Jan Heidrich

Self-Rated Health and its Relation to All-Cause and Cardiovascular Mortality in Southern Germany. Results from the MONICA Augsburg Cohort Study 1984–1995

PURPOSE Studies worldwide show that self-rated health (SRH) is a robust predictor of mortality among the elderly. Only few studies have focussed on a middle-aged population and no such study has been reported from Germany. This study examined the association between SRH and mortality in a middle-aged, population based cohort from Germany, using data from the MONICA (Monitoring Trends and Determinants in Cardiovascular Diseases) Augsburg project. METHODS The cohort comprises 1521 men and 1498 women aged 35-64; they were followed over 11 years from 1984-1995. Participants provided extensive data on medical conditions and cardiovascular risk factors through interviews and examinations. SRH was assessed globally and in comparison to those of the same age. We estimated relative hazards for mortality from all-causes and cardiovascular disease according to self-ratings of health. RESULTS Among males the adjusted hazards rate ratio (HRR) of mortality from all-causes was 1.5 (95% CI 1.1-2.2) for combined fair/poor perceived health compared with good/excellent health. Women with fair/poor ratings had no increased risk of dying (HRR = 1.1, 95% CI 0.7-1.9). Men who perceived worse health than persons of the same age showed an adjusted HRR of 1.7 (95% CI 1.0-2.9) as compared to those perceiving better health; in women the adjusted HRR was 1.9 (95% CI 1.0-3.7). The adjusted hazards for dying from cardiovascular diseases in men were 1.3 (95% CI 0.8-2.1) for those perceiving fair/poor and 1.7 (95% CI 0.7-3.7) for those perceiving worse health. CONCLUSIONS Self-rated health was a predictor of mortality in a middle-aged German population and contains information that is not entirely reflected in underlying medical conditions and risk factors. Self-assessments of health in comparison to individuals of the same age were stronger and more consistently associated with mortality. Global self-ratings of health and self-ratings in comparison to those of the same age may measure slightly different dimensions and the effect of self-rated health may differ among men and women.

Meta-Analysis of the Efficacy of Granulocyte-Colony Stimulating Factor in Animal Models of Focal Cerebral Ischemia

Background and Purpose— Recent reports have described the efficacy of the hematopoietic growth factor granulocyte-colony stimulating factor (G-CSF) in animal stroke models. Early clinical multicenter trials evaluating the effect of G-CSF in acute stroke and pilot clinical trials for the subacute phase are ongoing. To guide further development, a meta-analysis was performed to assess the effects of G-CSF on infarct size and sensorimotor deficits. Methods— Using electronic and manual searches of the literature, we identified studies describing the efficacy of G-CSF in animal models of focal cerebral ischemia. Two reviewers independently selected studies and extracted data on study quality, G-CSF doses, time of administration, and outcome measured as infarct volume and/or sensorimotor deficit. Data from all studies were pooled by meta-regression analyses. Results— Thirteen studies including 277 animals for infarct size calculation and 258 animals for assessment of sensorimotor deficit met the criteria for inclusion. Overall efficacy of G-CSF regarding infarct size reduction was 42%. Meta-regression analysis revealed a 0.8% (P<0.0001) decrease in infarct size per 1-&mgr;g/kg increase in G-CSF dose when applied within the first 6 hours and a 2.1% (P<0.0001) decrease when applied later than 6 hours after induction of ischemia with a significant (P=0.0004) greater infarct size reduction after delayed treatment. Sensorimotor deficits categorized into 3 subgroups improved between 24% and 40%. Conclusions— Our findings consolidate G-CSF as a drug that both reduces infarct size and enhances functional recovery. These effects are presumably dose dependent. In contrast to most other neuroprotectants, a beneficial outcome may also be achieved when treatment is delayed.

Blood pressure control and knowledge of target blood pressure in coronary patients across Europe: results from the EUROASPIRE III survey.

