The most cited Czech woman: physician by day, researcher by night

The global list of highly cited researchers for the past year features ten Czech representatives, including a single woman: the cardiologist Renata Cífková. As a physician, who heads the Centre for Cardiovascular Prevention at Thomayer Hospital in Prague and a professor at the First Faculty of Medicine at Charles University, she usually only finds time for her scientific papers at night and on weekends.

 The Highly Cited Researchers list has been published by the US company Clarivate Analytics since 2014; this year’s edition features seventeen Nobel Prize laureates. Professor Cífková appears on the list primarily due to her work on the European guidelines on cardiovascular disease prevention. Besides the prevention and treatment of high blood pressure, she now also specialises in secondary stroke prevention and the prevention of cardiovascular diseases in oncology patients.

Read more: The global list of the most cited researchers includes ten Czechs

When I arrived just after noon, you had already been teaching and examined several patients. Is this a typical day for you?
And on top of that, I left the hospital at 6 a.m. this morning, because I’ve been working on study results, so I only had two hours sleep. I am responsible for a small outpatient department and we are mostly funded by insurance payments for the treatments that we bill, so I spend the whole day with patients, which leaves only evenings for research. On the other hand, it comes in handy, since that’s when most of the top experts I work with are available. They are in a similar situation to me and have no time left during the day, even though they may have slightly better conditions. That’s just how it is, and don’t worry – I’m able to sleep for sixteen hours straight to catch up.

What drives you to do research?
I’m happy to be working with top experts from all over the world who are also nice people. They are completely reliable, they won’t double-cross you, and are easy to work with. People like Professor Giuseppe Mancia, the biggest guru in hypertension, or the great recently deceased Professor Alberto Zanchetti – you can really say they are gentlemen. I know that when they promise something, I can count on that, that the so-called gentlemen’s agreement is absolutely binding. I am extremely proud of my long-term work with them.

You have just named two men, and you are the only woman among the highly cited Czech researchers on the list. Does this say something about the situation of women in science? 
It’s sad and it shows that it’s still hard for women here to get to the very top. Women are also paid much less than men with the same skills, which is also true in research. So even though money usually isn’t the primary motivation for researchers, women are still worse off.

Is it the same elsewhere in the world?
In my field, that is, in the European Society of Cardiology, there has just been a revolution: for the first time ever, the president will be a woman, Barbara Casadei, an Italian who works at Oxford and does basic research. I know from the meetings that I attend at the European Society of Cardiology that she tries to put the question of women in science on the agenda. I know how complicated it can be – for example, I try to give as much help as I can to my colleagues on maternity leave.

How? 
They should have the option of working part-time. I know that some of my colleagues from among the department heads don’t want to have anything to do with those who aren’t willing to work full-time, and I don’t like that. On the other hand, I was inspired by the European Society of Cardiology, which provides childcare during their congresses – and those are events with over 30,000 participants – because both parents might be scientists who want to attend, and they need someone to take care of their children.

And how about the Czech Republic? 
I have suggested several times that we could do something similar during the congresses of the Czech Society of Cardiology, which usually have around 4,000 participants. It would be an invaluable help for young mothers who have to stay at home with their children. It’s a real problem for them that they don’t have anyone to mind their child during the congress.

Why didn’t it work out?
It turned out to be very complicated from the legal point of view. You need to obtain a lot of permissions to run a childcare facility in the Czech Republic.

Do you agree with the findings of the Czech Academy of Sciences that women have to face more obstacles to reach top positions?
Definitely. I was lucky – I was never wronged just because I was a woman. However, things would have certainly been easier for me if I was a man. It seems to me that men find it much easier to deal with competition from other men. When it’s a woman, it’s much harder. It’s like losing out twice.

One of the reasons you are on the list was your work on the European guidelines for hypertension. Since the 1980s, this has been preceded by the MONICA and post-MONICA studies that you have also participated in and that have collected information about the cardiovascular risks in the Czech population. 
Well, in fact, I criticised the first study you mentioned quite a lot.

