Spatial characteristics of non-communicable diseases and their associations to social conditions in a large urban cohort in Germany-Results from the Hamburg City Health Study.

BACKGROUND: Non-communicable diseases (NCDs) are responsible for many deaths. They are associated with several modifiable and metabolic risk factors and are therefore prone to significant regional variations on different scales. However, only few intra-urban studies examined spatial variation in NCDs and its association with social circumstances, especially in Germany. Thus, the present study aimed to identify associations of personal risk factors and local social conditions with NCDs in a large German city. METHODS: This study is based on a population-based cohort of the Hamburg City Health Study including 10,000 probands. Six NCDs were analyzed (chronic obstructive pulmonary disease [COPD], coronary heart disease [CHD], diabetes mellitus, heart failure, depression, and hypertension) in 68 city district clusters. As risk factors, we considered socio-demographic variables (age, sex, education) and risk behaviour variables (smoking, alcohol consumption). Logistic regression analyses identified associations between the district clusters and the prevalence rates for each NCD. Regional variation was detected by Gini coefficients and spatial cluster analyses. Local social condition indexes were correlated with prevalence rates of NCDs on city district level and hot-spot analyses were performed for significant high or low values. RESULTS: The analyses included 7,308 participants with a mean age of 63.1 years (51.5% female). The prevalence of hypertension (67.6%) was the highest. Risk factor associations were identified between smoking, alcohol consumption and education and the prevalence of NCDs (hypertension, diabetes, and COPD). Significant regional variations were detected and persisted after adjusting for personal risk factors. Correlations for prevalence rates with the local social conditions were significant for hypertension (r = 0.294, p < 0.02), diabetes (r = 0.259, p = 0.03), and COPD (r = 0.360, p < 0.01). CONCLUSIONS: The study shows that regional differences in NCD prevalence persist even after adjusting for personal risk factors. This highlights the central role of both personal socio-economic status and behaviors such as alcohol and tobacco consumption. It also highlights the importance of other potential regional factors (e.g. the environment) in shaping NCD prevalence. This knowledge helps policy- and decision-makers to develop intervention strategies.

Inflammatory burden, lifestyle and atherosclerotic cardiovascular disease: insights from a population based cohort study.

The inflammatory burden as measured by high-sensitivity C-reactive Protein (hsCRP) is recognized as a cardiovascular risk factor, which can however be affected by lifestyle-related risk factors (LRF). Up-to-date the interplay between hsCRP, LRF and presence and extent of atherosclerotic disease is still largely unknown, which we therefore sought to investigate in a contemporary population-based cohort. We included participants from the cross-sectional population-based Hamburg City Health Study. Affected vascular beds were defined as coronary, peripheral, and cerebrovascular arteries. LRF considered were lack of physical activity, overweight, active smoking and poor adherence to a Mediterranean diet. We computed multivariable analyses with hsCRP as the dependent variable and LRF as covariates according to the number of vascular beds affected. In the 6765 individuals available for analysis, we found a stepwise increase of hsCRP concentration both according to the number of LRF present as well as the number of vascular beds affected. Adjusted regression analyses showed an independent association between increasing numbers of LRF with hsCRP levels across the extent of atherosclerosis. We demonstrate increasing hsCRP concentrations according to both the number of LRF as well as the extent of atherosclerosis, emphasizing the necessity of lifestyle-related risk factor optimization.

Correlation of systolic and diastolic blood pressure with echocardiographic phenotypes of cardiac structure and function from three German population-based studies.

