1Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
2London School of Hygiene and Tropical Medicine, London, UK
3Hospital Universitario Gregorio Maranon, Madrid, Spain
4Policlinico S. Matteo, Pavia, Italy
5Clinical Epidemiology Unit, Erasmus MC, Rotterdam, The Netherlands
6Hopital Europeen Georges Pompidou, Paris, France
7Hopital Cardiovasculaire et Pneumologique Louis Pradel, Lyons, France
8Herzzentrum Luwigshafen, Ludwigshafen, Germany
9University of Newcastle upon Tyne, UK
10Adelaide and Meath incorporating National Children's Hospital, Dublin, Ireland
11Institute of Cardiology, Warsaw, Poland
12Aarhus University Hospital, Denmark
13University Medical Centre St Radboud, Nijmegen, The Netherlands
Received 9 June 2004; revised 29 November 2004; accepted 9 December 2004; online publish-ahead-of-print 16 February 2005.
* Corresponding author. Tel: +44 20 73518289; fax: +44 20 73518643. E-mail address: c.daly{at}rbh.nthames.nhs.uk
See page 949 for the editorial comment on this article (doi:10.1093/eurheartj/ehi294)
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Abstract |
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Methods and results Consecutive patients, 3779 in total, with a clinical diagnosis of stable angina by a cardiologist were enrolled. After initial assessment by a cardiologist, 78% were treated with aspirin, 48% with a statin, and 67% with a beta-blocker. ACE-inhibitors were prescribed by the cardiologist in 37% overall. Revascularization rates were low, with only 501 (13%) patients having PCI or coronary bypass surgery performed or planned. However, when restricted to patients with coronary disease documented within 4 weeks of assessment, over 50% had revascularization performed or planned. Among other factors, the national rate of angiography and availability of invasive facilities significantly predicted the likelihood of revascularization, OR 2.4 and 2.0, respectively.
Conclusion This survey shows a shortfall between guidelines and practice with regard to the use of evidence-based drug therapy and evidence that revascularization rates are strongly influenced by non-clinical, in addition to clinical, factors.
Key Words: Stable angina Pharmacological therapy Secondary prevention Coronary revascularization
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Introduction |
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With regard to pharmacological treatment of angina, there are innumerable studies of the effect of common anti-anginal drug classes (beta-blockers, calcium antagonists, and nitrates), or combinations thereof, on either symptoms or markers of ischaemia, silent or symptomatic, ambulatory or provoked.7,1113 Yet despite the high prevalence of angina and frequent need for anti-anginal drug therapy, there are relatively few studies of the prognostic effect of anti-anginal drug therapy, and even fewer with long-term follow-up. Beta-blockers are recommended as first line maintenance6,7,8 therapy (after pro re nata nitrate) for patients with stable angina on the basis of results from post-MI studies extrapolated to the stable angina population.
The 1997 European guidelines on the management of angina suggest that revascularization should be considered in patients who will benefit prognostically,14 or in whom symptoms are not controlled by medical therapy.
The purpose of this survey was to examine the initial management of newly presenting stable angina in its totality, including the adherence to guidelines and evidence-based practice in the pharmacological treatment of angina, and to attempt to examine some of the factors predictive of the decision to revascularize.
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Methods |
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The patient population was composed of patients at a new presentation to a cardiologist in whom a diagnosis was made of stable angina, caused by myocardial ischaemia due to coronary disease based on clinical assessment, and who did not have unstable angina. A new presentation was defined as a first ever presentation to a cardiologist, or new referral or re-referral after a period of at least 1 year of not attending (consulting) a cardiologist. Patients who required hospitalization within 24 h of the initial consultation, and were therefore considered likely to have unstable angina in a proportion of cases, were excluded from the survey, as were patients who had a prior history of revascularization, either percutaneous or surgical, or aetiology other than coronary disease, for example significant aortic stenosis, or hypertrophic cardiomyopathy. For all patients, the immediate medical treatment recommended, and follow-up arrangements were recorded. Anti-anginal drugs were defined as drugs intended to alleviate symptoms or ischaemia, such as beta-blockers, calcium antagonists, nitrates, nicorandil, or metabolic agents such as trimetazidine. In the case of guideline recommended treatments (anti-platelet therapy, statin therapy, and beta-blockade) not being prescribed, the investigator was asked to select a reason why the drug was not prescribed. The results of investigations performed, and changes to the initial management plan, including revascularization procedures performed or planned, were also recorded 4 weeks after assessment.
