original article

Wien Klin Wochenschr (2009) 121: 202–208 DOI 10.1007/s00508-009-1152-4 Printed in Austria © Springer-Verlag 2009

Wiener klinische Wochenschrift The Middle European Journal of Medicine

Cardiovascular risk status and primary prevention in postmenopausal women: the MENOCARD study Zoltan Vajo3 , Nandor Acs2, Karoly Toth2, Elek Dinya4 , György Paragh 3 , Albert Csaszar1 1 State

Health Center, Budapest, Hungary University Medical School, Budapest, Hungary 3 University of Debrecen Medical Center, Debrecen, Hungary 4 EGIS PLC, Budapest, Hungary 2 Semmelweis

Received May 23, 2008, accepted after revision January 22, 2009

Kardiovaskuläre Risikofaktoren und Primärprävention von postmenopausalen Frauen: Die MENOCARD Studie Zusammenfassung. Ziel: Unser Ziel war es, den Nutzen eines Screenings auf kardiovaskuläre Risikofaktoren sowie den Effekt der Anwendung professioneller Leitlinien zur Risikoreduktion bei postmenopausalen Frauen entsprechend dem Framingham und dem Hoch-Risiko „Systemic Coronary Risk Evaluation (SCORE)“ zu überprüfen. Methodik: Von 18 an der Studie teilnehmenden Menopause-Kliniken in Ungarn wurden 2789 Patienten rekrutiert. Die Ärzte wurden aufgefordert, entsprechend den professionellen Leitlinien zur Primärprävention kardiovaskulärer Erkrankungen bei diesen Patienten vorzugehen. Die Patienten wurden gebeten, ein Jahr lang alle vier Monate zur Kontrolle zu erscheinen. Ergebnisse: Das mittlere Alter der Patientinnen war 56,7 ± 6,9 Jahre. Die letzte Menstruation lag im Mittel 9,2 ± 7,2 Jahre zurück. 29,4% der Patientinnen erschienen zumindest zu einer Kontrolluntersuchung. Bei der Erstuntersuchung wurden hohe (> 5 mmol/L) GesamtCholesterinwerte bei 78%, hohe Triglyzeridwerte (> 1,7 mmol/L) bei 29%, ein hoher systolischer und/oder diastolischer Blutdruck (> 140/90 mmHg) bei 32%, Nüchternblutzuckerwerte > 6,1 mmol/L in 15%, sowie ein erhöhter Taillenumfang (> 88 cm) bei 85,8% der Patienten erhoben. 18,3% der Patientinnen waren und blieben Raucher. Nach 12 Monaten besserten sich alle Laborparameter und der Blutdruck signifikant. Sowohl die Beurteilung sowohl durch das Framingham System als auch durch das SCORE System ergaben eine deutliche Besserung im kardiovaskulären Risikostatus. Die Anzahl der Patientinnen mit einem metabolischem Syndrom sank bis zum Ende der Studie signifikant. Schlussfolgerungen: Ein Screening von postmenopausalen Frauen auf kardiovaskuläre Risikofaktoren, Correspondence: Dr. Zoltan Vajo, MD, PhD., Gledicsia u 11, Erd 2030, Hungary, E-mail: [email protected]