You openly criticised a government-run study during the communist era?
And I suffered the consequences. But I wouldn’t like to go into that. To cut a long story short, I criticised the design of the study. A lot of data was missing and by adding more factors – we have just finished our fourth cross-sectional survey in our post-MONICA study – we keep improving it.

What was some of the missing data?
One of the basic risk factors that was initially missing was a question about whether the patient had diabetes. There were no sugar level measurements. So, the first thing we changed was that we started taking the blood samples on an empty stomach and we added blood sugar levels on an empty stomach to the data. And then this year, we added glycated haemoglobin, so we now have reliable data on the prevalence of diabetes – that is, the number of people with diabetes. In the middle-aged population, it’s around 9%, but in the group of over 55, specifically between 55 and 64, it’s a quarter of all women, which is awful. And we have a device to measure obstructive sleep apnoea in outpatients. We haven’t finalised the data yet, but so far it seems that obstructive sleep apnoea is far less prevalent here than in the US. Right now, we are testing for primary hyperaldosteronism, which is the most common form of secondary hypertension. All the literature says that the prevalence is between 5% and 10%, but now it seems that it is 2% at most, maybe even less. It always depends on who you are examining. The 10% figures came from specialised centres in Italy, and of course, you have more patients like this in a specialised centre, but in the general population, it’s not such a big deal as it was made to be.

The data that you collected over the years was also used to build the SCORE cardiovascular risk charts. What is the situation in the Czech Republic?
When you look at the charts, there are two versions for Europe: for low-risk countries and for high-risk countries. When we compare the Czech chart to the European high-risk chart, the situation is even gloomier: it shows a persistently high cardiovascular risk, even though there has been a huge decrease over the past 30 years and mortality is now at a higher age, which is a great success story of prevention.

What is the biggest problem?
The problem is – and not just here, it’s all over the world – that even though we have a wonderful range of drugs to treat hypertension, only about 50% of the general population treated for hypertension reaches the target values of <140/90 mmHg.

How is that possible?
In general, there are multiple factors. It may be that the patients aren’t taking the medicine the way they are supposed to. Most of the patients are prescribed a combination of hypertension drugs, so the question is whether they missed one drug from the combination or all of them. Another issue is that the drug combinations are not set up right. If you know what you’re doing, it’s not a problem to get hypertension under control in most patients, since “resistant hypertension” is only present in about 5%, or at most, 10% of patients. And even then, these are often patients who don’t take their drugs because they want to profit, in some way, from having serious hypertension. Anyway, the current treatment of hypertension is based on drug combination and the new guidelines say that unless it’s borderline hypertension or hypertension in older people, we should always start with a combination of drugs, and to make this easy, it should be a fixed combination of two drugs in one pill. And this combination is often not set up right. Then there are administrative issues: doctors often only prescribe one package, so patients must keep constantly coming back for refills. If they at least had their blood pressure taken when they came to get their prescription, that would be okay, but I often hear that that’s not the case – they only have their blood pressure taken once, at the beginning.

I have also heard of “white coat syndrome”, where patients’ blood pressure is much higher when taken in a doctor’s office than it would be at home because they are stressed by the presence of doctors. How large can the difference be?
Yes, this really happens, and the difference can be up to twenty mmHg. This is one of the reasons why you need to measure blood pressure repeatedly because it’s a very unstable variable. Here at the Centre for Cardiovascular Prevention, we measure blood pressure with BpTRU – that’s an automated blood pressure monitor – with no staff present. We put the cuff on, measure the blood pressure, and then wait until the device automatically takes five more measurements. These stay recorded in the memory, plus the device calculates an average of these five measurements. This gives me six different values and then on top of that, I measure the patient’s blood pressure three more times with a traditional mercurial blood pressure monitor. I need more measurements because you can’t really tell much from a single value. Unfortunately, this is what often happens. The doctors’ excuse, of course, is that they don’t have time, but while I understand that they have a lot on their plate, this is no excuse. And a third factor is the drug copayments, even though I don’t think they are that high. I can combine the drugs so that the patient copayment is minimal in each drug class. It just takes more effort. On the other hand, Czechs do not really appreciate how much of their healthcare is covered by health insurance. I recently had a patient who works in Brussels, and she said that over there you must pay for every visit to the doctor and then you might get something back from your health insurance company, but no more than half of what you paid. In effect, patients pay half of the costs of outpatient visits from their own pockets. People here don’t realise how generous our system is.