Data management
The data were collected electronically by the investigators and stored centrally at the European Society of Cardiology based in Nice, France. The data collection software ran initial consistency checks at data entry level, with further checking performed by submitting the database to consistency checks as per a pre-written validation plan using SAS software. Missing or inconsistent values were thus highlighted automatically and queried by the data management team using phone or e-mail contact with the investigators.
Statistical analysis
Regional analyses of treatment initiated were performed according to the North, West, Central, and Mediterranean divisions as previously used in EHS methodology. Descriptive statistics were used to quantify the frequency of use of pharmacological and other treatments at presentation. The Student's t-test or ANOVA technique were used as appropriate to test differences in quantitative measures, and the 2 test was used to test differences in proportions. Two-sided P values are reported with 0.05 used as critical value to define statistical significance. Logistic regression was employed to define determinants influencing early (within 4 weeks) decision to pursue a revascularization strategy. Forwards and backwards stepwise procedures were used to select the most significant predictors of early revascularization, using P=0.05 as the significance level to enter, and P=0.05 as the significance level to stay. Variables considered included clinical details such as age and sex, type of centre, co-morbidity, symptom severity and duration, prior anti-anginal drug therapy, the result of exercise or other stress testing, and the rate of angiography stratified as high or low according to the median rate in the country. Separate multivariable analysis was carried out for the countries which had a high rate of referral for coronary angiography (>median) and those which had a low rate of referral (<median). This method avoids problems due to intra-regional heterogeneity in angiography rates, and reflects the general type practice within the national health service, and whether invasive or conservative practice is adopted (in terms of angiography at least). It is similar to methods used in previous analyses of treatment and outcome in acute coronary syndromes according to prevailing rates of PCI.15 All analyses were undertaken using STATATM statistical software.
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Results |
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Immediate medical therapy recommended
Prior to cardiology assessment, 49% of patients were taking aspirin and 22% of patients were taking a statin. Table 1 shows the frequency of use of secondary prevention and anti-anginal drugs in individual participating countries, after initial assessment by a cardiologist. The frequency of use of other cardiovascular medication is described in Table 2. After assessment by a cardiologist, 81% of patients were taking or were recommended an anti-platelet agent, 78% aspirin. A statin was prescribed in 48%, beta-blockers in 67%, and 61% were on a nitrate. Only 27% were taking a calcium channel blocker and, with few international exceptions, the use of nicorandil and metabolic agents such as trimetazidine or ranolazine was limited to a small percentage of cases. The majority of patients (59%) were on two or more anti-anginal drugs after assessment by a cardiologist, and only 13% were on no anti-anginal drug (Figure 1). The number of anti-anginal drugs per patient did not differ according to sex, but increased significantly with age up to 70 years (P0.002 for each decade increase in age up to 70 years). The intensity of anti-anginal drug therapy was also related to the severity of symptoms, with those with less severe symptoms [Canadian Cardiovascular Society (CCS) Class I] more likely to be on no anti-anginal medication, and those with more severe angina (CCS Class III) more likely to be on several drugs after assessment (P<0.001 for trend). There were 307 patients with unclassified symptoms, of whom half were not prescribed anti-anginal therapy. For the majority of these patients (66%) the reason for not initiating beta-blockade was recorded as awaiting investigations.
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ACE-inhibitors were prescribed in 40% of patients overall. However, the rate of prescription was higher (73%) in patients with clinical signs of heart failure. In diabetic patients ACE-inhibitors were also prescribed more frequently, with 56% of patients with diabetes receiving a recommendation for ACE-inhibitor therapy.
