Heat in Germany: Health risks and preventive measures.

Background: Climate change has already led to a significant temperature increase in Germany. The average temperature in the past decade was approximately 2°C above the pre-industrial level and eight of the ten hottest summers since the beginning of systematic weather records in 1881 were recorded in the last 30 years. Methods: Based on a selective literature search and authors' own results, the article summarises the current state of knowledge on heat and its health impacts for Germany, addresses adaptation measures, and gives an outlook on implementation and research questions. Results: Heat can aggravate pre-existing conditions such as diseases of the cardiovascular system, the respiratory tract, or the kidneys and trigger potentially harmful side effects for numerous medications. A significant increase in mortality is regularly observed during heat events. Previous approaches to mitigate the health impact of high temperatures include, for example, the heat alerts of the German Meteorological Service and recommendations for the preparation of heat-health action plans. Conclusions: Evidence on health impacts of heat and awareness of the need for heat-related health protection have grown in recent years, but there is still a need for further action and research.

Epidemiological trends in mortality, event rates and case fatality of acute myocardial infarction from 2004 to 2015: results from the KORA MI registry.

AIM: This study examines epidemiological trends of acute myocardial infarction (AMI) in Germany from 2004-2015 across different age groups, using data of the population-based KORA myocardial infarction registry. METHODS: Annual age-standardised, age-group- and sex-specific mortality and event rates (incident and recurrent) per 100,000 population as well as 28-day case fatality were calculated from all registered cases of AMI and coronary heart disease deaths in 25-74-year-olds from 2004-2015 and 75-84-year-olds from 2009-2015. Average annual percentage changes (AAPC) were calculated by joinpoint regression. RESULTS: Mortality rates declined considerably among the elderly (75-84 years), in men by -6.0% annually, due to declines of case fatality by -3.0% and incidence rate by 3.4% and in women by -10.0%, driven by declines in incidence (-9.1%) and recurrence rate (-4.9%). Significant mortality declines also occurred in males, 65-74 years of age (AAPC -3.8%). Among the age groups 25-54 years and 55-64 years, there was no substantial decline in mortality, event rates or case fatality except for a decline of incidence rate in 55-64-year-old men (AAPC -1.8%). CONCLUSION: Inhomogeneous AMI trends across age-groups indicate progress in prevention and treatment for the population >64 years, while among <55-year-olds, we found no significant trend in AMI morbidity and mortality.KEY MESSAGESAge standardised AMI mortality continued to decline from 2009 to 2015 in the study region.Declines in AMI mortality were driven by declines in event rates (both incidence and recurrence rates) and case fatality.AMI trends were inconsistent across different age groups with the strongest declines in mortality and event rates among the elderly population (75-84 years of age).

Admission ECG changes predict short term-mortality after acute myocardial infarction less reliable in patients with diabetes.

Prior studies examined association between short-term mortality and certain changes in the admission ECG in acute myocardial infarction (AMI). Nevertheless, little is known about possible differences between patients with diabetes and without diabetes in this regard. So the aim of the study was to investigate the association between 28-day case fatality according to certain ECG changes comparing AMI cases with and without diabetes from the general population. From 2000 until 2017 a total of 9756 AMI cases was prospectively recorded in the study Area of Augsburg, Germany. Each case was assigned to one of the following groups according to admission ECG: 'ST-elevation', 'ST-depression', 'only T-negativity', 'predominantly bundle branch block', 'unspecific changes' and 'normal ECG' (the last two were put together for regression analyses). Multivariable adjusted logistic regression models were calculated to compare 28-day case-fatality between the ECG groups for the total sample and separately for diabetes and non-diabetes cases. For the non-diabetes group, the parsimonious logistic regression model revealed significantly better 28-day-outcome for the 'normal ECG / unspecific changes' group (OR: 0.47 [0.29-0.76]) compared to the reference group (STEMI). Contrary, in AMI cases with diabetes the category 'normal ECG / unspecific changes' was not significantly associated with lower short-term mortality (OR: 0.87 [0.49-1.54]). Neither of the other ECG groups was significantly associated with 28-day-mortality in the parsimonious logistic regression models. Consequently, the absence of AMI-typical changes in the admission ECG predicts favorable short-term mortality only in non-diabetic cases, but not so in patients with diabetes.