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sowie die Anwendung professioneller Leitlinien zur Primärprävention kann das Risiko einer koronaren Herzerkrankung signifikant reduzieren. Die Compliance der Patientinnen, bei den Kontrollen zu erscheinen, muss aber unbedingt erhöht werden. Summary. Objective: Our aim was to evaluate the usefulness of screening for cardiovascular risk factors and the effect of applying professional guidelines for risk reduction in postmenopausal women, as judged by the Framingham and the high-risk systematic coronary risk evaluation (SCORE) methods. Methods: 18 menopause clinics in Hungary participated in the study, enrolling a total of 2789 patients. Physicians were asked to follow professional guidelines for the primary prevention of cardiovascular disease. Patients were requested to attend follow-up every four months for 12 months. Results: The mean age of the patients was 56.7 ± 6.9 years, and the time elapsed since the last menstrual period was 9.2 ± 7.2 years. Overall, 29.4% of patients attended at least one follow-up visit. At the initial visit, high total cholesterol level (> 5 mmol/l) was detected in 78% of patients, high triglyceride level (> 1.7 mmol/l) in 29%, high systolic and/or diastolic blood pressure (> 140/90  mmHg) in 32%, fasting plasma glucose level > 6.1 mmol/l in 15%. Increased waist circumference (> 88 cm) was found in 85.8% of the patients; 18.3% of the patients smoked, which did not change. After 12  months, all laboratory parameters and the blood pressure had improved significantly. Both the Framingham and SCORE systems showed a significant improvement in the cardiovascular risk status, and the rate of metabolic syndrome had decreased significantly by the end of the study. Conclusions: Screening postmenopausal women for cardiovascular risk and the application of professional guidelines for primary prevention may significantly reduce the risk of coronary artery disease in this group. Patient compliance with follow-up visits needs improvement.

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Key words: Postmenopausal, cardiovascular, risk, cholesterol, blood pressure.

Introduction Cardiovascular disease (CVD) is the leading cause of death and disability in most western industrialized countries including the USA, cutting across all ethnic, racial and gender groups. Despite the tremendous body of research to support the efficacy and cost-effectiveness of CVD prevention, interventions to prevent CVD are universally underutilized. Although there has been an overall reduction in the CVD death rate in the USA over the past few decades, the rate of decline is less for women than men. Age-adjusted rates have declined steadily but absolute mortality (the total number of deaths) has changed little in the past two decades. CVDs are still highly prevalent but have been pushed into older age groups, a trend obscured by age adjustment [1]. CVDs manifest earlier in the lives of men, and much of the focus of research has been on this group. The idea of the MENOpause and CARDiovascular risk (MENOCARD) study was inspired by the above and by the finding that CVD is also the leading cause of death of women, in certain age groups even exceeding the cardiovascular mortality of men [1, 2]. In women, many risk factors for CVD, such as hypertension, abdominal obesity and dyslipidemia, are more prevalent after the menopause, and the outcome of CVD is worse among these women than among men [3–5]. This also applies to Hungary, in central Europe, as evidenced by morbidity and mortality reports [6]. In addition to the above, the proportion of women who smoke has not been decreasing in Hungary, unlike the decrease in the USA [6]. Our aim was to evaluate the usefulness of screening for cardiovascular risk factors in postmenopausal women and the effect of applying professional guidelines for risk reduction, as judged by two widely recognized estimating systems, the Framingham and the systematic coronary risk evaluation (SCORE) methods [7, 8].

Methods Patients A total of 18 menopause clinics in Hungary participated in the study. Patients were enrolled between 1 May and 31 December 2004. Study participants were postmenopausal women presenting at the clinics with menopause-related complaints or intending to volunteer for the study after learning about it from the media. After taking the history, physical examination and laboratory tests, patients without evidence of CVD but with at least two cardiac risk factors were enrolled in the study. The risk factors were cigarette smoking, hypertension (blood pressure > 140/90 mmHg or on antihypertensive medication), low HDLcholesterol (HDL-C < 40 mg/dl; 1.02 mmol/l), family history of premature coronary heart disease (in male first-degree relative < 55 years or female first degree relative < 65 years), age (> 55 years), and history of diabetes mellitus. HDL-C > 60 mg/dl (1.54 mmol/l) was counted as a negative risk factor. Cardiovascular risk was calculated according to the Framingham and high-risk SCORE systems [7, 8]. wkw

