Admission glucose level and short-term mortality in older patients with acute myocardial infarction: results from the KORA Myocardial Infarction Registry.

STUDY OBJECTIVES: To investigate the association between admission blood glucose levels and 28-day mortality as well as in-hospital complications in older patients with incident acute myocardial infarction (AMI) undergoing modern treatment. METHODS: From a German population-based regional MI registry, 5530 patients (2016 women), aged 65-84 years, hospitalised with an incident AMI between 1 January 2009 and 31 December 2016 were included in the study. Multivariable logistic regression models were used to assess the associations between admission blood glucose and 28-day mortality as well as in-hospital complications after AMI. Analyses stratified according to age, diabetes and type of infarction (ST-elevation MI (STEMI)/non-STEMI) were conducted. RESULTS: The adjusted ORs for the association between admission blood glucose and 28-day mortality in young-old (65-74 years) and old (75-84 years) patients with AMI were 1.40 (95% CI: 1.21 to 1.62) and 1.21 (95% CI: 0.98 to 1.50) per 1 SD increase in admission blood glucose, respectively. Furthermore, higher admission blood glucose was related to case fatality irrespective of the diabetes status and type of infarction only in the under-75 group. For the patients aged 75-84 years, it was only true for those without diabetes and STEMI. Admission blood glucose was also associated with major cardiac complications in both age groups. CONCLUSION: Admission blood glucose was significantly associated with 28-day case fatality in patients with AMI aged 65-74 years but not 75-84 years; furthermore, in both age groups there was an increased risk of major complications. It seems that admission glucose may play a rather minor role in terms of case fatality in higher aged patients with AMI.

Micropollutants removal by full-scale UV-C/sulfate radical based Advanced Oxidation Processes.

The high chemical stability and the low biodegradability of a vast number of micropollutants (MPs) impede their correct treatment in urban wastewater treatment plants. In most cases, the chemical oxidation is the only way to abate them. Advanced Oxidation Processes (AOPs) have been experimentally proved as efficient in the removal of different micropollutants at lab-scale. However, there is not enough information about their application at full-scale. This manuscript reports the application of three different AOPs based on the addition of homogeneous oxidants [hydrogen peroxide, peroxymonosulfate (PMS) and persulfate anions (PS)], in the UV-C tertiary treatment of Estiviel wastewater treatment plant (Toledo, Spain) previously designed and installed in the facility for disinfection. AOPs based on the photolytic decomposition of oxidants have been demonstrated as more efficient than UV-C radiation alone on the removal of 25 different MPs using low dosages (0.05-0.5 mM) and very low UV-C contact time (4-18 s). Photolysis of PMS and H2O2 reached similar average MPs removal in all the range of oxidant dosages, obtaining the highest efficiency with 0.5 mM and 18 s of contact time (48 and 55% respectively). Nevertheless, PMS/UV-C reached slightly higher removal than H2O2/UV-C at low dosages. So, these treatments are selective to degrade the target compounds, obtaining different removal efficiencies for each compound regarding the oxidizing agent, dosages and UV-C contact time. In all the cases, H2O2/UV-C is more efficient than PMS/UV-C, comparing the ratio cost:efficiency (€/m3·order). Even H2O2/UV-C treatments are more efficient than UV-C alone. Thus, the addition of 0.5 mM of H2O2 compensates the increased of UV-C contact time and therefore the increase of electrical consumption, that it should be need to increase the removal of MPs by UV-C treatments alone.

The influence of lunar phases on the occurrence of myocardial infarction: fact or myth? The MONICA/KORA Myocardial Infarction Registry.

AIMS: The potential influence of lunar phases on the occurrence of myocardial infarction is still controversial. The purpose of the present study was to investigate the association of the lunar cycle on the occurrence of fatal and non-fatal myocardial infarction based on a myocardial infarction registry. METHODS AND RESULTS: We studied 15,985 patients consecutively hospitalised with an acute myocardial infarction (AMI) between 1 January 1985 and 31 December 2007 with a known date of symptom onset who were recruited from a population-based myocardial infarction registry. The exact hour of AMI onset was known for 9813 events. Poisson regression analysis was performed to examine the relation between the lunar cycle and the occurrence of AMI. There was no association between new moon, full moon, waning moon and waxing moon and the occurrence of AMI. However, we observed that the three days after a new moon may be significantly protective for the occurrence of AMI, rate ratio (RR) 0.94 (95% CI 0.91-0.98), and the day before a new moon had a slightly negative effect (RR 1.06, 95% CI 1.00-1.12). Stratified analysis did not reveal any susceptible subgroups. CONCLUSION: The moon phases did not show any apparent association with AMI occurrence. However, there might be a 'cardioprotective' time three days after a new moon.