Arterial hypertension is considered a risk factor for the development of heart failure. Here we investigate cross-sectional associations of systolic and diastolic blood pressure with subtle functional and morphological changes of left ventricular echocardiographic parameters representing early dysfunction in three representative German population-based studies. We assessed 26,719 individuals without symptomatic heart failure from the Hamburg City Health Study (HCHS, n = 7396, derivation cohort), the Gutenberg Health Study (GHS, 14,715, validation cohort) and the Study of Health in Pomerania (SHIP, 4608, validation cohort). Multivariable linear regression analyses with systolic and diastolic blood pressure as continuous exposure variables were adjusted for common cardiovascular risk factors and antihypertensive medication. Both systolic and diastolic blood pressure were consistently associated with measures of left ventricular hypertrophy (ß per standard deviation (SD) for LV mass (g) and systolic blood pressure: 5.09 (p < 0.001); diastolic blood pressure: 2.29 (p < 0.001) in HCHS). Systolic blood pressure correlated with declining diastolic function (ß per SD for E/e': 0.29, p < 0.001 in HCHS) and diastolic blood pressure with declining systolic function (ß per SD for LVEF, in %: - 0.15; p = 0.041 in HCHS) in all cohorts. Pending further validation, our results from three independent German population samples suggest differential effects of systolic versus diastolic blood pressure on left ventricular structure and function.

Association of sexual dysfunction according to DSM-5 diagnostic criteria with avoidance of and discomfort during sex in a population-based sample.

Background: Sexual dysfunction frequencies and diagnostic indicators among older populations are relevant for public health measures, but evidence from large population-based studies is still scarce. Aim: To determine sexual dysfunction frequencies for women and men according to the Diagnostic and Statistical Manual of Mental Disorders (fifth edition; DSM-5) among 45- to 74-year-old participants of the population-based Hamburg City Health Study and the factors associated with sexual dysfunction diagnoses. Methods: We determined sexual dysfunction frequencies according to the DSM-5 and the factors associated with sexual dysfunction diagnoses (quality/avoidance of and discomfort during sex) among 45- to 74-year-olds from 7786 participants of the population-based Hamburg City Health Study. We analyzed cross-sectional self-report questionnaire data collected between 2016 and 2019 using descriptive statistics, comparative tests (Fisher test, Mann-Whitney U test), and logistic regression. Outcomes: Outcomes included sexual dysfunction frequencies - specifically, sexual difficulties experienced frequently or more often, over at least six months in the last year, causing severe or very severe distress, and not associated with physical health or relationship problems - and items on quality/avoidance of and discomfort during sex. Results: Participants' median age was 62.0 years (IQR, 14) and 51.1% were women. The frequency of sexual dysfunction according to the DSM-5 was 9.3% (95% CI, 8.3%-10.4%) in women and 6.2% (95% CI, 5.4%-7.1%) in men, with women's sexual interest/arousal and men's erectile disorder being most common. Sexual dysfunction rates increased with age: whereas complaints were more frequent among women than men in the younger groups, participants aged ≥65 years with a sexual dysfunction were more often men. Quality/avoidance of and discomfort during sex were significantly associated with a diagnosis of sexual dysfunction. Clinical Implications: Results suggest that sexual dysfunction caused by other than physical health or relationship factors is important to consider in this population. In addition, the avoidance of, perceived quality of, and discomfort during sex serve as valuable diagnostic indicators for the presence of sexual dysfunction. Strengths and Limitations: This study draws on robust data from a large sample to give valuable insight on the frequency of sexual difficulties and dysfunctions as defined by DSM-5 criteria. Limitations represent the restriction to self-report questionnaire data, the focus on participants living in a metropolitan area, and the lack of experience of sexual difficulties due to a lack of sexual activity not being taken into account. Conclusion: The study provides estimates for DSM-5 sexual dysfunction frequencies among Germans from a metropolitan area and points to the diagnostic value of age-related changes as well as the quality/avoidance of and discomfort during sex.

Validation of a 0/1 h Algorithm for Rapid Diagnosis of Myocardial Infarction Using a High-Sensitivity Troponin I Assay.