Blood pressure (BP) was measured at clinic visits by certified staff using standardized procedures and instruments; it was measured in the right arm with a conventional mercury sphygmomanometer after the participant was seated and had rested for 5 minutes. The cuff, of appropriate size based on arm measurement, was inflated to 30 mmHg above palpated systolic BP, which was defined as the pressure level at which the first of ≥ 2 knocking sounds occurred in appropriate rhythm. Diastolic BP was the phase V Korotkoff value (disappearance of sound). The average of three readings, obtained at least 30 seconds apart, was used in the analysis. Hypertensive patients were defined as those who reported being told by a doctor that they had high blood pressure and were currently taking hypertension medicine and/or they had a clinic BP ≥ 140 mmHg systolic and/or BP ≥ 90 mmHg diastolic. Women who reported a diagnosis of hypertension but were not currently on blood pressure medication and did not have elevated pressures at the visit were classified as having unconfirmed hypertension. Those having neither a physician diagnosis nor elevated pressures constituted the remainder and were considered normotensive. Treated hypertensive patients were defined as those among the hypertensives who responded yes to the following question: “Do you now take medication for high blood pressure?” All medication was confirmed by checking the patients’ charts and medication bottles. Smoking habits were addressed by a questionnaire. Serum lipid and plasma glucose were measured using standard methods in an automated laboratory system (Hitachi 747 automatic analyzer). Waist circumference was measured using a narrow steel tape at the umbilicus, and also at end expiration after pushing out and relaxing the abdominal wall. Physicians were asked to follow the generally accepted professional guidelines of the American Heart Association (AHA) for primary prevention of CVD [9]. Briefly, the goals were as follows. Smoking goal: complete cessation. BP control goal: < 140/90 mmHg or < 130/85 mmHg if renal insufficiency or heart failure present or < 130/80 mmHg if diabetes present. Blood lipid management primary goals: LDL-C < 130 mg/dl (3.38 mmol/l) if ≥ 2 risk factors present and 10-year risk of coronary heart disease < 20%, or LDL-C < 100 mg/dl (2.6 mmol/l) if ≥ 2 risk factors present and 10-year risk ≥ 20% or if patient has diabetes. Additional lipid goals for therapy: triglycerides < 150 mg/dl (1.65 mmol/l) and HDL-C > 50 mg/dl (1.28 mmol/l). The weight management goal was to achieve and maintain a waist circumference ≤ 35 inches (89 cm) at iliac crest level; the glucose management goal was to achieve normal fasting plasma glucose (< 110 mg/dl, 6.1 mmol/l). Interventions were also as recommended in the AHA guidelines [9]. Briefly: physicians were asked to promote a healthy lifestyle: weight reduction; reduction of sodium intake; consumption of fruits, vegetables, and low-fat dairy products; moderation of alcohol intake; and physical activity in persons with systolic BP ≥ 130 mmHg or diastolic BP 80 mmHg. For persons with renal insufficiency or heart failure, physicians were asked to initiate drug therapy if systolic BP was ≥ 130 mmHg or diastolic BP 85 mmHg (≥ 80 mmHg diastolic for patients with diabetes). Physicians were also asked to initiate drug therapy for those with BP ≥ 140/90 mmHg if 6–12 months of lifestyle modification was not effective, depending on the number of risk factors present, and to add BP medication individualized to other patient requirements and characteristics such as age, race or the need for drugs with specific benefits. If LDL-C was above goal range, physicians were asked to rule out secondary causes by testing liver function, thyroidstimulating hormone level and urinalysis. After 12 weeks of therapeutic lifestyle change, physicians were asked to consider LDL-lowering drug therapy if ≥ 2 risk factors were present, the 10-year risk was > 10% and LDL-C ≥ 130 mg/dl (3.33 mmol/l), or if ≥ 2 risk factors were present, the 10-year risk was < 10% and the LDL-C ≥ 160 mg/dl (4.1 mmol/l). Physicians were asked