Background Blood pressure management is a key issue among patients with coronary heart disease (CHD). The present study aimed to identify particular patient groups that may need to be specifically targeted in secondary prevention of CHD. Methods EUROASPIRE III is a cross-sectional study conducted in 2006–2007 among patients up to 80 years of age hospitalized for CHD. Patients from 76 centres in 22 European regions were examined on average 15 months after hospitalization. Logistic regression analysis was applied to investigate factors associated with blood pressure control and knowledge of target blood pressure using the cut-point of less than 140/90 mmHg. Results Among 7649 patients using antihypertensive medication 50.4% achieved blood pressure control and 49.4% provided accurate knowledge of target blood pressure. Obese patients were less likely to show controlled blood pressure [odds ratio (OR) 0.72, 95% confidence interval (CI) 0.65–0.80] and accurate knowledge of blood pressure target values (OR 0.80, 95% CI 0.72–0.90). Dyslipidaemia was negatively associated with blood pressure control and accurate target knowledge. Patients with diabetes mellitus less frequently achieved blood pressure control (OR 0.89, 95% CI 0.79–0.99). Accurate knowledge of target blood pressure was positively related to blood pressure control (OR 1.12, 95% CI 1.00–1.24). Patients who received advice by a health professional to reduce salt intake, to reduce weight, and to increase physical activity more frequently showed accurate knowledge of blood pressure target values. Conclusion Blood pressure control and knowledge of target blood pressure are inappropriate in the European high-risk population of coronary patients. Particularly CHD patients with obesity, diabetes, and dyslipidaemia need better management and control of elevated blood pressure.

The Efficacy of Erythropoietin and Its Analogues in Animal Stroke Models. A Meta-Analysis

Background and Purpose— Erythropoietin (EPO) was explored regarding its suitability as a candidate stroke drug in animal experimental studies. We performed a meta-analysis to obtain an overall impression of the efficacy of EPO in published animal experimental stroke studies and for potential guidance of future clinical studies. Methods— By electronic and manual searches of the literature, we identified studies describing the efficacy of EPO in experimental focal cerebral ischemia. Data on study quality, EPO dose, time of administration, and outcome measured as infarct volume or functional deficit were extracted. Data from all studies were pooled by means of a meta-analysis. Results— Sixteen studies were included in the meta-analysis. When administered after the onset of ischemia, EPO and its analogues reduced infarct size by 32% and improved neurobehavioral deficits significantly. A meta-regression suggests higher doses of EPO to be associated with smaller infarct volumes. When administered earlier than 6 hours EPO was more effective compared to a later treatment initiation. Both hematopoietic and nonhematopoietic EPO analogues showed efficacy in experimental stroke. Conclusion— In conclusion, this analysis further strengthens confidence in the efficacy of EPO and its analogues in stroke therapy. Nonhematopoietic EPO analogues which are known to have less systemic adverse effects compared to EPO are also promising candidate stroke drugs. Further experimental studies are required that evaluate the safety of a combination of EPO with thrombolysis and whether EPO is also effective in animals with comorbidity.

Gender differences in the implementation of cardiovascular prevention measures after an acute coronary event

Objective To compare gender-related lifestyle changes and risk factor management after hospitalisation for a coronary event or revascularisation intervention in Europe. Method The EUROASPIRE III survey was carried out in 22 European countries in 2006–2007. Consecutive patients having had a coronary event or revascularisation before the age of 80 were identified. A total of 8966 patients (25.3% women) were interviewed and underwent clinical and biochemical tests at least 6 months after hospital admission. Trends in cardiovascular risk management were assessed on the basis of the 1994–1995, 1999–2000 and 2006–2007 EUROASPIRE surveys. Results Female survey participants were generally older and had a lower educational level than male participants (p<0.0001). The prevalences of obesity (p<0.0001), high blood pressure (BP) (p=0.001), elevated low-density lipoprotein (LDL)-cholesterol (p<0.0001) and diabetes (p<0.0001) were significantly higher in women than in men, whereas current smoking (p<0.0001) was significantly more common in men. The use of antihypertensive and antidiabetic drugs (but not that of other drugs) was more common in women than in men. However, BP (p<0.0001), LDL-cholesterol (p<0.0001) and HbA1c (p<0.0001) targets were less often achieved in women than in men. Between 1994 and 2007, cholesterol control improved less in women than in men (interaction: p=0.009), whereas trends in BP control (p=0.32) and glycaemia (p=0.36) were similar for both genders. Conclusion The EUROASPIRE III results show that despite similarities in medication exposure, women are less likely than men to achieve BP, LDL-cholesterol and HbA1c targets after a coronary event. This gap did not appear to narrow between 1994 and 2007.