Low serum calcium is associated with higher long-term mortality in myocardial infarction patients from a population-based registry.

Calcium plays an essential role in physiology of the cardiovascular system. Aberrations from normal serum calcium levels are known to be associated with several cardiovascular diseases. Its possible role as a predictor for long-term mortality after acute myocardial infarction (AMI) is still uncertain. In this study, a total of 3732 patients (aged 25-74 years) with incident AMI surviving at least 28 days after AMI was included. The median follow-up time was 6.0 years. Admission total serum calcium levels were divided into quartiles. The Kaplan-Meier-Curve suggested a division of the follow up time in two different time periods. So, Cox regression models were calculated to assess association between admission serum calcium levels and all-cause long-term mortality with two observation periods: 28-2500 days and > 2500 days. The final model was adjusted for various comorbidities, clinical characteristics, in-hospital treatment and medication. The third quartile (normal-high Calcium levels) served as the reference group. The fully adjusted Cox-regression model shows significantly higher mortality risk for low serum calcium (quartile 1) within the timeframe 28-2500 days after the event (OR 1.53 [1.19-1.98]). The other groups did not differ significantly from each other. In the later observation period (from 2500 days until death or censoring) no more significant differences were seen between the four calcium quartiles. In summary, low serum calcium is an independent predictor of adverse outcome in the first 2500 days (about 7 years) after AMI. On later points in time this effect attenuates, so that no more significant differences can be observed.

Hourly Exposure to Ultrafine Particle Metrics and the Onset of Myocardial Infarction in Augsburg, Germany.

BACKGROUND: Epidemiological evidence on the health effects of ultrafine particles (UFP) remains insufficient to infer a causal relationship that is largely due to different size ranges and exposure metrics examined across studies. Moreover, evidence regarding the association between UFP and cardiovascular disease at a sub-daily timescale is lacking. OBJECTIVE: We investigated the relationship between different particle metrics, including particle number (PNC), length (PLC), and surface area (PSC) concentrations, and myocardial infarction (MI) at an hourly timescale. METHODS: We collected hourly air pollution and meteorological data from fixed urban background monitoring sites and hourly nonfatal MI cases from a MI registry in Augsburg, Germany, during 2005-2015. We conducted a time-stratified case-crossover analysis with conditional logistic regression to estimate the association between hourly particle metrics and MI cases, adjusted for air temperature and relative humidity. We also examined the independent effects of a certain particle metric in two-pollutant models by adjusting for copollutants, including particulate matter (PM) with an aerodynamic diameter of ≤10µm or 2.5µm (PM10 and PM2.5, respectively), nitrogen dioxide, ozone, and black carbon. RESULTS: Overall, a total of 5,898 cases of nonfatal MI cases were recorded. Exploratory analyses showed similar associations across particle metrics in the first 6-12 h. For example, interquartile range increases in PNC within the size range of 10-100 nm, PLC, and PSC were associated with an increase of MI 6 h later by 3.27% [95% confidence interval (CI): 0.27, 6.37], 5.71% (95% CI: 1.79, 9.77), and 5.84% (95% CI: 1.04, 10.87), respectively. Positive, albeit imprecise, associations were observed for PNC within the size range of 10-30 nm and 100-500 nm. Effect estimates for PLC and PSC remained similar after adjustment for PM and gaseous pollutants. CONCLUSIONS: Transient exposure to particle number, length, and surface area concentrations or other potentially related exposures may trigger the onset of nonfatal myocardial infraction. https://doi.org/10.1289/EHP5478.

Projection of Temperature-Related Myocardial Infarction in Augsburg, Germany: Moving on From the Paris Agreement on Climate Change.

