Bulgaria urgently needs a National Plan for Cardiovascular Health, which focuses on prevention, early diagnosis, and treatment innovation.
The implementation of proven scientific healthcare solutions, the introduction of digital health technologies, improvements in staff training and more active communication with patient communities are important elements of the vision for cardiovascular health given that cardiovascular diseases are the leading cause of death in Bulgaria.
Those are the conclusions of the first meeting of the National Alliance for Cardiovascular Health, organized by the Bulgarian Society of Cardiology.
The topic of the meeting was "Improvement of health outcomes through anational plan for risk-based management of atherosclerotic cardiovascular diseases."
The meeting was organized in response to the European Society of Cardiology's call for coordinated urgent action to limit mortality caused by cardiovascular diseases in the EU countries and leverage the quality of healthcare European citizens receive.
"The number of premature deaths caused by cardiovascular diseases in Eastern Europe, including Bulgaria, has plateaued while in Western states it is decreasing. We are behind on solving this problem," said Prof. Assen Goudev, Head of the Cardiology Clinic at the University Hospital "Tsaritsa Yoanna - ISUL" and the current President of Bulgarian Society of Cardiology.
Professor Stephan Achenbach who is the current President of the European Society of Cardiology, pointed out that there are 60 million people with cardiovascular disease in the EU, and every year more than 13 million cases are newly diagnosed. He added that 36% of deaths in the EU are due to CVD, while 26% are due to cancer, which proves that cardiovascular disease continues to be the major cause of morbidity and mortality in Europe.
Prof. Achenbach also presented data from Bulgaria as an example of very high risk country, where men are at 8 time's higher risk of death from CVD than male peers in France.
Prof. Achenbach also presented the new European Society of cardiology recommendations for prevention and assessment of cardiovascular risk, adopted after the ESC annual congress in August, 2021. According to this document, EU is divided into low cardiovascular risk countries such as France and Spain and very high cardiovascular risk countries such as Bulgaria. A novelty is the stepwise approach to treatment intensification while dealing with the main risk factors - first to achieve intermediate values of blood pressure, cholesterol and glycaemic control then intensify to the target values.
This recommendations are tool to help physicians and patients pursue these targets in a way that fits patient profiles and preferences and reduces the chance for demotivation of patients when it is difficult to meet the expected target values.
Professor Fausto J. Pinto, President of the World Heart Federation, called for affordable medical care for cardiovascular health through the use of digital technologies. He stressed public attention on the fact that cardiovascular diseases are preventable, detectable and treatable when there is well-developed prevention programs and access to modern treatment. Heart health equity is a building block of every thriving society and a basic right. Catalyzing a movement for better health, inspiring changes in cardiovascular community and generating policies for equitable health care access are the ambitious long term goals of WHF and partners.
"I am asking decision-makers to pay urgent attention to the shortage of specialists in emergency departments and primary care. This problem also affects us, the hospital specialists who try to deal with the consequences of cardiovascular diseases. My further request is related to the two main diagnoses that put substantial strain on our health care system: myocardial infarction and strokes. While we are able to provide modern treatment to patients with cardiac arrest, stroke therapy in Bulgaria is lagging by 15 years. I call for invasive cardiology to also become an integral part of the treatment of ischemic strokes. This is the only way for us to ensure easily accessible, modern and equitable treatment in all parts of the country," commented Assoc. Prof. Vassil Veltchev, the past elected President of Bulgarian Society of Interventional Cardiology (BulSIC).
"Bulgaria still needs a solution with regards to automated defibrillators, which can be positioned in public venues and used to save people who experience the syndrome of sudden cardiac arrest. This issue must be finally resolved. The ordinary public - and not just qualified medics who use these devices - must be trained to provide help in extraordinary situations. The other problem we face is that patients with cardiovascular problems currently seek treatment mainly in hospitals. The Bulgarian Red Cross is about to launch a remote cardiac monitoring project for 500 people in Vratsa region," added Dr. Nadejda Todorowska, Deputy Head of the Bulgarian Red Cross.