Planned follow-up
After initial assessment, a follow-up visit was scheduled with the cardiologist for the majority of patients, 2725 (72%), with a median wait for this visit of 41 days. The median wait for this review appointment varied from 70 days in Northern Europe to 35 days in Central Europe. In total, only a quarter of patients had a definitive management plan (either revascularization or conservative management with all investigations completed) in place 4 weeks after initial assessment. The remainder of patients continued to await one or more investigations 4 weeks after assessment, or were observed for clinical progress before further management was instituted (Table 4).
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Because of the substantial variation in the rates of referral for coronary angiography between countries, separate analysis was carried out for the countries which had a high (>median) rate of referral for coronary angiography and those which had a low (<median) rate of referral (Table 8). A positive exercise test and sex were independently predictive of the use of revascularization in both circumstances. The availability of invasive facilities on site was also a predictive factor in countries with high national rates of angiography.
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Discussion |
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Anti-anginal therapy
In terms of specific anti-anginal drugs, beta-blockers and nitrates are clearly the most frequently employed with a smaller, but not inconsequential, proportion of patients on calcium antagonist, and combination therapy the order of the day for the majority of patients. The use of beta-blockers in this study is in line with reported usage in other studies of stable coronary disease.17,18 The small proportion of the population prescribed nicorandil or metabolic agents reflects the less established role of these drugs and a lack of emphasis on their use in the existing European, or even the more recent American, guidelines. It is also likely to reflect the newly presenting nature of the population. Nicorandil in particular has only been shown to reduce the combined outcome of MI, death, and hospitalization for unstable angina on a background of established medical therapy19 and these classes of drugs are frequently reserved for patients who have not successfully achieved symptomatic control with conventional drugs or their combination. In a more chronic stable angina population who would have had symptoms for a longer period, and a longer period in which to try several treatment options, a somewhat greater use of these medications might be expected.
With specific patient contraindications to aspirin, statins, and beta-blockers in only 5, 8, and 10% of the overall population it seems the results of trials of secondary prevention are broadly applicable to the general angina population, although contraindication to statin therapy is higher than might be expected after the results of studies such as the Heart Protection Study20 or Anglo-Scandinavian Cardiac Outcomes Trial,21 where a smaller proportion of patients were not randomized because of patient contraindications.
The fact that appropriate secondary preventative treatment is postponed awaiting the result of further investigation in almost a quarter of patients not commenced on such treatment is another important issue, given that most patients wait more than 6 weeks for clinical review. Although there may be good reason to withhold certain medication, in particular beta-blockers, prior to provocative stress tests, and it is not currently specifically addressed in the guidelines, it would appear reasonable, in the context of waiting periods of more than 1 month for investigations or clinical review, to commence appropriate therapy in a patient with a clinical diagnosis of angina at the time of initial diagnosis. Beta-blockade or other anti-anginal therapy could then be withdrawn for the brief time window required to perform the test if that is the practice within the individual institution.
That only 26% of patients have a definite management plan with all investigations completed within 4 weeks of the initial assessment is of concern and has important public health implications. The waiting times for non-invasive and invasive tests, and outpatient follow-up review are considerable, although the clinical impact of longer waiting times will only become available with follow-up. The scheduling of follow-up visits was subject to several variations in provision of services. It is apparent that in some countries, patients who were due to have invasive or specialized testing such as coronary angiography, myocardial perfusion scanning, or stress echocardiography, were referred onwards for further care without follow-up arranged with the local cardiologist. For example, in the UK, more than half of patients for whom no follow-up appointment had been made were on a waiting list for a coronary angiogram in another institution.
The conservatively managed group, who have had all requested investigations completed, and have been assigned to medical therapy, receive less intensive pharmacological treatment than the revascularization group, with fewer patients receiving either anti-platelet or lipid-lowering therapy, although the use of anti-anginal drug therapy is comparable. Thus, if an excess in cardiovascular morbidity and mortality is observed in the conservatively treated group in the future, it cannot truly be described as failure of treatment but rather failure to treat as these patients have not been optimally medically managed.17 A possible explanation may be that patients in whom the interventional approach is adopted are more likely to be treated in university or teaching institutions, not just with greater facilities, but also with a greater emphasis on evidence-based treatment. It has also been shown in the setting of acute coronary syndromes that the availability of invasive facilities on site increases the likelihood of use of evidence-based secondary preventative therapy.22 A key factor in the success of future European Society of Cardiology guidelines will be their penetration to all strata of health care systems so that such dichotomy in treatment standards is attenuated.