BACKGROUND: Substantial efforts are required to limit global warming to under 2 °C, with 1.5 °C as the target (Paris Agreement goal). We set out to project future temperature-related myocardial infarction (MI) events in Augsburg, Germany, at increases in warming of 1.5 °C, 2 °C, and 3 °C. METHODS: Using daily time series of MI cases and temperature projections under two climate scenarios, we projected changes in temperature-related MIs at different increases in warming, assuming no changes in population structure or level of adaptation. RESULTS: In a low-emission scenario that limits warming to below 2 °C throughout the 21st century, temperature-related MI cases will decrease slightly by -6 (confidence interval -60; 50) per decade at 1.5 °C of warming. In a high-emission scenario going beyond the Paris Agreement goals, temperature-related MI cases will increase by 18 (-64; 117) and 63 (-83; 257) per decade with warming of 2 °C and 3 °C, respectively. CONCLUSION: The future burden of temperature-related MI events in Augsburg at 2 °C and 3 °C of warming will be greater than at 1.5 °C. Fulfilling the Paris Agreement goal of limiting global warming to no more than 1.5 °C is therefore essential to avoid additional MI events due to climate change.

Temporal variations in the triggering of myocardial infarction by air temperature in Augsburg, Germany, 1987-2014.

AIMS: The association between air temperature and mortality has been shown to vary over time, but evidence of temporal changes in the risk of myocardial infarction (MI) is lacking. We aimed to estimate the temporal variations in the association between short-term exposures to air temperature and MI in the area of Augsburg, Germany. METHODS AND RESULTS: Over a 28-years period from 1987 to 2014, a total of 27 310 cases of MI and coronary deaths were recorded. Daily meteorological parameters were measured in the study area. A time-stratified case-crossover analysis with a distributed lag non-linear model was used to estimate the risk of MI associated with air temperature. Subgroup analyses were performed to identify subpopulations with changing susceptibility to air temperature. Results showed a non-significant decline in cold-related MI risks. Heat-related MI relative risk significantly increased from 0.93 [95% confidence interval (CI): 0.78-1.12] in 1987-2000 to 1.14 (95% CI: 1.00-1.29) in 2001-14. The same trend was also observed for recurrent and non-ST-segment elevation MI events. This increasing population susceptibility to heat was more evident in patients with diabetes mellitus and hyperlipidaemia. Future studies using multicentre MI registries at different climatic, demographic, and socioeconomic settings are warranted to confirm our findings. CONCLUSION: We found evidence of rising population susceptibility to heat-related MI risk from 1987 to 2014, suggesting that exposure to heat should be considered as an environmental trigger of MI, especially under a warming climate.

Association of sleep disturbances within 4 weeks prior to incident acute myocardial infarction and long-term survival in male and female patients: an observational study from the MONICA/KORA Myocardial Infarction Registry.

BACKGROUND: Sleep-related investigations in acute myocardial infarction (AMI) patients are rare. The aim of this study was to examine sex-specific associations of patient-reported sleep disturbances within 4 weeks before AMI and long-term survival. METHODS: From a German population-based, regional AMI registry, 2511 men and 828 women, aged 28-74 years, hospitalized with a first-time AMI between 2000 and 2008 and still alive after 28 days, were included in the study (end of follow-up: 12/2011). Frequency of any sleep disturbances within 4 weeks before AMI was inquired by a 6-categorical item summarized to 'never', 'sometimes' and 'nightly'. Cox regression models were calculated. RESULTS: Over the median follow-up time of 6.1 years (IQR: 4.1) sleep disturbances were reported by 32.3% of male and 48.4% of female patients. During the observation period, 318 men (12.7%) and 131 women (15.8%) died. Men who 'sometimes' had sleep disturbances showed a 56% increased mortality risk compared to those without complaints in an age-adjusted model (HR 1.56; 95%-CI 1.21-2.00). Additional adjustment for confounding variables attenuated the effect to 1.40 (95%-CI 1.08-1.81). Corresponding HRs among women were 0.97 (95%-CI 0.65-1.44) and 0.99 (95%-CI 0.66-1.49). HRs for patients with nightly sleep disturbances did not suggest any association for both sexes. CONCLUSIONS: Our study found that nightly sleep disturbances have no influence on long-term survival in male and female AMI patients. Contrary to women, men who reported sometimes sleep disturbances had a higher mortality. Further investigations on this topic taking into account the role of obstructive sleep apnoea are needed.