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to start drugs and advance the dose to bring LDL-C to goal range, usually with a statin but also to consider bile acid–binding resin or niacin. Also, if the LDL-C goal was not achieved, physicians were asked to consider combination therapy (statin+resin, statin+niacin), and after the LDL-C goal had been reached, to consider the triglyceride level: if 150–199 mg/ dl (1.68–2.24 mmol/l) to treat with therapeutic lifestyle changes; if 200–499 mg/dl (2.25–5.6 mmol/l) to treat elevated nonHDL-C with therapeutic lifestyle changes and, if necessary, consider higher doses of statin or adding niacin or fibrate; if > 500 mg/dl (5.61 mmol/l) to treat with fibrate or niacin to reduce risk of pancreatitis. If HDL-C was < 50 mg/dl (1.28 mmol/l), physicians were asked initiate or intensify therapeutic lifestyle changes; for higher-risk patients, to consider drugs that raise HDL-C, such as niacin, fibrates or statins. If fasting plasma glucose was above goal level, physicians were asked to initiate hypoglycemic therapy to achieve near-normal fasting plasma glucose: first step diet and exercise; second-step oral hypoglycemic drugs (sulfonylureas and/or metformin with ancillary use of acarbose and thiazolidinediones); third-step initiation of insulin. Patients were requested to present for follow-up every four months for 12 months (total 4 visits including the first). All patients provided written informed consent to participate in the study. The proportion of metabolic syndrome was evaluated using the National Cholesterol Education Program ATP III criteria (10). Briefly, waist circumference ≥ 88 cm, triglycerides ≥ 150 mg/dl (1.7 mmol/l), HDL-C < 50 mg/dl (1.28 mmol/l), blood pressure ≥ 130/85 mmHg, fasting plasma glucose > 110 mg/dl (6.1 mmol/l). The risk of coronary heart disease was calculated using the Framingham and the high-risk SCORE systems [7, 8]. The risk factors included in the Framingham calculation are age, sex, total cholesterol, HDL cholesterol, systolic blood pressure, treatment for hypertension, and cigarette smoking. Age, sex, total cholesterol, systolic blood pressure and smoking status are considered in the SCORE system [7, 8].

Total number of patients (n = 2789)

Group A: Attended at least 1 follow-up visit (n = 821)

Did not present for any followup visits (n = 1968)

Group B: Final visit attended (n = 404)

Final visit not attended (n = 417)

Skipped 1 or 2 visits (n = 46)

Group C: all visits attended (n = 358)

Fig. 1.  Patient groups according to number of follow-up visits attended

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Statistical analysis As continuous variables, the results were given by descriptive methods (means ± SD) and their normality was checked using the Shapiro–Wilk W test. Positively skewed distributions, such as for triglycerides, were converted into normal distribution by taking logs of the original values. Laboratory data and blood pressure values for the patients (grouped according to the number of follow-up visits) were compared using the general linear model to evaluate differences between time points with Tukey’s HSD post-hoc test: during follow-up, times were compared with a two-way repeated-measures procedure (group x time) with random effects (clinics). The covariate was age. Risk data (Framingham and high-risk SCORE) and change in the occurrence of metabolic syndrome were analyzed in the general linear model. To evaluate differences between time points with Tukey’s HSD post-hoc test, the follow-up times were compared in a three-way repeated-measures procedure (risk group x group x time) with random effects (clinics). The covariate was age. The proportion of patients with metabolic syndrome by ATP III criteria in the three groups at the start and end of the study was analyzed by the difference between two proportions [11]. Differences were considered statistically significant at P < 0.05. All statistical tests were two-sided. The SAS statistical software package SAS/STAT, Software Release 9.1.3 (SAS Institute Inc., Cary, North Carolina 27513, USA) was used for each analysis. Descriptive statistical methods (mean ± SD) were used for population data and laboratory test results. Laboratory data were compared using paired two-sample t-tests. Framingham and SCORE risk data and change in the occurrence of metabolic syndrome were analyzed using chi-squared (χ2) tests. P < 0.05 was considered statistically significant.

