Matthias Hochadel

Long-term exposure to ambient air pollution and cardiopulmonary mortality in women.

Background: Living close to major roads or highways has been suggested to almost double the risk of dying from cardiopulmonary causes. We assessed whether long-term exposure to air pollution originating from motorized traffic and industrial sources is associated with total and cause-specific mortality in a cohort of women living in North Rhine-Westphalia, Germany. Methods: The study was a follow-up of a series of cross-sectional studies carried out during the 1980s and 1990s on the health of women (age 50–59 years). Approximately 4800 women were followed up for vital status and migration. Exposure to air pollution was defined by distance to major roads calculated from Geographic Information System data and by 1- and 5-year average nitrogen dioxide (NO2) and particle (PM10) concentrations calculated from air monitoring station data. We analyzed associations between exposure and mortality using Coxs proportional hazards models adjusting for confounders. Relative risks (RRs) refer to an interquartile range increase in exposure (16 &mgr;g/m3 for NO2; 7 &mgr;g/m3 for PM10). Results: During the follow-up period, 8% of the women died, 3% from cardiopulmonary causes. Cardiopulmonary mortality was associated with living within a 50-meter radius of a major road (adjusted RR = 1.70; 95% confidence interval = 1.02–2.81), with NO2 (1.57; 1.23–2.00 for 1-year average), and with PM10 (1.34; 1.06–1.71 for 1-year average). Exposure to NO2 was also associated with all-cause mortality (1.17; 1.02–1.34). No association was seen with noncardiopulmonary nonlung cancer mortality. Conclusions: Living close to major roads and chronic exposure to NO2 and PM10 may be associated with an increased mortality due to cardiopulmonary causes.

Contemporary management of octogenarians hospitalized for heart failure in Europe: Euro Heart Failure Survey II

AIMS International guidelines are frequently not implemented in the elderly population with heart failure (HF). This study determined the management of octogenarians with HF enrolled in Euro Heart Failure Survey II (EHFS II) (2004-05). METHODS AND RESULTS We compared the clinical profile, 12 month outcomes, and management modalities between 741 octogenarians (median age 83.7 years) and 2836 younger patients (median age 68.4 years) hospitalized for acute/decompensated HF. Management modalities were also compared with those observed in EHFS I (2000-01). Female gender, new onset HF (de novo), hypertension, atrial fibrillation, co-morbidities, disabilities, and low quality of life were more common in the elderly (all P < 0.001). Mortality rates during hospital stay and during 12 months after discharge were increased in octogenarians (10.7 vs. 5.6% and 28.4 vs. 18.5%, P < 0.001). Underuse and underdosage of medications recommended for HF were observed in the elderly. However, a significant improvement was observed when compared with EHFS I both in the overall HF octogenarian population and in the subgroup with ejection fraction < or =45% for prescription rates of ACE-I/ARBs, beta-blockers, and aldosterone antagonists at discharge (82 vs. 71%; 56 vs. 29%; 54 vs. 18.5%, respectively, all P < 0.01), as well as for recommended combinations and dosage. Prescription rates remained stable for 12 months after discharge in survivors. CONCLUSION Our study confirms that the contemporary management of very elderly patients with HF remains suboptimal but that the situation is improving.

Characteristics, outcomes, and predictors of mortality at 3 months and 1 year in patients hospitalized for acute heart failure

Acute heart failure (AHF) has a poor prognosis. We evaluated 3‐ and 12‐month mortality in different clinical classes of AHF patients from 30 European countries who were included in the EuroHeart Failure Survey (EHFS) II.

Gender related differences in patients presenting with acute heart failure. Results from EuroHeart Failure Survey II

This analysis evaluates the gender differences in patients hospitalised for acute heart failure (AHF) in the EuroHeart Failure Survey II (EHFS).

The role of cardiac registries in evidence-based medicine.