Knowledge and perception of guidelines and secondary prevention of coronary heart disease among general practitioners and internists. Results from a physician survey in Germany

Aims This study investigated knowledge and perception of guidelines in secondary prevention of coronary heart disease and the impact of guideline knowledge on treatment practices in coronary patients among primary care physicians. Design and methods A representative questionnaire survey was performed in 2002–2003 among all 1023 general practitioners and office-based internists in the Region of Münster, Germany. The survey instrument contained questions on knowledge and attitudes toward guidelines, risk factors and treatment practices in secondary prevention of coronary heart disease. Results In total, 681 (66.6%) physicians participated. Seventy percent of physicians reported knowledge of at least one guideline. Participants expressed mainly positive attitudes toward guidelines but also reported important barriers to their implementation such as lack of reimbursement. Only 63 and 32%, respectively, reported to start antihypertensive and lipid-lowering treatment according to guidelines. Physicians reporting guideline knowledge were more likely to initiate lipid-lowering treatment of elevated low-density lipoprotein (LDL)-cholesterol [odds ratio (OR) 2.3; 95% confidence interval (CI) 1.5–3.5], to intensively advise overweight patients (OR 1.5; 95% CI 1.0–2.5), to make use of nicotine replacement therapy or cessation courses in smoking patients (OR 1.7; 95% CI 1.2–2.4), and to comply with an overall measure of guideline adherence (OR 1.8; 95% CI 1.1–2.8). Conclusions In this study, guideline knowledge led to improved cardiovascular risk factor treatment among GPs and internists. Many physicians, however, do not treat coronary patients according to evidence-based guidelines. Further dissemination of guidelines and educational efforts are essential to improve secondary prevention of coronary heart disease.

educational level and risk profile of cardiac patients in the EUROASPIRE II substudy

Study objective: To ascertain, whether, conventional risk factors and readiness of coronary patients to modify their behaviour and to comply with recommended medication were associated with education in patients with established coronary heart disease. Design and methods: EUROASPIRE II was a cross sectional survey undertaken in 1999–2000 in 15 European countries to ascertain how effectively recommendations on coronary preventions are being followed in clinical practice. Consecutive patients, men and women ⩽71 years who had been hospitalised for acute coronary syndrome or revascularisation procedures, were identified retrospectively. Data were collected through a review of medical records, interview, and examination at least six months after hospitalisation. The education reached was ascertained at the interview. Main results: A total of 5556 patients (1319 women) were evaluated. Significantly more patients with ischaemia had only primary education, in contrast with the remaining diagnostic groups. Body mass index and glucose were negatively associated with educational level, while HDL-cholesterol was positively associated. Men with highest education had significantly lower systolic blood pressure and total cholesterol. The prevalence of current smoking decreased significantly from primary to secondary and high education only in men. Both men and women with primary educational level were more often treated with antidiabetics, and antihypertensives, but less often with lipid lowering drugs. The effectiveness of treatment was virtually the same in all education groups. Conclusions: Patients with higher education had lower global coronary risk, than those with lower education. This should be considered in clinical practice. Particular strategies for risk communication and counselling are needed for those with lower education status.

Changes in alcohol intake and risk of coronary heart disease and all-cause mortality in the MONICA/KORA-Augsburg cohort 1987-97