Not so long ago, wine was touted as one of the ways to help prevent cardiovascular diseases, even at scientific conferences. You are a wine connoisseur, what is your opinion on that?
I like wine because my father made his own wine and we had a vineyard in the Central Bohemian Highlands. I enjoyed it there very much and we spent a lot of time there. But to answer your question: the view on wine drinking has changed. It turns out that alcohol, even if it’s wine, should only be drunk in moderation. In fact, I was recently asked by the Czech Society of Cardiology to write a statement on this matter.

What did you say?
It turns out that from the point of view of cardiovascular health, we can tolerate some amount of alcohol, but we should not recommend it.

How much is it?
It’s about two drinks a day for men and one for women, since the activity of alcohol dehydrogenase, the enzyme that breaks down alcohol, is lower in women. And it should not be every day, but five days a week at most.

Let’s return to your career. You left for an academic visit to Canada just before the Velvet Revolution in 1989, initially for a year... 
… and in the end, I stayed for two and a half. I waited for five years for permission to go; they didn’t want to let me. I finally left in August 1989, which was an early sign that the regime was about to collapse, even though I obviously didn’t understand that at the time.

 Did you want to stay there?
Not at all, I was extremely happy about all the wonderful changes that were happening back home. I was a bit like a schizophrenic, whose body was in Canada, while her soul was here. To a certain extent, I thought it was my duty to go back. You should go out in the world to learn something and then come back home to make it better with what you have learned.

 What did you want to improve? 
What I picked up in Canada was the partnership between the patient and the doctor. That’s what I’m still trying to build over here. I keep getting more and more patients, and my existing patients often bring other family members and friends. Another thing I learned was that it is not enough to criticise: positive criticism must come with an idea about how to move forward. While I was in Canada, I worked on the epidemiology of cardiovascular diseases, and when I returned, I didn’t go back to criticising the MONICA study as I had done before. I realised that the data was valuable despite the criticism. So, I expanded and improved the survey and continued with the study.

What is now holding back your research in the Czech Republic?
I spend a lot of energy on trivial everyday issues, from the lack of nurses to the constant haggling with insurance companies, to having to justify my business trips abroad. I get ten days a year for those trips, which means that I exceed the limit in June and use my days off for the rest or have to ask the hospital director for special permission. And that’s even though I have reached the age when I only go abroad when I am invited to speak, I’m not actively trying to go anywhere, and unfortunately, I have to refuse a lot of invitations.

 Is there anything that has made you feel proud lately? 
Thanks to one of our grants, we were able to implement systematic care for stroke patients, who were not receiving the same level of follow-up care as heart attack patients. By working together with the European Society of Hypertension, we had patients examined according to our protocols in Poland, Croatia, and other countries, which provided us with data for long-term comparison. Another area, which is still rather uncommon and will continue to grow, is cardiac care for cancer survivors. A whole new discipline, oncocardiology, is emerging. I can say that many patients now do not die of cardiovascular diseases, but they live long enough to get cancer. And it is beginning to look similar with oncological diseases. The patients survive oncological diseases, but their treatment often significantly accelerates the process of atherosclerosis; in a nutshell, they live long enough to get heart attacks. So far, nobody has really delved into this issue, because everyone was focused on just surviving the treatment. However, we now have early diagnostics and much better treatment, and many people survive cancer. That makes it even more important to identify cardiovascular risk factors at the time of the cancer diagnosis, get them under control, and provide follow-up care.