Patient-reported symptoms in acute myocardial infarction: differences related to ST-segment elevation: the MONICA/KORA Myocardial Infarction Registry.

OBJECTIVES: The early recognition of symptoms of myocardial infarction (MI) is crucial for patients with both ST-segment elevation (STEMI) and non-STEMI (NSTEMI). However, to date, only a few studies have examined the differences between patients with STEMI and NSTEMI with regard to the range of presenting MI symptoms. DESIGN: The study population comprised 889 individuals with STEMI and 1268 with NSTEMI, aged 25-74, hospitalized with a first-time MI between January 2001 and December 2006 recruited from a population-based MI registry. The occurrence of 13 symptoms was recorded during a standardized patient interview. RESULTS: Patients with STEMI were significantly younger, more likely to be smokers and less likely to have a history of hypertension or sleep disturbances prior to the acute MI (AMI) event than those with NSTEMI. A total of 50% of the patients attributed their experienced symptoms to the heart. Logistic regression modelling revealed that patients with STEMI were significantly more likely than patients with NSTEMI to complain of vomiting [odds ratio (OR) 2.34, 95% confidence interval (CI) 1.76-3.05], dizziness (OR 1.63, 95% CI 1.30-2.03) and diaphoresis (OR 1.49, 95% CI 1.23-1.81). Furthermore, patients with STEMI were less likely to experience dyspnoea (OR 0.81, 95% CI 0.68-0.98) or pain in the throat/jaw (OR 0.80, 95% CI 0.66-0.98). CONCLUSIONS: Only half of all patients correctly attributed their symptoms to the heart. Patients with STEMI and NSTEMI showed differences regarding several presenting symptoms. Further research is needed to replicate our results, and public awareness of AMI symptoms needs to be improved.

[Multimorbidity and successful aging: the population-based KORA-Age study]. / Multimorbidität und erfolgreiches Altern: Ein Blick auf die Bevölkerung im Rahmen der KORA-Age-Studie.

BACKGROUND: The objective of the KORA-Age research consortium is to assess the determinants and consequences of multimorbidity in the elderly and to look into reasons for successful aging in the general public. PATIENTS AND METHODS: In the KORA-Age cohort study 9,197 persons were included who where born in the year 1943 or before and participants of previous KORA cohort studies conducted between 1984 and 2001 (KORA: Cooperative Health Research in the Region of Augsburg). The randomized intervention study KORINNA (Coronary infarct follow-up treatment in the elderly) tested a nurse-based case management program with 338 patients with myocardial infarct and included an evaluation in health economics. RESULTS: A total of 2,734 deaths were registered, 4,565 participants submitted a postal health status questionnaire and 4,127 participants were interviewed by telephone (response 76.2% and 68.9% respectively). A gender and age-stratified random sample of the cohort consisting of 1,079 persons took part in a physical examination (response 53.8%). CONCLUSION: The KORA-Age consortium was able to collect data in a large population-based sample and is contributing to the understanding of multimorbidity and successful aging.

Admission C-reactive protein and short- as well as long-term mortality in diabetic versus non-diabetic patients with incident myocardial infarction.

BACKGROUND: To investigate the association between admission C-reactive protein (CRP) levels and 28-day case fatality as well as long-term mortality after an incident acute myocardial infarction (AMI) in non-diabetic and diabetic patients. METHODS: The study was based on 461 diabetic and 1,124 non-diabetic persons consecutively hospitalized with a first-ever MI between January 1998 and December 2003 recruited from a population-based MI registry. The study population was stratified into two groups of admission CRP concentrations (cut-off point median

Differences in trends in estimated incidence of myocardial infarction in non-diabetic and diabetic people: Monitoring Trends and Determinants on Cardiovascular Diseases (MONICA)/Cooperative Health Research in the Region of Augsburg (KORA) registry.

