Prevenția Bolilor Cardiovasculare

Objectives

National Clinical Protocol PCN-423, approved by Moldova’s Ministry of Health in February 2023, provides a life-course framework to prevent and reduce atherosclerotic cardiovascular disease, disability and premature mortality through coordinated public and individual action, active patient participation and multidisciplinary care.[1][2][3]It prioritises primary prevention in family medicine while also strengthening secondary and tertiary prevention, rehabilitation and long-term management of established disease.[4][5][6]

• Estimate total cardiovascular risk and identify high- and very-high-risk people, using SCORE2 for apparently healthy adults aged 40–69 years and SCORE2-Older Persons for those aged 70 years or over, while considering lifetime risk, treatment benefit, comorbidity, frailty, polypharmacy and patient preferences.[7][8][9]
• Prioritise people with established atherosclerotic cardiovascular disease, diabetes, moderate or severe chronic kidney disease, markedly elevated individual risk factors, genetic lipid or blood-pressure disorders, or a family history of premature cardiovascular disease.[10][7][11]
• Reduce modifiable risks through smoking cessation, healthy eating, physical activity, weight management, and control of blood pressure, lipids and blood glucose.[5][12][13]
• Address risk modifiers and associated conditions, including psychosocial stress, socioeconomic factors, chronic inflammatory disease, cancer treatment, chronic obstructive pulmonary disease, sleep disorders, pregnancy-related conditions, frailty and environmental pollution.[14][15][16][17]
• Extend preventive cardiology to children through risk-based identification and management of obesity, dyslipidaemia, hypertension, diabetes risk, unhealthy behaviours and relevant family history.[18][19][20]
• Apply risk-adjusted medication, disease-specific management and cardiac rehabilitation to reduce recurrent events, hospitalisation and cardiovascular mortality among people with established cardiovascular disease.[21][22][23]

Implementation

Implementation is designed to operate across primary care, specialised outpatient services and hospital therapy or cardiology departments, with family doctors and nurses providing routine risk assessment and preventive care alongside cardiologists and other specialists.[2][24][25]Prevention is individualised through shared clinician-patient decision-making, staged treatment intensification and informed discussion of anticipated benefits, adverse effects, costs and patient preferences.[4][8][26]

• Develop institutional protocols from the national protocol, aligned with current international guidance and each institution’s available capacity; protocol development involved the Ministry of Health, Institute of Cardiology and other national clinical, medicines, insurance and expert bodies.[6][27]
• Deliver opportunistic or systematic screening through consultations and population or targeted programmes, including repeat cardiovascular-risk assessment, generally at five-year intervals or earlier when risk is close to a treatment threshold.[28][29][24]
• Use SCORE2 and SCORE2-Older Persons for formal risk stratification, and use residual-risk tools such as SMART, SMART-REACH and DIAL for relevant people with confirmed cardiovascular disease or diabetes after general prevention targets are met.[8][30]
• Provide lifestyle support through individual or group education, behaviour-change techniques, telephone counselling, activity-tracking devices, dietary counselling, smoking-cessation support and family engagement.[31][32][13]
• Apply staged, risk-based pharmacological management, including antihypertensive and lipid-lowering therapy, diabetes therapies with cardiovascular or renal benefit where indicated, antiplatelet or anticoagulant treatment for selected conditions, and referral to cardiology when preventive treatment decisions are uncertain or difficult to implement.[21][33][34][35]
• Deliver supervised, structured, multidisciplinary cardiac rehabilitation after cardiovascular events, revascularisation and in eligible heart-failure patients; improve access through automated referral, electronic scheduling, structured follow-up, home-based rehabilitation, telemedicine and mobile-health interventions.[36][37]
• Equip services with relevant personnel, blood-pressure monitors, electrocardiography, anthropometric and glucose-testing equipment, lipid testing, echocardiography, functional testing, laboratory investigations and access to neurology, nephrology and endocrinology consultation where needed.[25]
• Monitor implementation through protocol performance indicators and a criteria-based medical audit form. Indicators include documented risk assessment, smoking-cessation treatment, lifestyle advice, lipid profiling, blood-pressure control and glycaemic control among patients under family-doctor supervision.[2][38][39]
• Record patient-level assessment, risk classification, investigations, specialist referral, treatment initiation, adherence, monitoring, complications, follow-up frequency and outcomes within the audit framework.[40][41][42][43][44]
• Review the protocol in 2028; the available material does not specify budgets, financing sources, quantified allocations or a comprehensive reporting and accountability framework beyond the described indicators and audit arrangements.[5][25][38][40]

Monitoring & Evaluation

The protocol combines clinical monitoring of individual cardiovascular risk and treatment response with institutional performance measurement and a criteria-based medical audit. It specifies a 2028 review after its 2023 development, but the supplied material does not establish a comprehensive national reporting, surveillance or accountability framework.[2][5][25][40]