Determinants of adherence and effects on health-related quality of life after myocardial infarction: a prospective cohort study.

BACKGROUND: Adherence to recommendations and medication is deemed to be important for effectiveness of case management interventions. Thus, reasons for non-adherence and effects on health-related quality of life (HRQoL) should be fully understood. The objective of this research was to identify determinants of non-adherence to medication and recommendations, and to test whether increased adherence improved HRQoL in patients after myocardial infarction (MI) in a case management intervention. METHODS: Data were obtained from the intervention group of the KORINNA study, a randomized controlled trail of a nurse-led case management intervention with targeted recommendations in the elderly after MI in Germany. Reasons for non-adherence were described. Logistic mixed effects models and OLS (ordinary least squares) were used to analyze the effect of recommendations on the probability of adherence and the association between adherence and HRQoL. RESULTS: One hundred and twenty-seven patients with 965 contacts were included. Frequent reasons for non-adherence to medication and recommendations were "forgotten" (22%; 11%), "reluctant" (18%; 18%), "side effects" (38%; 7%), "the problem disappeared" (6%; 13%), and "barriers" (0%; 13%). The probability of adherence was lowest for disease and self-management (38%) and highest for visits to the doctor (61%). Only if patients diverging from prescribed medication because of side effects were also considered as adherent, 3-year medication adherence was associated with a significant gain of 0.34 quality-adjusted life years (QALYs). CONCLUSIONS: Most important determinants of non-adherence to medication were side effects, and to recommendations reluctance. Recommended improvements in disease and self-management were least likely adhered. Medication adherence was associated with HRQoL. TRIAL REGISTRATION: Current Controlled Trials ISRCTN02893746 , retrospectively registered, date assigned 27/03/2009.

Association between admission anemia and long-term mortality in patients with acute myocardial infarction: results from the MONICA/KORA myocardial infarction registry.

BACKGROUND: Previous studies have shown that the presence of anemia is associated with increased short- and long-term outcomes in patients with acute myocardial infarction (AMI). This study aims at examining the impact of admission anemia on long-term, all-cause mortality following AMI in patients recruited from a population-based registry. Contrary to most prior studies, we distinguished between patients with mild and moderate to severe anemia. METHODS: This prospective study was conducted in 2011 patients consecutively hospitalized for AMI that occurred between January 2005 and December 2008. Patients who survived more than 28 days after AMI were followed up until December 2011. Hemoglobin (Hb) concentration was measured at hospital admission and classified according to the World Health Organization (WHO). Mild anemia was defined as Hb concentration of 11 to < 12 g/dL in women and 11 to < 13 g/dL in men; moderate to severe anemia as Hb concentration of < 11 g/dL. Adjusted Cox regression models were calculated to compare survival in patients with and without anemia. RESULTS: Mild anemia and moderate to severe anemia was found in 183 (9.1%) and 100 (5%) patients, respectively. All-cause mortality after a median follow-up time of 4.2 years was 11.9%. The Cox regression analysis showed significantly increased mortality risks in both patients with mild (HR 1.74, 95% CI 1.23-2.45) and moderate to severe anemia (HR 2.05, 95% CI 1.37-3.05) compared to patients without anemia. CONCLUSION: This study shows that anemia adversely affects long-term survival following AMI. However, further studies are needed to confirm that anemia can solely explain worse long-term outcomes after AMI.

Peripheral arterial disease is associated with higher mortality in patients with incident acute myocardial infarction.