BACKGROUND: Current guidelines recommend 0/1 h algorithms using high-sensitivity cardiac troponin (hs-cTn) for fast diagnosis of myocardial infarction (MI). Yet, for some assays, existing data is limited. We aimed to evaluate the diagnostic performance and the prognostic value of a rapid 0/1 h algorithm for the Access hs-cTnI assay. METHODS: In consecutive patients presenting with suspected MI, we measured concentrations of Access hs-cTnI at presentation and after 1 hour. Final diagnosis was adjudicated independently by 2 cardiologists. Parameters for diagnostic performance were calculated, applying the recently derived European Society of Cardiology (ESC) 0/1 h algorithm for Access hs-cTnI. Additionally, we assessed the prognostic utility of Access hs-cTnI for the composite end point of all-cause mortality and incident MI at 3 years. RESULTS: In 1879 patients, 257 non-ST-elevation MIs occurred. Application of the 0/1 h algorithm classified 44.5% as rule-out, 20.3% as rule-in, and triaged 35.1% to the observe group. High rule-out safety was confirmed with a sensitivity of 97.7% (95% CI, 95.0%-99.1%) and a negative predictive value of 99.3% (95% CI, 98.4%-99.7%). Rule-in capacity was moderate with a specificity of 88.0% (95% CI, 86.3%-89.6%) and a positive predictive value of 50.8% (95% CI, 45.7%-55.9%). After exclusion of patients with ST-elevation MI the results showed strong prognostic value, even after adjustment for cardiovascular risk factors and comorbidities, with adjusted hazard ratios of 2.51 (95% CI, 1.56-4.04) in the observe and 3.55 (95% CI, 2.18-5.79) in the rule-in group for the composite end point of all-cause mortality and incident MI at 3 years, compared to ruled-out patients. CONCLUSION: The ESC 0/1 h algorithm for Access hs-cTnI allows safe and efficient triage of patients with suspected MI and has strong prognostic utility up to 3 years after the initial evaluation.

Pragmatic screening for heart failure in the general population using an electrocardiogram-based neural network.

AIMS: We aim to develop a pragmatic screening tool for heart failure at the general population level. METHODS AND RESULTS: This study was conducted within the Hamburg-City-Health-Study, an ongoing, prospective, observational study enrolling randomly selected inhabitants of the city of Hamburg aged 45-75 years. Heart failure was diagnosed per current guidelines. Using only digital electrocardiograms (ECGs), a convolutional neural network (CNN) was built to discriminate participants with and without heart failure. As comparisons, known risk variables for heart failure were fitted into a logistic regression model and a random forest classifier. Of the 5299 individuals included into this study, 318 individuals (6.0%) had heart failure. Using only the digital ECGs instead of several risk variables as an input, the CNN provided a comparable predictive accuracy for heart failure versus the logistic regression model and the random forest classifier [area under the curve (AUC) of 0.75, a sensitivity of 0.67 and a specificity of 0.69 for the CNN; AUC 0.77, a sensitivity of 0.63 and a specificity of 0.76 for the logistic regression; AUC 0.79, a sensitivity of 0.67 and a specificity of 0.72 for the random forest classifier]. CONCLUSIONS: Using a CNN build on digital ECGs only and requiring no additional input, we derived a screening tool for heart failure in the general population. This could be perfectly embedded into clinical routine of general practitioners, as it builds on an already established diagnostic tool and does not require additional, time-consuming input. This could help to alleviate the underdiagnosis of heart failure.

Comparison of cine cardiac magnetic resonance and echocardiography derived diameters of the aortic root in a large population-based cohort.

Transthoracic echocardiography (TTE) and cine cardiac magnetic resonance imaging (CMR) are established imaging methods of the aortic root. We aimed to evaluate the comparability of measurements in TTE and standard cine CMR sequences of the aortic root. Our study included 741 subjects (mean age 63.5 ± 8 years, 43.7% female) from the Hamburg City Health Study (HCHS). Subjects underwent CMR and TTE. Aortic root measurements were performed at the level of the aortic annulus (AoAn), sinus of Valsalva (SoV), and sinotubular junction (STJ) by standard cine CMR in left ventricular long axis and left ventricular outflow tract view. Measurements were performed applying the leading-edge to leading-edge (LL) convention and inner-edge to inner-edge (II) convention in TTE and the II convention in CMR. Inter correlation coefficients (ICCs) demonstrated high inter- and intraobserver reproducibility for CMR and TTE measurements of SoV and STJ (ICCs 0.9-0.98) and moderate reproducibility for AoAn (ICCs 0.68-0.91). CMR measurements of SoV and STJ showed strong agreement with TTE: while correlations were comparable (r = 0.75-0.85) bias was lower with TTE II (bias - 0.1 to - 0.74) versus TTE LL measurements (mean bias - 1.49 to - 2.58 mm). The agreement for AoAn was fair (r = 0.51-0.57) with variable bias (mean bias 0.39-3.9). Standard cine CMR and TTE derived aortic root measurements are reproducible and comparable with higher agreement for TTE II instead of LL measurements. These results support an interchangeable application of TTE and standard CMR for screening of aortic root diseases thereby possibly reducing redundant multimodality imaging.