Revascularization
Although the overall revascularization rates seem low, when restricted to those in whom obstructive coronary disease has been documented within 4 weeks of the initial assessment, just over half have been referred for, or have had, a revascularization procedure, mostly PCI. This is substantially greater than the 19% of patients who underwent revascularization during a much longer period of follow-up in Ghandi's study23 of new cases of angina which included unstable angina, or other estimates of revascularization in stable angina2426 and more in line with current studies of ACS.15,2729 The overall number of revascularization procedures in the survey will inevitably rise as time progresses and more patients come to have scheduled angiography performed and analysed; however, as the highest-risk patients on clinical and non-invasive testing were prioritized for earlier angiography, it is likely that the rate of referral for revascularization may decelerate after the first month.
Clinically appropriate reasons for referral such as severe (CCS class III) symptoms or a positive exercise test are independently associated with a 2.5-fold increase in the likelihood of referral for revascularization, but women are only half as likely to be referred for revascularization, even when other potential confounding features such as the results of exercise ECG, are adjusted for. Reports regarding a bias against revascularization in women have previously offered conflicting results.30,31 The results of angiography were not recorded in all patients at the 4-week follow-up and it is not possible to comment on the potential effect of angiographic results on this finding in this study. Type of centre and prevailing national rate of angiography are also independent predictors of revascularization, reflecting the influence of service capacity and availability of on-site revascularization facilities on referral patterns. In centres/countries where there is sufficient capacity to perform angiography promptly, there may be a lower threshold to proceed to revascularization for fiscal as well as clinical reasons.
Limitations
Although this was a survey of stable angina, because assessment by a cardiologist was chosen as the sampling point, the data may not be generalizable to the overall population with stable angina in the community, because of selection bias. However, the population is reflective of the patient profile presenting to cardiologists and suitable for investigation of their management practices. Inclusion in the study was based on the diagnosis of angina by the attending physician, and is thus also open to interpretation bias, but as patient management was based on the working diagnosis of angina, the population is suitable for evaluation of patient management. Because of the existing infrastructure in place at the time this survey was initiated, the survey is somewhat biased towards larger teaching or university-affiliated centres, with more centres with on-site catheterization facilities than would be the case in practice. The enrolment of consecutive patients, the increased recruitment of community hospitals, and the large population recruited over a relatively short period of time have contributed to making this survey as representative of clinical practice in Europe as possible within the constraints of feasibility, and it contributes a truly unique data source to the literature. The numbers of patients from some of the 36 countries which contributed data are too small to be representative of practice in that individual country, but where trends in prevalence or practices emerge between countries in a region, the larger regional sample size is likely to be representative. Finally, given the potential sources of bias in the analysis, the results must be considered as indicative rather than factual. In light of this, and as the nature of the study is exploratory rather than definitive, caution is advised in interpretation of the results, but the findings are nonetheless worthy of consideration and generate important questions as well as providing novel information in this area.
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Appendix |
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EHS Team (European Heart HouseFrance): Malika Manini, Operations Manager; Claire Bramley, Data Monitor; Valérie Laforest, Data Monitor; Charles Taylor, Database Administrator; Susan Del Gaiso, Administrator.
Main Investigator Centre (London, United Kingdom): Kim Fox (Chairman); Caroline Daly (Research Fellow).
Statistical Centre (London School of Hygiene and Tropical Medicine): Felicity Clemens, Bianca de Stavola.
National Coordinators: Austria: Kurt Huber. Belgium: Guy De Backer. Bulgaria: Vera Sirakova. Czech Republic: Roman Cerbak. Denmark: Per Thayssen. Finland: Seppo Lehto. France: François Delahaye. Georgia: Bondo Kobulia. Germany: Uwe Zeymer. Greece: Dennis Cokkinos. Hungary: Kristof Karlocai. Ireland: Emer Shelley. Israel: Shlomo Behar. Italy: Aldo Maggioni. Lithuania: Virginija Grabauskiene. Netherlands: Jaap Deckers. Norway: Inger Asmussen. Poland: Janina Stepinska. Portugal: Lino Gonçalves. Russia: Vyacheslav Mareev. Slovakia: Igor Riecansky. Slovenia: Miran F. Kenda. Spain: José Luis Lopez-Sendon. Sweden: Annika Rosengren. Switzerland: Peter Buser. Turkey: Tugrul Okay. Ukraine: Oleg Sychov. United Kingdom: Kevin Fox.