BACKGROUND: Little data is available on short- and long-term survival in patients with peripheral arterial disease (PAD) after acute myocardial infarction (AMI). We aimed to examine the association of PAD and 28-day case fatality as well as long-term mortality in a population-based sample of patients with incident AMI. METHODS: In this secondary analysis of data from the German MONICA/KORA Myocardial Infarction Registry 4307 patients aged 28-74years with incident AMI with and without history of PAD (information derived from medical chart) were included. Data were collected between 2000 and 2008. Patients were followed-up until December 2011. Associations between PAD and 28-day case fatality were examined via multivariable logistic regression models, between PAD and long-term mortality with Cox proportional hazards regression models, respectively. RESULTS: From 303 (8.9%) patients with PAD, 22 (7.3%) died within 28-days post-AMI in contrast to 96 (2.9%) of patients without PAD. However, the fully adjusted model (OR 1.55, 95% CI 0.89-2.70) revealed no significant association. Long-term follow-up (median 5.7years) yielded 100 (32.4%) versus 483 (14.4%) cases of deaths among patients with and without PAD, respectively. This association was significant (fully adjusted model: HR 1.70, 95% CI 1.35-2.13), persisted up to 11years after AMI and was present in all subgroups according to age, sex and history of diabetes. The highest long-term mortality risk was found for patients younger than 63years with PAD (HR 2.19; 95% CI 1.41-3.39). CONCLUSION: AMI patients with PAD differ considerably from their counterparts without PAD in terms of long-term survival.

Medication use in long-term survivors from the MONICA/KORA Myocardial Infarction Registry.

BACKGROUND: Prior studies reported high guideline adherence for secondary prevention medications (SPM) at hospital discharge in patients with acute myocardial infarction (AMI). Less is known about medication use in long-term AMI survivors. METHODS: Of the 2077 registered persons with an AMI between 2000 and 2008 who responded to a postal follow-up survey in 2011, 1311 men and 356 women, aged between 34.4 and 84.9years, reported medication intake 7days prior to the survey. These study participants also had their current health condition and comorbidities assessed. Information regarding index AMI was selected from the population-based MONICA/KORA MI registry. Multivariable logistic regression models were conducted to identify factors associated with SPM use (all 4 drug classes). RESULTS: The median time between index AMI and the follow-up survey was 6.1years (IQR: 3.9). At follow-up, a total of 10,422 medications were reported and polypharmacy was observed in 73.8%. Regarding SPM, the proportion of patients taking antiplatelet agents, beta-blockers, statins, and renin-angiotensin-aldosteron system blockers were 90.9%, 86.7%, 85.4%, and 79.3% respectively. Factors associated with SPM use were hypertension (odds ratio [OR] 1.48, p=0.006), SPM prescription at hospital discharge (OR 2.68, p<0.0001), revascularization therapy at index AMI (OR 2.46, p>0.0001), number of medications taken at follow-up (OR 1.48, p<0.0001), and several comorbidities such as lung disorders (OR 0.17; p<0.0001), depression (OR 0.53, p=0.001), neurological disorders (without stroke) (OR 0.34, p=0.002), and cancer (OR 0.45, p=0.005). CONCLUSION: SPM use several years after AMI was high and associated with treatment at index AMI and patients' comorbidities.

Admission serum potassium concentration and long-term mortality in patients with acute myocardial infarction: results from the MONICA/KORA myocardial infarction registry.

BACKGROUND: Conflicting with clinical practice guidelines, recent studies demonstrated that serum potassium concentrations (SPC) of ≥4.5 mEq/l were associated with increased mortality in patients with acute myocardial infarction (AMI). This study examined the association between SPC and long-term mortality following AMI in patients recruited from a population-based registry. METHODS: Included in the study were 3347 patients with AMI aged 28-74 years consecutively hospitalized between 1 January 2000 and 31 December 2008 and followed up until 31 December 2011. Patients were categorized into five SPC groups (<3.5, 3.5 to <4.0, 4.0 to <4.5, 4.5 to <5.0, and ≥5.0 mEq/l). The outcome of the study was all-cause mortality. Cox regression models adjusted for risk factors, co-morbidities and in-hospital treatment were constructed. RESULTS: In our study population, 249 patients (7.4%) had a low SPC (<3.5 mEq/l) and 134 (4.0%) patients had a high SPC (≥5.0 mEq/l). Patients with SPC of ≥5.0 mEq/l had the highest long-term mortality (29.9%) and in the adjusted model, their risk of dying was significantly increased (HR 1.46, 95% CI 1.03 to 2.07) compared to patients with SPC between 4.0 and <4.5 mEq/l. Analyses of increasing observation periods showed a trend towards a higher risk of dying in patients with SPC between 4.5 and <5.0 mEq/l. CONCLUSION: An admission SPC of ≥5.0 mEq/l might be associated with an increased mortality risk in patients with AMI. Patients with an admission SPC between 4.5 and <5.0 mEq/l might have an increased mortality risk in the first few years following AMI.