Results A total of 2789 women were enrolled and three patient groups were created according to the number of followup visits attended (Fig. 1): Group A (n = 821, 29.4%) consisted of patients attending at least one follow-up (at month 4, 8 and/or 12), Group B (n = 404) completed the first and the fourth (final) visits, their results representing a 12-month follow-up period; Group C (n = 358, 12.8%) attended every follow-up, representing the patients with the greatest compliance receiving the closest follow-up. The effect of treatment according to specific professional guidelines could thus be assessed. The mean age of the patients was 56.7 ± 6.9 years; the time elapsed since the last menstrual period was 9.2 ± 7.2 years. At the initial visit, the following proportions were detected: high total cholesterol level (> 5 mmol/l) in 78% of the patients, high triglyceride level (> 1.7 mmol/l) in 29%, high systolic and/or diastolic BP (> 140/90 mmHg) in 32%. A fasting plasma glucose level of > 6.1 mmol/l was present in 15% of patients and a history of diabetes mellitus in 5.8%. Increased waist circumference (> 88 cm) was found in 85.8% of the patients. LDL-C was > 3  mmol/l in 72% of patients; cigarette smoking was identified in 18.3%. A total of 29.4% of patients attended at least one follow-up. Table 1 shows the laboratory results and blood pressure values for each patient group. Baseline values and changes from baseline were similar for each group. All laboratory parameters except HDL-C levels changed significantly compared with baseline (Table 1). Smok-

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Table 1.  Laboratory and blood pressure values for the three patient groups at the start and end of the study Group

Start (mean ± SD)

End (mean ± SD)

P

A Total cholesterol (mmol/l) LDL-cholesterol (mmol/l) HDL-cholesterol (mmol/l) Triglycerides Fasting plasma glucose (mmol/l) Systolic BP (mmHg) Diastolic BP (mmHg)

6.07 ± 1.07 3.69 ± 0.94 1.57 ± 0.51 1.77 ± 1.22 5.65 ± 1.21 136.94 ± 20.51 85.03 ± 10.48

5.21 ± 0.81 2.98 ± 0.77 1.58 ± 0.41 1.49 ± 1.03 5.51 ± 1.14 129.89 ± 15.67 80.60 ± 8.34

< 0.0001 < 0.0001 0.7278 < 0.0001 < 0.0001 < 0.0001 < 0.0001

B Total cholesterol (mmol/l) LDL-cholesterol (mmol/l) HDL-cholesterol (mmol/l) Triglycerides Fasting plasma glucose (mmol/l) Systolic BP (mmHg) Diastolic BP (mmHg)

6.06 ± 1.02 3.66 ± 0.90 1.64 ± 0.55 1.66 ± 0.95 5.58 ± 0.88 135.44 ± 20.14 85.86 ± 9.89

5.07 ± 0.77 2.81 ± 0.76 1.68 ± 0.44 1.39 ± 0.71 5.41 ± 1.01 128.82 ± 15.67 81.12 ± 8.53

< 0.0001 < 0.0001 0.1806 < 0.0001 < 0.0001 < 0.0001 < 0.0001

C Total cholesterol (mmol/l) LDL-cholesterol (mmol/l) HDL-cholesterol (mmol/l) Triglycerides Fasting plasma glucose (mmol/l) Systolic BP (mmHg) Diastolic BP (mmHg)

6.08 ± 1.04 3.63 ± 0.85 1.67 ± 0.56 1.65 ± 0.96 5.69 ± 0.84 133.58 ± 19.92 85.60 ± 9.93

5.03 ± 0.74 2.76 ± 0.73 1.71 ± 0.45 1.34 ± 0.71 5.38 ± 0.72 127.52 ± 14.95 80.64 ± 7.52

< 0.0001 < 0.0001 0.1844 < 0.0001 < 0.0001 < 0.0001 < 0.0001

ing habits did not change during the study period. Waist circumference was 99.75 ± 11.73 cm at the start of study and did not change. In comparison with baseline, both the Framingham and high-risk SCORE risk estimation systems showed a statistically significant improvement in the cardiovascular risk status for all three groups of patients (Figs. 2–4). The level of improvement was similar in all the groups. The proportion of metabolic syndrome at the start and end of the study is shown in Fig. 5 for the three groups and decreased significantly in all of them.