There was no national coordinator in the participating countries which are not mentioned in the above list.
EHS Board Committee: Maarten Simoons (Chairman), The Netherlands; David Wood (past chairman), United Kingdom; Angeles Alonso, Spain; Shlomo Behar, Israel; Eric Boersma, The Netherlands; Harry Crijns, The Netherlands; Kim Fox, United Kingdom; Anselm Gitt, Germany; Malika Manini, France; Keith McGregor, France; Barbara Mulder, The Netherlands; Markku Nieminen, Finland; Sylvia Priori, Italy; Lars Rydén, Sweden; Luigi Tavazzi, Italy; Alec Vahanian, France; Panos Vardas, Greece; William Wijns, Belgium; Uwe Zeymer, Germany.
List of Industry Sponsors: Servier Laboratories Ltd.
Participating Centres, Investigators and Data Collection Officers: Albania: Ahmet Kamberi, Tirana. Austria: Dagmar Burkart-Küttner, Georg Gaul, Katharina Hohenecker, Vienna. Bosnia & Herzegovina: Vulic Dusko, Banjaluka, Republika Sprska. Belgium: Isabelle Liebens, Bruxelles. Bulgaria: Vera Sirakova, Varna; Valentin Asenov Petrov, Shoumen; Dimitar Raev, Sofia. Belarus: Igor Polonetsky, Nikolay Manak, Minsk. Cyprus: Costas Zambartas, Helen Kleanthous, Loizos Antoniades, Nicosia; Joseph A. Moutiris, Marios Ioannides, Limassol. Czech Republic: Jiri Spac, J. Spinar, Ivana Pirochtova, Tomas Brabec Brno; Renata Kolosova, Frydek-Mistek; Miroslav Rubacek, Ostrava. Germany: E. Blank, G. Sabin, L. Waldelich, Essen; H.M. Hoffmeister, Sollingen; C. Seibold, R. Morell, Fürstenfeldbrück; Frank Rupprecht, Mainz; Norbert Schoen, Muhldorf; Ralf Hewing, Munster; Corinna Lenz, U. Zeymer, Kassel; B. Witzenbichler, Heinz Peter Schultheiss, Berlin; Achim Gutersohn, R. Erbel, S. Churzidse, Essen; A. Gitt, Konstanze Gehrke, J. Senges, U. Zeymer, Ludwigshafen am Rhein. Denmark: Helle Cappelen, Lisette Okkels Jensen, P. Thayssen, Odense C; Jan Kyst Madsen, Marie Seibaek, Copenhagen. Spain: L. Lopez Bescos, Madrid; Luis Hilario Villanueva, Raul Moreno, Rosana Hernandez, Madrid; Fernando Olaz Preciado, M. Soledad Alcasena Juango, Pamplona; Josep M. Alegret, Tarragona; C. Permanyer Miralda, Barcelona; Luis Sosa Martin, San Lorenzo de El Escorial; Maria Irurita Latasa, Las Palmas de Gran Canaria; Josep Sadurni i Serrasolsas, Vic; Juan Ramon Siles Rubio, Norbero Herrera Guttierez, Cabra (Cordoba); Isabel Antorrena Miranda, Villajoyosa; Alicia Bautista Paves, Motril; Antonio Salvador Sanz, Valencia; A. Alonso Garcia, Almudena Castro Conde, Madrid; Francisco Marin Ortuno, Alicante; Maria Jesus Salvador Taboada, Barcelona; Fransisco Epelde Gonzalo, Terrassa; Ignacio Santos Rodriguez, Pedro L. Sanchez Fernandez, Salamanca. Finland: Kirsti Savolainen, S. Lehto, Kuopio. France: Thierry Lefevre, Massy; Jean Jacques Blanc, Brest; Herve Le Breton, Jean