The 3-Year Cost-Effectiveness of a Nurse-Based Case Management versus Usual Care for Elderly Patients with Myocardial Infarction: Results from the KORINNA Follow-Up Study.

OBJECTIVES: To assess the 3-year cost-effectiveness of a nurse-based case management intervention in elderly patients with myocardial infarction from a societal perspective. METHODS: The intervention consisted of one home visit and quarterly telephone calls in the first year, and semi-annual calls in the following 2 years. The primary effect measures were quality-adjusted life-years (QALYs), on the basis of the EuroQol five-dimensional questionnaire (EQ-5D-3L) and adjusted life-years from patients' self-rated health states according to the visual analogue scale (VAS-ALs). A linear regression model was used for adjusted life-years and a gamma model for costs. Estimation uncertainty was addressed by cost-effectiveness acceptability curves, which indicate the likelihood of cost-effectiveness for a given value of willingness to pay. The secondary objective was to examine EQ-5D-3L utility scores and VAS scores among survivors using linear mixed models. RESULTS: Primary outcomes regarding QALY gains (+0.0295; P = 0.76) and VAS-AL gains (+0.1332; P = 0.09) in the intervention group were not significant. The overall cost difference was -€2575 (P = 0.30). The probability of cost-effectiveness of the case management at a willingness-to-pay value of €0 per QALY was 84% in the case of QALYs and 81% in the case of VAS-ALs. Secondary outcomes concerning survivors' quality of life were significantly better in the intervention group (EQ-5D-3L utilities: +0.104, P = 0.005; VAS: +8.15, P = 0.001) after 3 years. CONCLUSIONS: The case management was cost-neutral and led to an important and significant improvement in health status among survivors. It was associated with higher QALYs and lower costs but the differences in costs and QALYs were not statistically significant.

Presenting symptoms, pre-hospital delay time and 28-day case fatality in patients with peripheral arterial disease and acute myocardial infarction from the MONICA/KORA Myocardial Infarction Registry.

Background Previous studies have indicated that patients with acute myocardial infarction (AMI) who have a history of peripheral arterial disease (PAD) have different characteristics and poorer outcomes than patients without PAD. However, data on short-term mortality are conflicting and it is unclear whether patients with PAD have a different scope of AMI symptoms or differences in pre-hospital delay time (PHDT) compared with patients without PAD. The objective of this study was to determine the associations between a history of PAD and presenting AMI symptoms, PHDT and 28-day case fatality in a population-based sample of patients with AMI. Design This was an observational study. Methods Information on history of PAD was obtained from the patients' medical records and their AMI symptoms were assessed by interviews with patients. Multivariable logistic regression models were used to determine the association of PAD with AMI symptoms and 28-day case fatality. A multivariable linear regression model was developed to examine the relations between PAD and PHDT. Results From the 5848 patients with AMI included in this study, 9.8% had a history of PAD. Patients with PAD were significantly less likely to report chest symptoms (odds ratio (OR) 0.52, 95% confidence interval (CI) 0.41-0.66) or pain in the upper left extremity (OR 0.67, 95% CI 0.54-0.84) than patients without PAD. PAD was significantly related with longer PHDT in patients <69 years of age ( p = 0.0117) and men ( p = 0.0104). A significantly higher 28-day case fatality (OR 2.09, 95% CI 1.47-2.96) was found in patients with PAD compared with patients without PAD. Conclusions Patients with PAD should receive comprehensive education on the possibility of atypical AMI symptoms and the need to call emergency medical services immediately.

Predictors of non-invasive therapy and 28-day-case fatality in elderly compared to younger patients with acute myocardial infarction: an observational study from the MONICA/KORA Myocardial Infarction Registry.