Discussion To our knowledge, this is the first study from Hungary, in central Europe, or from any of the former socialist countries, on cardiovascular risk assessment and primary prevention of CVD in postmenopausal women. Because the risk of CVD increases with age, there is a need for increased awareness of the importance of CVD as a major public health issue for older women. In the present study the impact of the application of professional guidelines for primary prevention of CVD was most apparent in the lipid and BP values. Both systolic and diastolic BP values decreased significantly, as did total and LDL-C, as well as triglyceride levels. Of note is that in our patient population the mean level of wkw

HDL-C did not change during the study; however, it was above the goal even at the beginning of the study. The scores in the Framingham and high-risk SCORE global risk estimation systems also significantly improved by the end of the study when compared with baseline. This can be attributed to the decrease in total cholesterol levels and in BP, since the age and sex of the patients did not change. HDL-C levels and smoking habits also remained unchanged. It is noteworthy that in our study the proportion of current smokers was 18.3%, whereas in the Women’s Health Initiative it was found that only 7% of postmenopausal women currently smoke in the USA [12]. The metabolic syndrome is a matter of immense concern for atherosclerosis prevention [13]. Key features are visceral obesity, dyslipidemia, hyperglycemia and arterial hypertension. Persons with the metabolic syndrome are essentially at twice the risk for CVD compared with those without the syndrome. The decrease in serum triglyceride levels, fasting plasma glucose levels and BP values explain the reduced rate of metabolic syndrome we found at the end of the study. We observed no significant change in waist circumference and HDLC levels, the other parameters included in the diagnostic criteria of metabolic syndrome by the ATP III [10]. It is interesting that among the women identified as at risk for CVD, fewer than 30% attended one or more

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Framingham

Score

250

350 300

Group A, end

Group A beginning

250

Group A, end

Number of patients

Number of patients

200

Group A beginning

150 100 50

200 150 100 50

0

0 0

5

10

15

20

25

0

risk

5

10 score

15

20

Fig. 2.  Risk assessment of Group A at the start and end of the study (P < 0.0001 for all) Score

160

160

140

140

120

Group B baseline

100

Group B end

120

Group B baseline

100

Group B end

Number of patients

Number of patients

Framingham

80 60 40

80 60 40 20

20

0

0 0

5

10

risk

15

20

0

25

2

4

6

8

10

12

14

score

Fig. 3.  Risk assessment of Group B at the start and end of the study (P < 0.0001 for all) Framingham

Score 140

120

Nummber of patients

Number of patients

140 Group C beginning

100

Group C end

80 60 40 20

120

Group C beginning

100

Group C end

80 60 40 20 0

0 0

5

10

risk

15

20

25

0

2

4

6

8

10

12

14

score

Fig. 4.  Risk assessment of Group C at the start and end of the study (P < 0.0001 for all)

follow-up visits, and only 12.8% of patients completed all scheduled visits. This is probably explained by the fact that in a recent survey only 8% of women identified heart disease as their greatest health concern and fewer than 33% identified heart disease as the leading cause of death [14]. According to a recent study in the USA, fewer than one in five physicians know that more women than men die each year from CVD [15]. Consequently, in the Women’s Health Initiative study, BP was controlled in only

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36.1% of hypertensive postmenopausal women, with lower rates of control in the oldest group [12]. Furthermore, even among high-risk women, only 7–12% attain the AHA’s standards for all lipid fractions, and only onethird receive recommended drug treatment, highlighting the significant opportunities to apply evidencebased recommendations to manage lipid abnormalities in high-risk women [16]. It is important to note that the physicians participating in the present study were specialists (gynecolo-

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5.

6. 7. 8.

9.

Fig. 5.  The proportion of metabolic syndrome by ATP III criteria in the three patient groups at the start and end of the study P < 0.0001 for all groups)

gists working at menopause clinics, consulting cardiologists if needed). A study with primary care physicians is currently being conducted by the authors. Also, the study population was selective as it included women who presented to menopause clinics for menopauserelated complaints and the study design was uncontrolled. Thus, the findings cannot be generalized to the entire postmenopausal population. In conclusion, we suggest that screening of postmenopausal women for cardiovascular risk and application of professional guidelines and therapeutic goals for primary prevention can significantly reduce the risk of coronary artery disease in this patient group, as judged by the Framingham and high-risk SCORE systems. Nevertheless, physician awareness, adherence to professional guidelines and patient compliance all need improvement.

10.

11. 12.

13.

14.