Michel Clerc, Rennes. United Kingdom: Alistair Pell, Judith Anderson, Airdrie; Helen Gracey, Jennifer Adgey, Belfast; Bev Durkin, Wakefield; Bronia Ward, Ian Rushmer, Robert Bain, Grimsby; M.A. Memon, Bridlington; R. Muthusamy, Rotherham; R.A. Perry, S. Aziz, Liverpool; Judith Beevers, Paul Brooksby, Pontefract; Christopher Travill, Susan Gent, Luton; J.M. Glancy, Hereford; Graham Ranson, Phil Keeling, Torquay; Steven Lindsay, Bradford; Ali Khaddam, Merseyside; Lesley Davies, William J. Penny, Cardiff; Emma Birks, Sam Kaddura, London; D. Wood, Joanna Tenkorang, London; Fhiona Holland, Jonathan Pitts, St Leonards-on-Sea; Jane Burton, Moira Marriott, Robert Henderson, Nottingham. Georgia: Gulnara Tabidze, Tbilisi. Greece: Nastasia Tsiavou, Athanassios Dritsas, D. Cokkinos, Athens; Christina Chrysohoou, Athens; Ioannis Vogiatzis, Veria; Alexandros Gotsis, Komotini; Dimitrios Psirropoulos, Thelassoniki; Vasilios Kotsis, Athens; Mary Marketou, Heraklion, Crete; Ioannis Skoularigis, Larisa; Evdokia Adamopoulou, Pireus. Croatia: Vjeran Nikolic Heitzler, Zagreb; Ante Samodol, Sibenik; Josip Vincelj, Zagreb. Hungary: Bato Zoltan, Istvan Preda, Budapest. Israel: A. Battler, Alejandro Solodky, Petach Tikva; Aviva Grosbard, Gisella Kon, Beer Sheva; Mohammed Omari, N. Kogan, Nazareth. Italy: Alfredo Galassi, Giuseppe Giuffrida, Catania; F. Naccarella, Stefano Sdringola Maranga, Bologna; Colomba Falcone, Pavia; Giuseppe Sangiorgi, San Donato Milan; Salvatore Novo, Palermo; Giuseppe Ambrosio, Perugia; Carla Boschetti, Francesco Pelliccia, Roma; Francesco De Tommasi, San Giovanni Valdamo; Paolo Testarmata, Ancona; Emanuele Carbonieri, San Bonifacio; Gaetano Nucifora, Paolo Fioretti, Udine; Antonella Muscella, Giacento Pettinati, Casarano; Massimo Villella, San Giovanni Rotondo; Alessandro Boccanelli, Giorgio Bottero, Roma; Dorita Chersevani, Monfalcone; Andrea Albani, Bolzano; Bruno Casiraghi, Seriate; Gabriella Giuliano, Gorizia; Piera Costanzo, De Marie, Rita Trinchero, Torino; Alessandro Desideri, Castelfranco Veneto; Claudio Pandullo, Trieste. Lebanon: Elie Chammas, Beirut. Lithuania: Ruta Babarskiene, Kaunas; Milda Kovaite, V. Grabauskiene, Eugenijus Kosinskas, Vilnius. Vitas Vysniauskas, Marijampole. Latvia: Gustavs Latkovskis, Uldis Kalnins, Riga. Macedonia: Biljana Filipovska Simic, Skopje. Moldova: Eleanora Vataman, Kishinau. Netherlands: Chris Jansen, J. Deckers, GD Rotterdam; Arno Breeman, E. de Swart, Metske van der Wal, AB Zwolle; Henriette Tebbe, R. Brons, KA Meppel; Chris Jansen, Jeroen Vos, EA Rotterdam; Chris Jansen, C.M. Leenders, TD Rotterdam; Chris Jansen, Rotterdam; E. de Swart, Metske van der Wal, Harderwijk; Adrie van den Dool, Heidi Fransen, Robby Nieuwlaat, Maastricht; Henriette