"Summary analysis of the healthcare system in Bulgaria - national health indicators" was presented by Assoc. Prof. Michail Okoliyski who is the National Professional Officer at the World Health Organization, Country Office in Bulgaria. United Nations' sustainable development goals prioritize solving certain problems by 2030. One of them is the reduction in the premature mortality rate from cardiovascular diseases by 25%, as well the impact of major risk factors on cardiovascular diseases such as smoking, salt consumption and a sedentary lifestyle. The city of Vidin has the highest standardized mortality rates in Bulgaria, while Sofia has the lowest. This indicates the inequitable access to healthcare services, Assoc. Prof. Okoliyski explained. "Annual prophylaxis examinations are obligatory; however only 38% of the adult population have undergone them. Obviously, the existing controlling mechanisms have not been functioning well."
The Bulgarian Society of Cardiology announced results from an ESTAT study among 1,001 adult Bulgarian citizens showing that 7 out of 10 Bulgarians know that cardiovascular disease is the leading cause of death, disability, and poor quality of life. Younger (up to 39 yrs.) respondents show less awareness and are less likely to monitor their cardiovascular health. Participants in the study rank high blood pressure (84%), high cholesterol levels (80%), family history and smoking (60%) as the most significant factors triggering a predisposition for cardiovascular disease. Meanwhile only 40% of respondents thought age was a determining factor.
"Preventive and health promotion care is under-resourced. Only 2% of the healthcare budget goes on chronic non-communicable diseases," added Assoc. Prof. Okoliyski. The public's lack of awareness about patients' rights and responsibilities is one of the greatest weaknesses in the sector. The rate of hospitalization in the country is 315 per 1000 people, which is much higher than the EU average, and this is partly due to the underdevelopment of preventive healthcare services. There are no clinical pathways for the prevention of socially significant diseases such as hypertension, acute coronary syndrome, and diabetes. There are no integrated national pharmaceuticals' policies. The high ratio of out-of-pocket payments creates challenges for adhering to medical products' prescriptions. Bulgaria ranks 4th among the EU countries with the highest pharmaceutical expenditures per capita.
"30% of hospitalizations come from hospitals which are technologically inept and skew the overall hospitalization statistics. What we need is technologically advanced hospital assistance on top of the well distributed structures," said Dr. Ivan Madjarov, Chairman of the Bulgarian Medical Association Board. "The level of individual patient responsibility is extremely low. We need a mechanism stimulating the Bulgarian population to attend prophylactic examinations, for example by altering the incentives offered through health insurance."
Prof. Arman Postadjian, President of the Bulgarian Hypertension League, spoke of "healthcare strategy build on risk-based programs for primary and secondary prevention". He said: "Currently primary care physicians have the responsibility to estimate the cardiovascular risk category of their patients - the higher the risk, the more intense the action should be. But, in the absence of financing, this measure does not naturally continue through further check-ups and initiation of target treatment. The term "atherosclerotic cardiovascular disease" must be used more often because it covers an etiologically heterogeneous group of disorders, which however require strict and high quality secondary preventive measures. It's not surprising that Bulgaria is among the few countries globally without a national program for rehabilitation after a cardiovascular event as part of a strategy for long-term care and monitoring," Prof. Postadjian explained.
"The European Society of Cardiology's call for a unified European response to tackle cardiovascular diseases with better prevention, treatment and rehabilitation is timely. To make this happen, we need reliable data. The call to digitalize the healthcare system is also highly relevant. In Estonia, for example, a digital network encompasses all participants in the healthcare system and collects relevant data. In Bulgaria, data collection is used mostly for reimbursement purposes and is quite disconnected. We have some good examples of digital projects, thanks to the enthusiasm of certain nonprofit organizations. Let's hope that we finally implement a national strategy to make sure these good examples increasingly become a reality," said Prof. Ivo Petrov, Head of the Cardiology Clinic at Acibadem City Clinic's - Cardiovascular Center and Chair of the Bulgarian Endovascular Therapy Association.
"The Bulgarian Society of Cardiology participates in European initiatives, so we know that the gathering of data is extremely challenging. We have some epidemiological data at our availability, but we need national registers - this is the road to creating a national strategy for combating the consequences of cardiovascular disease. The state needs to take on the responsibility of administering these registers with the goal of determining the scale of the problem and charting possible solutions," said Assoc. Prof. Maria Tokmakova, head of ward at the Cardiology clinic at University Hospital "St. George"- Plovdiv and past elected president of the Bulgarian Society of Cardiology.
She also highlighted the poor monitoring of resource utilization and variability of quality of care due to lack of established quality performance indicators.