BACKGROUND: A substantial proportion of patients with acute myocardial infarction (AMI) did not receive invasive therapy, defined as percutaneous coronary intervention and/or coronary artery bypass grafting. Aims of this study were to evaluate predictors of non-invasive therapy in elderly compared to younger AMI patients and to assess the association between invasive therapy and 28-day-case fatality. METHODS: From the German population-based registry, 3475 persons, consecutively hospitalized with an AMI between 2009 and 2012 were included. Data were collected by standardized interviews and chart review. All-cause mortality was assessed on a regular basis. Multivariable logistic regression analyses were conducted. RESULTS: The sample consisted of 1329 patients aged 28-65 years (age category [AC] 1), 1083 aged 65-74 years (AC 2), and 1063 aged 75-84 years (AC 3). The proportion of patients receiving non-invasive therapy was 10.7, 17.7, and 35.8 % in AC 1, 2, and 3, respectively. Predictors of non-invasive therapy in all ACs were non-ST segment elevation MI, bundle branch block, reduced left ventricular ejection fraction, prior stroke, absence of hyperlipidemia, and low creatine kinase. Elderly women (≥65 years) were less likely to receive invasive therapy. Stratifying the models by type of AMI revealed fewer predictors in patients with ST segment elevation MI. Regarding 28-day-case fatality, strong inverse relations with invasive therapy were seen in all AC: odds ratio of 0.35 (95 % confidence interval [CI] 0.15-0.84), 0.45 (95 % CI 0.22-0.92), and 0.39 (95 % CI 0.24-0.63) in AC 1, 2 and 3, respectively. CONCLUSION: In today's real-life patient care we found that predictors of non-invasive therapy were predominantly the same in all age groups, but differed particularly by type of AMI. Further research is necessary to investigate the real reasons for non-invasive therapy, especially among elderly women. Moreover, we confirmed that receiving invasive therapy was inversely associated with 28-day-case fatality independent of age.

Variables associated with disability in male and female long-term survivors from acute myocardial infarction. Results from the MONICA/KORA Myocardial Infarction Registry.

Increasing attention is paid on functional limitations and disability among people with chronic diseases. However, only few studies have explored disability in persons with acute myocardial infarction (AMI). The objective of this study was to provide a description of disability and to identify determinants of disability in a population-based sample of long-term AMI survivors. The sample consisted of 1943 persons (35-85years) with AMI from the German population-based MONICA/KORA Myocardial Infarction Registry, who responded to a postal follow-up survey in 2011. Disability was assessed with the 12-item version of the World Health Organization Disability Schedule (WHODAS). Multivariate linear regression models were established in order to identify socioeconomic and clinical factors, risk factors and comorbidities which are associated with disability. The mean WHODAS score for the total sample was 7.86±9.38. The regression model includes 26 variables that explained 37.2% of the WHODAS variance. Most of the explained variance could be attributed to the presence of depression, female sex, joint disorders, digestive disorders, and stroke. Depression was the most important determinant of disability in both sexes. Replacement of single comorbidities by the total number of comorbidities resulted in a model with 15 variables explaining 31.9% of the WHODAS variance. Most of the variance was explained by the number of comorbidities. Further significant determinants of disability were female sex, low education level, angina pectoris, and no revascularization therapy. In AMI patients, the number of comorbidities and particularly the presence of depression are important determinants of disability and should be considered in post-AMI health care.

Mismatch of presenting symptoms at first and recurrent acute myocardial infarction. From the MONICA/KORA Myocardial Infarction Registry.