Impact of Sex and Cardiovascular Risk Factors on Myocardial T1, Extracellular Volume Fraction, and T2 at 3 Tesla: Results From the Population-Based, Hamburg City Health Study.

BACKGROUND: Reliable reference intervals are crucial for clinical application of myocardial T1 and T2 mapping cardiovascular magnetic resonance imaging. This study evaluated the impact of sex and cardiovascular risk factors on myocardial T1, extracellular volume fraction (ECV), and T2 at 3T in the population-based HCHS (Hamburg City Health Study). METHODS: The final study sample consisted of 1576 consecutive HCHS participants between 46 and 78 years without prevalent heart disease, including 1020 (67.3%) participants with hypertension and 110 (7.5%) with diabetes. T1 and T2 mapping were performed on a 3T scanner using 5b(3b)3b modified Look-Locker inversion recovery and T2 prepared, fast-low-angle shot sequence, respectively. Stepwise regression analyses were performed to identify variables with an independent impact on T1, ECV, and T2. Reference intervals were defined as the interval between the 2.5% and 97.5% quantiles. RESULTS: Sex was the major independent influencing factor of myocardial native T1, ECV, and T2. Female patients had significantly higher upper limits of reference intervals for native T1 (1112-1261 versus 1079-1241 ms), ECV (23%-33% versus 22%-32%), and T2 (36-46 versus 35-45 ms) compared with male patients (all P<0.001). Cardiovascular risk factors, such as diabetes and hypertension, did not systematically affect native T1. There was an independent association of T2 by hypertension and, to a lesser degree, by left ventricular mass, heart rate (all P<0.001), and body mass index (P=0.001). CONCLUSIONS: Sex needs to be considered as the major, independent influencing factor for clinical application of myocardial T1, ECV, and T2 measurements. Consequently, sex-specific reference intervals should be used in clinical routine. Our findings suggest that there is no need for specific reference intervals for myocardial T1 and ECV measurements in individuals with cardiovascular risk factors. However, hypertension should be considered as an additional factor for clinical application of T2 measurements. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT03934957.

Heart failure in the general population and impact of the 2021 European Society of Cardiology Heart Failure Guidelines.

AIM: The diagnosis of heart failure (HF) has been refined in several steps in recent years, reflecting evolving diagnostic and therapeutic approaches. The European Society of Cardiology (ESC) recently published a modified definition of HF in the 2021 heart failure (HF) guidelines. The impact of this new diagnostic algorithm on the prevalence of HF is not known. The aim of this study was to describe the contemporary prevalence of HF in a representative, completely phenotyped sample from the general population. METHODS AND RESULTS: This analysis was conducted among 7074 participants (aged 45-78 years, 51.5% women) from the population-based Hamburg City Health Study. Compared with the 2016 version, HF prevalence increased with the 2021 HF guidelines from 4.31% to 4.83% (12% increase). This increase was driven by a higher number of subjects with HF with reduced/mildly-reduced ejection fraction (0.47% to 0.52%; 1.37% to 2.12%), while the number of subjects with HF with preserved ejection fraction decreased from 2.46% to 2.19%. Importantly, this did not impact the known risk factor profiles of the phenotypes. Although four drugs are recommended for all subjects with HFrEF in the new guidelines, several adjunctive therapies are recommended for dedicated cases/scenarios (e.g. <1% eligibility for ivabradine/vericiguat/devices). CONCLUSION: Heart failure remains common in a contemporary general population sample. The number of patients with HF will increase when the current diagnostic criteria are applied. This offers opportunities to initiate preventive therapies, especially in patients with HFmrEF and HFrEF.

