosage adjustments.
Conclusion: Approximately 74% of Hungarian patients receiving lipid-modifying therapy in our study did not achieve cholesterol goals. The proportion of patients realising their TC goals was higher in those treated by specialists but still did not exceed one-third.


Cardiovascular disease, including coronary heart disease (CHD) and stroke, is a leading cause of mortality, morbidity and healthcare expenditures. Worldwide, cardiovascular disease accounts for 17 million deaths annually, including >4.3 million or 49% of deaths in Europe.[1,2,3] These conditions also account for 23% of all illnesses and deaths and €169 billion in healthcare expenditures each year in the EU.[3]

Although recent statistical data have demonstrated a mild decrease in the incidence of cardiovascular diseases in Hungary, these conditions were still responsible for 51% of overall mortality.[4] In contrast, death rates from cardiovascular disease declined by 22.1% in the US from 1993 to 2003.[5]

A national health initiative undertaken in Hungary (Johan Béla National Programme for the Decade of Health[6]) has established a major objective of lowering average total cholesterol (TC) from 5.7 mmol/L (220 mg/dL) to 5.3 mmol/L (205 mg/dL) by 2010, and to reduce CHD mortality by 20% in persons aged <65 years by 2010. Findings from EUROASPIRE (the European Action on Secondary Prevention by Intervention to Reduce Events) have demonstrated increases in the use of lipid-modifying therapies, with rising proportions of CHD patients achieving TC goals, across Europe in general and Hungary in particular.[7,8,9] However, there remains considerable room for improvement.

From 1995-6 through to 2000-1, the proportion of patients with CHD in Europe who received lipid-modifying therapy increased from 32.0% to 62.9%.[9] However, at both time points, the proportions of CHD patients receiving lipid-modifying treatment in Hungary were the lowest of all Euro-pean countries: 22.3% in 1995-6 and 51.4% in 2000-1.[9] Consistent with these relatively low rates of use of lipid-modifying therapies, the majority of CHD patients failed to achieve even older, less aggressive TC goals, both in Europe generally and in Hungary in particular.[9] Across Europe, the proportion of all CHD patients achieving TC <5.0 mmol/L rose from 13.8% in 1995-6 to 41.2% in 2000-1, including an increase from 11.0% to 39.8% in Hungary.[9] Even among European CHD patients receiving lipid-modifying therapies, <50% achieved cholesterol goals: 49.2% in Europe and 48.4% in Hungary.[9] Unfortunately, these findings in fact overestimate the proportions of patients, particularly those with CHD, who attain their consensus cholesterol targets in clinical practice.[10,11,12,13,14,15,16,17,18,19,20] In the recent REALITY (Return on Expenditure Achieved for Lipid Therapy) study, approximately 60% of Europeans did not achieve their national guideline cholesterol targets.[11]

Few studies have been conducted in actual clinical settings to assess management of dyslipidaemia in Eastern Europe. The present multicentre observational study was conducted under the auspices of the REALITY study to evaluate dyslipidaemia management strategies and their effects on cholesterol goal achievement in Hungary.


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