Dr. Péter Ofner, Former Director of the Gottsegen Hungarian Insititute of Cardiology, shares his insights on the cardiological capabilities of the institute, the epidemiological profile of the country, the collaborations with industry players, and outlooks for the future of this field as well as the country.
Can you introduce the Gottsegen Hungarian Institute of Cardiology?
The Institute was founded in 1957 by Dr György Gottsegen who was the only internal medicine specialist in Hungary at that time. He was a visionary as he realized that without invasive diagnostics, modern cardiology could no longer exist. His idea was to centralize all cardiology capabilities and expertise in a building: cardiac centre as we know them today are organisations of recent years.
This institute encompasses all cardiological profiles with a pediatric centre catering to congenital problems and one dedicated to adult cardiology. A lot of patients who have reached adult age who are in need of complex heart operation such as intervention cardiology, coronary replacements, and electrophysiology. With more than 10,000 inpatients and 50,000 out-patients per year, the adult cardiology department is the busiest tertiary referral center in Hungary. In addition, the pharmacological division is also very active, with 57 international clinical trials done last year and still ongoing.
Heart complications and disease are the biggest issues in Hungary and lead to arteriosclerotic coronary problems when left untreated. Hence, the institute launched the myocardial infarction registry more than ten years ago. With the 10,000 myocardial infarctions a year, the countrywide database produces detailed data on the pre-hospital phase, hesitation time, transport time, door-to-balloon time, and on the medications upon discharge. Additionally, it can follow drug compliance of these 100,000 ST-Elevation Myocardial Infarction (STEMI) cases and accurately assess the 30-day and one-year mortality rate. This tool allows the institute to assess the areas it performs well, which seems to be the hospital phase. We have 20 intervention centres in the country and in case of emergency, every Hungarian citizen can reach a cardiac centre within an hour. When assessing the door-to-balloon time and the 30-day mortality, it is comparable with European standards.
However, Hungarians suffer from higher rates of diabetes and hypertension compared to the rest of the European countries. Hence, patients have more health complications, and these are all factors that increase the risk of infarctions. When we did a comparison with SWEDHEART, the one-year mortality revealed to be an area of improvement, as patients who suffered from non-ST-Elevation Myocardial Infarction (NSTEMI) during the intervention were missed.
Preventative drugs taken by patients is also an area that needs to be improved: patients who are discharged adhere to 80-90 percent of all recommended drugs, but after a year that number drops to 20 percent. Patient education seems to be an important issue in this country and is directly correlated to adherence and recurring diseases and complications.
What are the main contributors to the high rates of cardiovascular diseases?
This is not only an issue with Hungary but for the whole of Eastern Europe. It is only recently that the countries have experienced a social-political change, compared to western Europe. There is a maladaptation of a new lifestyle, where people do not pay attention as closely to what they eat, drink, or how much they smoke. The numbers are dropping but it remains still high compared to European averages. If there is no knowledge, no potential, or incentives to do better, then it allows for these elements to exasperate cardiovascular diseases. These health crises are symptoms of social issues which are complex nature and take time to change.
How much is the government prioritizing cardiovascular health?
The government supports cardiovascular health by emphasizing preventative measures and screening programs. However, the efforts are not sufficient as the ecosystem is still not strong enough for every citizen to have access to. There are labour shortages in medical practices and infrastructure, which do not channel every citizen through the healthcare system. It is a comprehensive issue which needs to have a multi-faceted approach in order for these initiatives to produce the desired results. There are economic and financial factors in place that preceded the healthcare system which need to be resolved beforehand in order to implement effective initiatives. Nevertheless, the healthcare system is making progress in the right direction, and the field of cardiovascular has made strides over the last 30 years. Intervention possibility is an important topic in Europe, and if there 20 centres in a small country like Hungary, it indicates that the population has good access to cardiac care.
Is it the role of the government or doctors and health institutions to improve the healthcare environment?
Both. Either side has access to resources that the other party can use to improve the healthcare system. Pharmaceutical companies are also stakeholders and have means to shape the ecosystem as well. Therefore, it is important to create a dialogue between them in order to improve the entire health value chain and, inadvertently, the system. The institute sets itself apart from other centres through education by focusing on clinical practices and preventative measures. These areas are the ones it can impact the most and improve the healthcare system.
How prominent are cardiovascular clinical trials in the country?
The institute is engaged in 57 international trials, and it remains for pharmaceutical companies an interesting area. Cardiovascular is a field where all leading pharmaceutical companies present are involved in clinical trials, as it is the most significant epidemiological health issue. The country is ready to accept more trials and the infrastructure, as well as the manpower, are present to conduct them. However, compared to 10 or 20 years ago there are not as many new cardiac drugs that are released in the market, with exception coagulants. Lipid, statin, and antibody trials are limited compared to large scale intervention trials. There is a change in the focus of trials, shift from drug trials to device, catheterization, and intervention procedure trials.
To what extent is the institute collaborating with the industry?
The institute is collaborating with a myriad of industry players, ranging from pharmaceuticals to medical devices producers. The extent of this is both in theory as well as in practice, meaning that serves as an advisor during the development of cardiovascular products and in its practical application. Myotic valve replacement is a new field of cooperation, as it is an expertise that we want to strengthen.
What are the future priorities of the institute?
The future of cardiovascular treatments is with microsurgical intervention and improving heart failures. Coronary interventions massively tax the patients and if invasiveness can be reduced, this would translate in a faster recovery. Nevertheless, there are instances that patients are saved through these interventions, but there is still a risk that they succumb to heart failure due to myocardial damage. Heart failure rates are even worse than malignancies. For this, artificial heart programs, pacemaker therapies, and heart transplants could be a solution to mitigating this issue.
Do you have a final message?
Hungary is a good position as it has the luxury to observe the best practices of the first adopters such as the United States and Europe. It has the luxury to learn from their mistakes and adopt positive outcomes. No other medical profession has made such strides over the past decades like cardiology. I am very optimistic about the future of this field, but also its development in Hungary. It has had a tremendous impact on society and it is moving in the right direction.