Cardiovascular disease remains the primary cause of mortality, and a major cause of disability in the developed world.1 This significant burden necessitates ongoing improvements in patient management, to minimize the impact of cardiovascular conditions on both patients and healthcare systems. These improvements in cardiovascular care are promoted by an evidence-based approach, shaped by comprehensive clinical guidelines. The scientific basis of recommendations is an important feature of clinical guidelines, and influences the degree to which they are followed in clinical practice.2 Recent studies have assigned the highest evidence grading to randomized controlled trials (RCTs) that are clinically important, and representative of the clinical population covered by the guideline recommendation.3 For example, this highest grading was assigned to a recommendation based on a meta-analysis of RCTs showing low-dose diuretics to be the most effective first-line treatment for cardiovascular event prevention in hypertensive patients. This study reviewed data from 42 RCTs which were, crucially, representative of the population that the recommendation was made for (i.e. hypertensive patients).3,4 The importance of the applicability of evidence to recommendations highlights the need to consider evidence from clinically relevant situations, not all of which have been assessed by RCTs. This evidence can originate from expert consensus, as well as non-randomized prospective studies. Although generally providing a lower evidence-level than RCTs,3,5 observational studies can make an important contribution to the evidence base when the study outcomes are clinically important, and the populations involved are representative. Indeed, information from several registries was considered in the recent American Heart Association Acute Coronary Care in the Elderly Scientific Statement.6 Non-randomized prospective registries document the treatment and outcomes for consecutive patients in clinical practice. Therefore, data are gained from a ‘real-world’ selection of patients, many of whom would be excluded from RCTs, …

GIS-Based Estimation of Exposure to Particulate Matter and NO2 in an Urban Area: Stochastic versus Dispersion Modeling

Stochastic modeling was used to predict nitrogen dioxide and fine particles [particles collected with an upper 50% cut point of 2.5 μm aerodynamic diameter (PM2.5)] levels at 1,669 addresses of the participants of two ongoing birth cohort studies conducted in Munich, Germany. Alternatively, the Gaussian multisource dispersion model IMMISnet/em was used to estimate the annual mean values for NO2 and total suspended particles (TSP) for the 40 measurement sites and for all study subjects. The aim of this study was to compare the measured NO2 and PM2.5 levels with the levels predicted by the two modeling approaches (for the 40 measurement sites) and to compare the results of the stochastic and dispersion modeling for all study infants (1,669 sites). NO2 and PM2.5 concentrations obtained by the stochastic models were in the same range as the measured concentrations, whereas the NO2 and TSP levels estimated by dispersion modeling were higher than the measured values. However, the correlation between stochastic- and dispersion-modeled concentrations was strong for both pollutants: At the 40 measurement sites, for NO2, r = 0.83, and for PM, r = 0.79; at the 1,669 cohort sites, for NO2, r = 0.83 and for PM, r = 0.79. Both models yield similar results regarding exposure estimate of the study cohort to traffic-related air pollution, when classified into tertiles; that is, 70% of the study subjects were classified into the same category. In conclusion, despite different assumptions and procedures used for the stochastic and dispersion modeling, both models yield similar results regarding exposure estimation of the study cohort to traffic-related air pollutants.

Reperfusion strategy in Europe: temporal trends in performance measures for reperfusion therapy in ST-elevation myocardial infarction

AIMS The rate and type of reperfusion, as well as time delays to reperfusion are directly associated with mortality and are established as performance measures (PMs) in the treatment of ST elevation myocardial infarction (STEMI). To date, little information exists about PMs for reperfusion in clinical practice in Europe and their temporal changes. METHODS AND RESULTS Using the Euro Heart Survey ACS-III data set (2 years of inclusions between 2006 and 2008, 138 centres in 21 countries), we selected patients with STEMI eligible for reperfusion therapy. Recorded variables corresponded to the CARDS data set. The rate and type of reperfusion, as well as door to needle and door to artery times were assessed and compared between periods. Timely reperfusion was defined as a door to needle time < 30 min, or a door to artery time < 90 min. We assessed changes in PMs for reperfusion over the 2 years of recruitment. Among 19 205 patients included in the registry, 7655 had STEMI, and 6481 were admitted within the first 12 h and eligible for reperfusion. The rate of patients who underwent reperfusion increased from 77.2 to 81.3%, with an increase in the use of primary percutaneous coronary intervention (P-PCI). The door to needle and door to artery times decreased significantly during the study period, from 20 to 15 min (P = 0.0011) and from 60 to 45 min (P < 0.0001) respectively. As a result, the number of eligible patients receiving reperfusion therapy in a timely manner increased from 53.1 to 63.5% (P < 0.0001). In parallel, over the 2-year period, in-hospital mortality decreased from 8.1 to 6.6% (P = 0.047). CONCLUSION In centres participating in the Euro Heart Survey ACS III, PMs for reperfusion in STEMI improved significantly between 2006 and 2008, with greater use of PCI. Similarly, the rate of patients reperfused in a timely manner also increased, with a significant reduction in door to needle and door to artery times.