Tebbe, M.J. De Boer, Zwolle; Herman Broers, Robby Nieuwlaat, Tilburg; Colinda Koppelaar, M. Bijl, Dordrecht. Poland: Alicja Kowalska, Krystyna Loboz-Grudzien, Wroclaw; Beata Wozakowska-Kaplon, Kielce; Malgorzata Krzciuk, Ostrowiec Swietokrzyski; M. Krzeminska-Pakula, Michal Plewka, Lodz; Anna Lewczuk, Teresa Stefankowska-Olenska, Bialystok; Joanna Bakun, Suwalki; Antoni Torunski, Grazyna Swiatecka, Gdansk; Jaroslaw Krol, Miroslaw Dluzniewski, Warszawa; Elzbieta Zinka, Marek Gksecki, Koszalin; Jerzy Jankowski, Poznan; Krystyna Jaworska, Malgorzata Wagrowska, Urszula Kazmierczak, Torun; Lidia Orzechowska-Slomska, Chelmza; Aleksander Kabara, Golub Dobrzyn; Michal Plewka, T. Waszyrowski, Lodz; Teresa Kawka-Urbanek, Michal Plewka, Pawel Wojewoda, Skierniewice; Piotr Kokowicz, Warszawa; Hanna Kalotka-Kreglewska, Warszawa; Joanna Biegajlo, Warszawa; Jerzy Sacha, Wladyslaw Pluta, Opole; Anna Madro, Teresa Widomska-Czekajska, Lublin; Arkadiusz Stasiewski, Krzysztof Sokolowski, Tadeusz Krzys, Poznan; B. Grzegorzewski, Malgorzata Dudek-Niechcial, M. Pruski, Katowice; Jolanta Surwillo, Przemyslaw Aponowicz, Koscierzyna; Wlodzimierz Krasowski, Gdansk; Michal Szpajer, Gdynia; Bozena Adamczyk, Dabrowa Gornicza; Anna Krol, Lipno; Janusz Kostrzewa, Rypin; Marek Bronisz, Inowroclaw; Wlodzimierz Rajewski, Bydgoszcz; Andrzej Stojek, Irena Kulon, Andrzej Gebala, Krakow; P. Buszman, Kazimierz Radwan, Iwona Szkrobka, Katowice. Portugal: H. Madeira, Luis Sargento, Lisbon; Daniel Ferreira, Rafael Ferreira, Amadora; Joao Carlos Araujo Morais, Leira; Pedro Sarmento, Lisbon; Madalena Teixeira, Vasco Gama Ribeiro, Gaia. Romania: Mircea Ioachim Popescu, Oradea; Bostaca Ioan, Iasi; Codin T. Olariu, Arad; Istvan Albert, Sfantu Gheorge; Anca Dan, Khalid Tammam, Bucarest; A. Iancu, Camelia Stanescu, Cluj-Napoca; M. Dorobantu, Bucharest; D.L. Dumitrascu, Cluj. Georgia: Bondo Kobulia, Gulnara Tabidze, Irina Jashi, Zaza Chapichadze, Tbilisi. Russia: D. Aronov, Elena Tikhomirova, Olga Goudkova, Moscow; Mirolyubova Olga, Arkhangelsk. Sweden: Jan Erik Karlsson, Jokoping; Matthias Lidin, Pia Oblack, Stockholm; K. Aström-Olsson, Lund; Cecilia Dahlen, Falun. Slovenia: Iztok Gradecki, Novo Mesto; I. Kranjec, Katja Prokselj, Ljubljana; Vojko Kanic, Maribor. Slovakia: Eva Hrbata, Daniela Ondusova, Martin Studencan, Kosice; Peter Kurray, Banska Bystrica; Juraj Cencarik, Presov; Jan Murin, Bratislava. Turkey: Baris Ikitimur, Capa-Istanbul; Emrullah Basar, Kayseri; Bahattin Balci, Osman Yesildag, Kuruelit/Samsun; Zerrin Yigit, Haseki Istanbul; Ayhan Olcay, Capa Istanbul; Jale Cordan, Gorukle/Bursa. Ukraine: Mariya Orynchak, Ivano-Frankivsk. Serbia & Montenegro: Masar Gashi, Prishtina.
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