Associations between a Subjective Living Environment and Quality of Life among People with Arterial Hypertension-Results from the Hamburg City Health Study.

Hypertension is a global public health concern and an important contributor to cardiovascular disease. It remains disputed how important life circumstances are for the etiology of hypertension. Thus, the aim of this study is to assess the spatial variation of hypertension within an urban population and to investigate the association with the quality of life of city dwellers and their subjective evaluation of their residential district, as well as their home environment, using the example of Hamburg, Germany. In this cross-sectional study, the first 10,000 participants from the Hamburg City Health Study (HCHS) were analysed. Only participants who had resided at the current address for a minimum of five years were considered. In the descriptive analysis, participants with and without arterial hypertension were compared considering various parameters. The subjective quality of the living environment was obtained using an appropriate subjective living environment index. Quality of life was mapped using the EuroQol Group quality of life questionnaire (EQ-5D) score and the two (mental and physical health) scores of the Short Form Health Questionnaire SF-8. The Gini-coefficient was used to quantify the regional economic variation within Hamburg. Linear and logistic regression analyses were performed. Regional levels were 68 city district clusters in Hamburg. The analysis included n = 8192 participants living at least five years in Hamburg at the time of participation in the HCHS. There was a spatial variation in the prevalence of arterial hypertension within Hamburg. Prevalence rates between city district clusters ranged from 50.0% to 88.5%. The results showed that city district clusters with a worse subjective perception of the living environment were partly associated with an increased prevalence of arterial hypertension. Furthermore, a negative association was observed between arterial hypertension prevalence and the sociodemographic status of participants in the city district clusters. Thus, participants with a high level of education suffered less frequently from arterial hypertension than participants with a rather low level of education. The subjective living environment index and quality of life were significantly related to the occurrence of arterial hypertension; however, more extensive and detailed studies are necessary to derive possible clinical implications.

Applying the ESC 2016, H2 FPEF, and HFA-PEFF diagnostic algorithms for heart failure with preserved ejection fraction to the general population.

AIMS: Heart failure with preserved ejection fraction (HFpEF) is common in patients presenting with dyspnoea. Recently, clinical tools were developed to facilitate the diagnosis of HFpEF. Here, we apply the European Society of Cardiology (ESC) 2016 heart failure guidelines and the H2 FPEF and HFA-PEFF scores to a middle-aged sample of the general population and compared the different groups with each other. METHODS AND RESULTS: This study included the first 10 000 participants of the population-based Hamburg City Health Study. A total of 5613 subjects, aged 62 ± 8.7 years (51.1% women), qualified for the analysis. Unexplained dyspnoea was present in 407 (7.3%) subjects. In those, the estimated prevalence of HFpEF was 20.4% (ESC 2016), 12.3% (H2 FPEF), and 7.6% (HFA-PEFF). The majority of subjects was classified as HFpEF not excludable according to the HFA-PEFF (57.7%) and H2 FPEF (59.2%) scores. For all algorithms, subjects diagnosed with HFpEF showed elevated age and body mass index as well as a higher prevalence of atrial fibrillation, diabetes, and arterial hypertension compared with those without HFpEF or HFpEF not excludable. The distribution of those co-morbidities and risk factors varied between the differently diagnosed HFpEF groups with the highest burden in the HFpEF group defined by the H2 FPEF score. The overlap of subjects diagnosed with HFpEF according to the different algorithms was very limited. CONCLUSIONS: Unexplained dyspnoea is common in the middle-aged general population. The ESC 2016 algorithm and the H2 FPEF and HFA-PEFF scores detect different, discordant subpopulations of probands with breathlessness. Further classification of the HFpEF syndrome is desirable.