Long-term exposure to NO2 and PM10 and all-cause and cause-specific mortality in a prospective cohort of women

We assessed whether long-term exposure to air pollution is associated with all-cause and cause-specific mortality during a period of declining particulate matter concentrations. Approximately 4800 women aged 55 years from North Rhine-Westphalia, Germany, were followed for up to 18 years. Exposure to air pollution was assessed in two ways: (1) using the distance between the residential address and the nearest major road, as calculated from Geographic Information System data and (2) calculating 1-year average particulate matter concentrations below 10 µm (PM10) and nitrogen dioxide (NO2) levels using data from the nearest air-monitoring station data to the subjects’ residences. Ninety-two per cent of all subjects lived in the same community during the entire follow-up period. Associations between mortality and exposure were assessed using Coxs proportional hazards models, including confounder adjustment. Sixteen per cent of women passed away during the follow-up period. An increase of 7 μg/m3 PM10 (IQR) was associated with an increased HR for all-cause (HR 1.15, 95% CI (1.04 to 1.27)), cardiopulmonary (HR 1.39, 95% CI (1.17 to 1.64)), and lung cancer mortality (HR 1.84, 95% CI (1.23 to 2.74)). An increase of 16 μg/m3 (IQR) NO2 exposure was associated with all-cause (HR 1.18, 95% CI (1.07 to 1.30)) and cardiopulmonary mortality (HR 1.55, 95% CI (1.30 to 1.84)). The association between cardiopulmonary mortality and PM10 was reduced for the extended follow-up period, during which PM10 concentrations (but not NO2 concentrations) were lower. Living close to a major road was associated with an increased relative risk for all-cause, cardiopulmonary and respiratory mortality. These associations were temporally stable. Long-term exposure to ambient PM10 and NO2 was associated with increased mortality rates.

Comparison of Treatment and Outcome of Acute Coronary Syndrome in Patients With Versus Patients Without Diabetes Mellitus

The aim was to evaluate management and outcomes in patients with diabetes mellitus (DM) with acute coronary syndrome (ACS). The EHS-ACS-II was a multinational survey conducted in 2004 that included 6,385 consecutive patients with ACS. The management and outcomes of patients with and without DM were compared. DM was recognized in 1,587 patients (25%) with ACS. Patients with DM had a less favorable risk-factor profile, less typical presentation, and longer delay in seeking medical attention; presented more frequently with arrhythmias, heart failure, renal failure, and major bleeding; and had higher in-hospital and 1-year mortality. They were treated more often with diuretics and inotropic agents and less often with antiaggregants (glycoprotein IIb/IIIa and clopidogrel). Insulin was administered to 53% of patients with DM during hospitalization and 31% at discharge. Patients with DM with ST-elevation (STE) myocardial infarction underwent similar primary percutaneous and coronary interventions (but received less thrombolytic therapy). Patients with DM with non-STE ACS underwent less in-hospital revascularization and had significantly higher 1-year mortality. Multivariable analyses showed DM as a predictor of 1-year mortality (odds ratio 1.37, 95% confidence interval 1.09 to 1.71), but not in-hospital mortality. In conclusion, given the current treatment, patients with and without DM with ACS had similar in-hospital adjusted mortality, but patients with DM had increased 1-year mortality. Patients with DM with non-STE ACS posed a higher risk group.

Eczema, respiratory allergies, and traffic-related air pollution in birth cohorts from small-town areas

BACKGROUND Traffic-related air pollution (TAP) impairs respiratory health and could influence the development of allergies, as was demonstrated in urban areas with relatively high pollution. Whether eczema is affected by TAP was rarely investigated. OBJECTIVE To investigate whether exposure to TAP affects eczema and respiratory allergies also in small-town areas with lower concentrations of pollution. METHODS Between 1995 and 1999, we recruited 3390 newborns from small-town areas. Diagnoses and symptoms of eczema and respiratory allergies were recorded by annual questionnaires. Seventy-seven percent of families participated until the childs 6th birthday, when a clinical test for eczema and IgE-sensitization was performed. Individual exposure to traffic-related soot and NO(2) at the childrens home addresses was determined by land-use-regression. We used Cox-regression/log-binomial-regression to determine its confounder-adjusted association with incidence and prevalence of eczema and respiratory allergies. RESULTS The prevalence of eczema at age 6 was significantly higher in children who resided in areas where TAP was higher. The adjusted relative risk for doctor diagnosed eczema for instance was 1.69 (95% confidence interval 1.04-2.75) per 90%-range of soot concentration. Current eczema at the 6 year clinical investigation was likewise associated, children with parental allergies showed significantly stronger effects (p<0.05). Incidence of eczema was not affected. No associations between TAP and asthma, hay fever, or allergic sensitization emerged. CONCLUSION Eczema was sensitive to TAP, effects emerged even in lower polluted small-town areas of Germany. They could be seen for prevalence but not incidence of eczema. This is equivalent to a longer duration of eczema in exposed children.