Background Most studies on the effect of alcohol consumption on coronary heart disease or all-cause mortality assess alcohol intake at one point in time and therefore do not take into consideration changes in drinking habits over time. We investigate whether a second assessment of alcohol intake substantially improves estimation of the effects of alcohol intake on these outcomes. Design A prospective cohort study of 2710 men and women, age 35-64 years at baseline in 1984/85 in the Augsburg region in southern Germany. We recorded incident fatal and non-fatal coronary events and all-cause mortality until 1997. Alcohol intake and other explanatory variables were assessed in 1984/85 and 1987/88. Methods Based on these assessments, participants were classified as non-drinkers, quitters, starters and constant drinkers. We calculated hazard rate ratios for coronary events and all-cause mortality in these groups and adjusted for several potential confounders using Coxs proportional hazards model. These estimates were compared with hazard rate ratios based on a single assessment of alcohol intake in 1987/88. Results Among male constant drinkers the adjusted hazard rate ratio (HRR) for coronary events was lowest among those consuming 0.1-19.9 g alcohol per day, compared with non-drinkers [HRR 0.29; 95% confidence interval (Cl) 0.12-0.70]. The lowest all-cause mortality risk was observed among men drinking 20.0-39.9 g per day (HRR 0.48; 95% Cl 0.26-0.88). In female constant drinkers the HRR for all-cause mortality was 0.71 (95% Cl 0.40-1.26) for those reporting 0.1-19.9 g daily alcohol consumption. Hazard rate ratios for alcohol intake classified by two assessments consistently revealed a more pronounced beneficial effect of alcohol consumption than those for alcohol intake groups based on a single measurement. Conclusions Assessment of alcohol intake at two points in time seems slightly to improve the risk estimation for coronary heart disease (CHD) and for all-cause mortality, compared with a single measurement. Thus, our findings strengthen the evidence of a beneficial effect of light to moderate alcohol consumption on coronary heart disease and all-cause mortality.

Stroke risk perception among participants of a stroke awareness campaign

BackgroundSubjective risk factor perception is an important component of the motivation to change unhealthy life styles. While prior studies assessed cardiovascular risk factor knowledge, little is known about determinants of the individual perception of stroke risk.MethodsSurvey by mailed questionnaire among 1483 participants of a prior public stroke campaign in Germany. Participants had been informed about their individual stroke risk based on the Framingham stroke risk score. Stroke risk factor knowledge, perception of lifetime stroke risk and risk factor status were included in the questionnaire, and the determinants of good risk factor knowledge and high stroke risk perception were identified using logistic regression models.ResultsOverall stroke risk factor knowledge was good with 67–96% of the participants recognizing established risk factors. The two exceptions were diabetes (recognized by 49%) and myocardial infarction (57%). Knowledge of a specific factor was superior among those affected by it. 13% of all participants considered themselves of having a high stroke risk, 55% indicated a moderate risk. All major risk factors contributed significantly to the perception of being at high stroke risk, but the effects of age, sex and education were non-significant. Poor self-rated health was additionally associated with high individual stroke risk perception.ConclusionStroke risk factor knowledge was high in this study. The self perception of an increased stroke risk was associated with established risk factors as well as low perception of general health.

Depression, anxiety, and risk factor control in patients after hospitalization for coronary heart disease: the EUROASPIRE III Study:

Objective: To assess in coronary heart disease (CHD) patients: (1) differences in the prevalence of depression and anxiety between samples selected from 22 countries; (2) the association of depression and anxiety with age, education, diagnostic category, favourable behaviours, use of cardioprotective drugs, and reaching the secondary prevention treatment targets. Design: Cross-sectional study. Methods: The study group consisted of 8580 patients from 22 European countries examined at least 6 months after hospitalization due to CHD. Depression and anxiety were assessed using Hospital Anxiety and Depression Scale (HADS). Results: Prevalence of depression (HADS depression score ≥8) varied from 8.2% to 35.7% in men and from 10.3% to 62.5% in women. Prevalence of anxiety (HADS anxiety score ≥8) varied from 12.0% to 41.8% in men and from 21.5% to 63.7% in women. Older age, female sex, low education, and no history of invasive treatment were associated with more frequent depression and anxiety. Depression and anxiety were associated with less frequent modification of lifestyle. Depression was related with body mass index, waist circumference, fasting glucose, and more frequent self-reported diabetes but not with reaching the treatment targets for blood pressure and lipids. Conclusions: High prevalence of depression and anxiety in CHD patients, and relation with less frequent lifestyle modification, call to integrate methods of identification and minimizing unfavourable effects of depression and anxiety into the cardiac rehabilitation and prevention programmes.