Acknowledgements The authors are indebted to the physicians and centers participating in the MENOCARD program. The MENOCARD study was supported by an unrestricted educational grant from EGIS Pharmaceuticals PLC, Budapest, Hungary.

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Physicians and menopause centers Dr. András Bentzik (County Hospital, Department of Obstetrics and Gynecology, Kecskemét); Dr. László Birinyi (DEOEC, Obstetrics and Gynecology Clinic); Dr. Lajos Erdélyi (City Hospital, Department of Obstetrics and Gynecology, Sopron); Dr. Péter Go ´´cze (PTE, Faculty of Medicine, Obstetrics and Gynecology Clinic); Dr. Marina Hacsunc (St János Hospital, Menopause Clinic); Dr. Gábor Hetényi (St. István Hospital, Department of Obstetrics and Gynecology); Dr. Erno ´´ Huszár (BAZ County Hospital, Department of Obstetrics and Gynecology, Miskolc); Dr. Sándor Koloszár (SZTE, Obstetrics and Gynecol-

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ogy Clinic); Dr. László Ko ´´szegi (Balassa János Hospital, Department of Obstetrics and Gynecology, Szekszárd); Dr. Ádám László (Bajcsy Zsilinszky Hospital, Department of Obstetrics and Gynecology); Dr. Zsolt Likár (Petz Aladár Hospital, Department of Obstetrics and Gynecology, Gyo ´´r); Dr. Zoltán Magyar (SE, Faculty of Medicine, Obstetrics and Gynecology Clinic I); Dr. Judit Nagy (County Hospital, Department of Obstetrics and Gynecology, Kecskemét); Dr. Károly Pap (Jósa A. Hospital, Department of Obstetrics and Gynecology, Nyíregyháza); Dr. János Pomucz (Pándy Kálmán Hospital, Department of Obstetrics and Gynecology, Gyula); Dr. Pál Ruttner (Markusovszky E. Hospital, Department of Obstetrics and Gynecology, Szombathely); Dr. Ferenc Teremi, (Százhalombatta Institute of Health); Dr. György Timmermann (City Hospital, Department of Obstetrics and Gynecology, Sopron); Tamás Tóth (PTE Faculty of Medicine, Obstetrics and Gynecology Clinic).

Consulting cardiologists and centers István Czuriga MD and Katalin Untenberger MD (DEOEC, Clinic of Medicine, Debrecen); Prof. Tamás Forster MD and An-

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drea Vas MD (SZTE, II. Clinic of Medicine, Szeged); Zoltán Hegedu ´´s MD (Sopron Municipal Hospital, Department of Cardiology); Tibor Hídvégi MD (Aladár Petz Hospital, Department of Diabetology, Gyo ´´r); Prof. András Jánosik MD and Géza Gönczi MD (St. János Hospital, III. Department of Medicine, Cardiology, Budapest); Mihály Józan MD (János Balassa Hospital, Department of Cardiology, Szekszárd); Emil Kaló MD (Hospital of BAZ County, Department of Cardiology, Miskolc); András Katona MD (Kálmán Pándy Hospital, Department of Cardiology, Gyula); Prof. Ede Kékes MD (International Medical Services, Budapest); Gábor Késmárky MD (PTE Faculty of Medicine, I. Clinic of Medicine, Department of Cardiology, Pécs); Imre Kovács MD (Markusovszky Hospital, Department of Cardiology, Szombathely); Gabriella Masszi MD (Bajcsy-Zsilinszki Hospital, Department of Cardiology, Budapest); Zoltán Nádházi MD (Semmelweis University Faculty of Medicine, II. Clinic of Medicine, Budapest); András Nagy MD and Attila Kiss MD (Kecskemét County Hospital, Clinic of Medicine); Prof. Aladár Rónaszéki MD (Sándor Péterfy Hospital, Department of Cardiology); Marianna Sváb MD and Péter Polgár MD (Aladár Jósa Hospital, Clinic of Medicine, Nyíregyháza); Zsolt Njúra MD (Százhalombatta Health Institute, Department of Cardiology).

5–6/2009  Cardiovascular risk status and primary prevention in postmenopausal women

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