• Assess cardiovascular risk repeatedly using SCORE2 for apparently healthy adults in the relevant age groups and SCORE2-Older Persons for older people, while considering lifetime risk, comorbidities, frailty, polypharmacy, risk modifiers, expected treatment benefit and patient preferences.[7][8][11][9]
• Repeat opportunistic cardiovascular-risk screening after five years, or sooner when risk is close to a treatment threshold; the protocol also recommends periodic rather than one-off risk assessment.[28][29]
• Monitor major risk factors through total-risk assessment, including smoking, blood pressure, serum lipids, glucose status, obesity, family history, lifestyle and psychosocial factors.[3][28][14]
• Track clinical targets including blood pressure, low-density lipoprotein cholesterol, fasting glucose and glycated haemoglobin. Illustrative targets include blood pressure below 140/90 mmHg for general prevention and below 130/80 mmHg where feasible for high-risk patients; glycated haemoglobin below 7%; and progressively lower low-density lipoprotein cholesterol targets for higher-risk groups.[5][45][46]
• Monitor treatment adherence, review discharge recommendations after cardiac events or interventions, and evaluate treatment effects after initiation to determine whether intensification is needed.[21][47][8]
• Conduct condition-specific monitoring, including renal disease progression and albuminuria in chronic kidney disease, cardiac dysfunction during cancer treatment, cardiovascular risk in chronic obstructive pulmonary disease, and hypertension or diabetes screening for specified female-specific risk histories.[15][16][17]
• Measure body mass index annually or more frequently for adults who are overweight or obese, use waist circumference to guide weight-management action, and record smoking status within brief cessation interventions.[48][49]
• Apply paediatric screening at defined intervals, including anthropometric assessment and family-history review at consultations from age two, annual blood-pressure measurement from age three, and selective or universal lipid screening at specified ages.[19]

Performance monitoring is explicitly structured around percentage indicators for the population supervised by each family doctor in the preceding year. These cover documented SCORE2 or SCORE2-Older Persons assessment, smoking-cessation therapy, lifestyle advice, lipid profiling, blood-pressure control and glycaemic control.[38][39]

• Calculate indicators as the documented eligible patient group or activity divided by the total family-doctor population, multiplied by 100.[38][39]
• Measure the proportion of people over 40 with a lipid profile in the previous five years, patients under 60 with hypertension and latest documented blood pressure below 140/90 mmHg, and patients with diabetes whose latest glycated haemoglobin is below 7.0%.[38][39]
• Monitor implementation of primary-prevention activities and results, for which a class IIb, level C recommendation is identified.[25]
• Use a medical audit form to record risk factors, investigations, SCORE2 or SCORE2-Older Persons use and correctness, supervision frequency, referrals, complications, comorbidities, treatment initiation, adherence, treatment monitoring and outcomes.[40][41][42][43][44]
• Record outcomes as improvement, no change, progression, myocardial infarction, stroke, other complications or unknown outcome, and record removal from dispensary follow-up, including death.[44]

The extracts identify an audited medical institution and the person completing the audit form, but do not specify reporting frequency, data-quality assurance, evaluation methods, population surveillance, performance targets, responsible reporting bodies or formal consequences for non-performance.[40][38][39]

Costing & Financing

No explicit budgets, costed activities, financing sources, allocations, funding gaps, resource-mobilisation measures or monetary economic assumptions are provided in the supplied extracts. Cardiovascular disease is nevertheless characterised as contributing to health-system costs, and the protocol identifies personnel, equipment and diagnostic capacity needed for implementation.[2][50][25]

• Require delivery capacity across primary healthcare institutions, consultative-diagnostic institutions, and hospital therapy or cardiology departments.[2][25]
• Require family doctors and nurses, cardiologists, functional-diagnostics physicians and nurses, alongside hospital-level access to neurology, nephrology and endocrinology consultations.[25]
• Provide equipment and diagnostic capacity including blood-pressure monitors, stethoscopes, electrocardiographs, weighing and height-measurement equipment, glucometers, cholesterol testing, echocardiography, functional testing and standard laboratory investigations.[25]
• Consider the cost-benefit relationship of risk-factor treatment in shared decision-making, recognising that it depends on treatment effect and duration and that treatment duration is generally longer for younger people.[26]
• Consider cost-effectiveness when selecting non-invasive cardiovascular-risk tests for asymptomatic people.[12]
• Recognise rapid smoking cessation as the most cost-effective strategy for preventing atherosclerotic cardiovascular disease.[9]

The extracts do not quantify the costs of medicines, rehabilitation, screening, laboratory testing, imaging, workforce, equipment or telemedicine, and do not identify whether existing institutional resources are sufficient to meet the protocol requirements.[35][36][25]