BACKGROUND: It is unknown whether the symptoms of first and recurrent acute myocardial infarction (AMI) are similar in the same person. This study examined the frequency of symptom mismatch, which factors are associated with a symptom mismatch and how symptom mismatch is related to 28-day case fatality. DESIGN: Observational study. METHODS: The sample consisted of 1282 persons with a first and recurrent AMI, recruited from a population-based AMI registry, 1985-2011. Occurrence of 11 symptoms was recorded in first and recurrent AMI using standardized patient interview. Logistic regression modelling adjusted for demographic and clinical variables was applied. RESULTS: Mismatch was highest for dyspnoea (40.6%) and lowest for chest symptoms (10.4%). Compared with women, men were less likely to have a mismatch of pain between the shoulder blades (odds ratio (OR) 0.58, 95% confidence interval (CI) 0.43-0.79), pain in the throat/jaw (OR 0.67, 95% CI 0.50-0.91), nausea (OR 0.62, 95% CI 0.47-0.82), vomiting (OR 0.50, 95% CI 0.36-0.71), or fear of death (OR 0.71, 95% CI 0.53-0.94), or to have three or more mismatching symptoms (OR 0.60, 95% CI 0.45-0.79). Persons with diabetes were more likely to have a mismatch in chest symptoms, whereas persons with hyperlipidaemia or persons who received any revascularization therapy at first infarction were significantly less likely to have a mismatch of chest symptoms. Twenty-eight-day case fatality significantly increased with the number of mismatching symptoms (OR 1.14, 95% CI 1.02-1.28). CONCLUSIONS: Patients with AMI may benefit from information about the possibility that a recurrent infarction may be associated with different symptoms.

Acute myocardial infarction in the elderly: Treatment strategies and 28-day-case fatality from the MONICA/KORA myocardial infarction registry.

OBJECTIVES: Aim of this observational study was to analyze today's real-life treatment strategies in elderly patients with an acute myocardial infarction (AMI) and to assess the association between 28-day-case fatality and invasive strategy (percutaneous coronary intervention/coronary artery bypass grafting). BACKGROUND: Elderly patients increasingly constitute a large proportion of the AMI population. METHODS: The present study is an analysis of all patients aged 75-84 years, who were enrolled in the German population-based MONICA/KORA MI registry between 2009 and 2012 and who were defined as nonfatal at least 24 hours surviving AMI cases according to MONICA definition. Multivariable logistic regression analyses were conducted for the total study population and stratified by type of AMI (ST-segment elevation MI [STEMI], Non-ST-segment elevation MI [NSTEMI], and bundle branch block [BBB]). RESULTS: Out of the 1,191 elderlies, 61.9% were treated invasively. In the multivariable analysis, the odds ratio (OR) for 28-day-case fatality in patients treated with invasive versus conservative strategy was 0.43 (95% CI 0.27-0.69). Stratified analyses revealed an OR of 0.27 (95% CI 0.13-0.56) for patients with NSTEMI. In patients with STEMI or BBB also a positive trend for invasive strategy was observed (OR 0.40; 95% CI 0.13-1.27 and OR 0.76; 95% CI 0.16-3.66, respectively). CONCLUSIONS: Invasive revascularization therapy was independently associated with short-term survival in elderly patients, particularly in those with NSTEMI.

Validity of self-reported hospital admissions in clinical trials depends on recall period length and individual characteristics.

RATIONALE, AIMS AND OBJECTIVES: We investigated the validity of self-reported admission data compared to administrative records in a clinical trial. METHOD: In the randomized KORINNA study (ISRCTN02893746), hospital admission data were collected in telephone interviews with 273 elderly patients quarterly over a 1-year period and thereafter annually over a 2-year period. Data were compared with administrative records and discharge letters. Mixed models were used to investigate if recall period and individual characteristics influence validity. RESULTS: Specificity (>99%) and sensitivity (94%) of self-reported data did not differ for different recall periods (3 months vs. 12 months). The differences between self-reported and registered inpatient days were not statistically significant. Having regard to all the admissions within the time period of last interview and dropping out, the bias was up to 40% underestimation. The chance of disagreement was significantly smaller [odds ratio (OR) of misremember an admission = 0.596, P = 0.049, confidence interval (CI) = 0.355 to 1.00; OR of misremember length of stay = 0.521, P = 0.002, CI = 0.344 to 0.789] for 3-month periods, but this was primarily driven by number of admissions within the recall period. Individuals with better health and longer stays had a significantly smaller chance of disagreement. CONCLUSIONS: The bias within one year was not influenced by applying various recall periods, although the probability of correctly self-reported single hospital admission was higher using a recall period of three months. It can be recommended that lengthened recall periods of 12 months are appropriate for gathering self-reported hospital admission data in elderly people with myocardial infarction.