Dr. Alexander Simidchiev is the Head of the Non-invasive Diagnostics Ward at the Ministry of Internal Affairs' Medical Institute. It is his belief that modern medicine relies on good communication within medical teams. "We need to know what took place yesterday, so that we can predict what will happen tomorrow even if we have data on what's currently going on," Dr. Simidchiev said.
He highlighted the detrimental effect of air pollution on wellbeing. According to Dr. Simidchiev, air quality accounts for 50% of all the factors that impact the individual's health.
"Higher morbidity rates are associated with greater pharmaceutical products expenditure and more days of work disability," noted Assoc. Prof. Zornitsa Mitkova from the Center for Competency and Health Analysis at the Medical University-Sofia. The implementation of prevention programs leads to long-term healthcare expenditure savings. "Cardiovascular disease therapy is generally accessible for working people, but we observe higher prescription rates for certain medications. The National Healthcare Insurance Fund's (NHIF) expenditures grow even though the medicinal products' prices have not shifted. Funding of the current approach to the treatment and prevention of arterial hypertension by NHIF results in to 300,000 BGN annual savings while funding for a treatment that will result in 1 % decrease in glycated hemoglobin leads to savings of up to 20 million BGN over a 4-year period," she added.
"The impact of patients is rising with the improvement of the level of public awareness. Maintaining a healthy lifestyle is a personal responsibility within the broader framework of public healthcare. We cross the boundaries of personal responsibility with cardiovascular diseases," said Hristina Nikolova, who is a NHIF Supervisory Board Member. Her conviction is that the primary prevention of cardiovascular disease and the promotion of healthy lifestyle choices needs to start in childhood and should involve institutions outside healthcare (Ministry of Education, Ministry of Sport, Ministry of Economy, etc.).
"The Bulgarian Society of Cardiology has always insisted on evidence-based medical care. We have advocated the implementation only of proven and cost-effective solutions before the NHIF. .However, retrospectively, our recommendations were routinely neglected. We hope that, finally, the decision-making institutions will start to heed the opinions of the scientific community. We cannot allow ignorance to dominate given that we strive towards modernization. The European plan for cardiovascular health does not focus only on prevention and I hope that we will get the chance to introduce innovative therapies in partnership with the NHIF and Bulgarian Medical Association so that they may meaningfully contribute to a safe, effective and equitable healthcare," Prof. Goudev commented.
"The big problem is that the Bulgarian healthcare system represents an inverted pyramid. We are facing a severe shortage in the number of general practitioners. There is also a chronic shortage in the number of available nurses. We need improved databases and digital healthcare solutions. If we want to deliver efficient management of cardiovascular diseases at a population level, we need a systemic change at every level of the system along with improvement in the quality of medical education. Simply providing patients with medical information is not enough," said Prof. Snejana Tisheva, Head of the First Cardiology Clinic at the University Hospital "Dr. G. Stranski" in Pleven. She encouraged patient organizations to be more active in the pursuit of public health goals.
Assoc. Prof. Vasil Traykov, Head of Department at Acibadem City Clinic Tokuda Hospital Sofia and Chair of the Bulgarian Association for Cardiac Stimulation and Electrophysiology focused the discussion on sudden cardiac death syndrome and the need for population training in cardio-pulmonary resuscitation. "The sooner the life-saving intervention is performed, the greater the chance of survival. Patient organizations can do a lot to help," he said.
"Digital healthcare solutions impact time spans and information. Healthcare is one of the strategic sectors without a clear vision for digitalization. Digitalization of the healthcare system should be at the foundation of the updated National Healthcare Strategy (2021-2030). We developed a detailed strategy for digitalization based on good examples from other European countries," Mira Ganova, CEO of the Digital Health and Innovation Cluster Bulgaria said.
"Remote monitoring and data collection innovative solutions complement the traditional treatment process and help to address the existing regional inequities in access to healthcare service. We need to encourage the implementation of digital technologies by introducing them both to our colleagues and the general public. Digital technologies provide tools for big data analytics that can support the actions of clinical and policy decision makers for value-based healthcare delivery under the framework of population health management," said Assoc. Prof. Kiril Karamfilov, Head of the Cardiology Clinic at University Hospital "Aleksandrovska", Sofia.
"Innovation needs to assist patients and simultaneously raise enthusiasm among younger physicians, many of whom are experiencing burnout syndrome. We are either going to face the 21st Century's challenges or come to terms with being last in healthcare rankings," Prof. Goudev concluded.