AIMS/HYPOTHESIS: One major objective of the St Vincent Declaration was to reduce the excess risk of myocardial infarction in patients with diabetes mellitus. We estimated the trend of the incidence and relative risk of myocardial infarction in the diabetic and non-diabetic populations in southern Germany from 1985 to 2006. METHODS: Using data from the Monitoring Trends and Determinants on Cardiovascular Diseases (MONICA)/Cooperative Health Research in the Region of Augsburg (KORA) Project in southern Germany, we ascertained all fatal and non-fatal first myocardial infarctions between 1985 and 2006 (n = 14,891, age 25-74 years). We estimated the diabetic and the non-diabetic populations using data on diabetes prevalence from surveys, and evaluated incidence of myocardial infarction in the two estimated populations. To test for time trends, we fitted Poisson regression models. RESULTS: Of individuals with first myocardial infarction, 71% were male and 28% known to have diabetes. In the non-diabetic population, myocardial infarction incidence decreased by about 1.5% to 2.0% per year. A comparable decrease was seen in the population of diabetic women. However, in the population of diabetic men, incidence of myocardial infarction increased by about 1% per year. Over the whole study period, myocardial infarction incidence decreased by 34% and 27% in non-diabetic men and women respectively (RR 0.66, 95% CI 0.59-0.74 and 0.73, 0.62-0.87 respectively). In diabetic women, it decreased by 27% (RR 0.73, 0.61-0.88), whereas in diabetic men, it increased by 25% (RR 1.25, 1.07-1.45). CONCLUSIONS/INTERPRETATION: Our results suggest that the St Vincent goal of reducing excess cardiovascular morbidity in diabetic individuals has not been achieved and that the situation in men has actually got worse.

A technical mixture of 2,2',4,4'-tetrabromo diphenyl ether (BDE47) and brominated furans triggers aryl hydrocarbon receptor (AhR) mediated gene expression and toxicity.

Polybrominated diphenyl ethers (PBDE) are found as ubiquitous contaminants in the environment, e.g., in sediments and biota as well as in human blood samples and mother's milk. PBDEs are neuro- and developmental toxins, disturb the endocrine system and some are even carcinogenic. Structural similarities of PBDEs with dioxin-like compounds, e.g., 2,3,7,8-tetrachloro-dibenzodioxin (TCDD), have raised concern about a possible "dioxin-like" action of PBDEs. TCDD exerts its toxicity via binding to and activation of the aryl hydrocarbon receptor (AhR). AhR ligands are in contrast to PBDEs usually coplanar compounds. Thus, PBDEs are not likely to be strong AhR agonists. The aim of this study was to analyze the effects of the most abundant PBDE congener, 2,2',4,4'-tetrabromo diphenyl ether (BDE47), on AhR activity and signaling. Initially, we measured cytochrome P450 1A1 (Cyp1A1) induction as a readout for AhR activation by BDE47. Low grade purified BDE47 increased CYP1A1 levels in transformed and primary rat hepatocytes and human hepatoma cells. Chemical analysis of the BDE47 sample identified trace contaminations with brominated furans such as 2,3,7,8-tetrabromo dibenzodioxin (TBDF), which most likely were responsible for the observed activation of AhR. Subsequently, the BDE47 mixture was studied for its effect on AhR mediated toxicity and global gene expression. Indeed, in rat hepatoma cells and in zebrafish embryos the BDE47 mixture provoked changes in gene expression and toxicity similar to known AhR agonists. In addition to the dioxin-like actions, the BDE47 sample enhanced Cyp2B and Cyp3A expression suggesting that commercial PBDE mixtures, which also often contain brominated furans, may disturb cellular homeostasis at multiple levels.

20-year trends in clinical characteristics, therapy and short-term prognosis in acute myocardial infarction according to presenting electrocardiogram: the MONICA/KORA AMI Registry (1985-2004).

OBJECTIVES: To examine the extent to which evidence-based beneficial therapy is applied in practice, whether this is changing over time and is associated with improved outcomes. BACKGROUND: Randomized trials have proved efficacy of several treatments for acute myocardial infarction (AMI) with ST-elevation (STEMI), non-ST-elevation (NSTEMI) and bundle branch block (BBB). DESIGN AND SETTING: We prospectively examined all 6748 consecutive patients with AMI aged 25-74 years hospitalized in the study region's major clinic stratified into four time-periods: 1985-1989 (n = 1622), 1990-1994 (n = 1588), 1995-1999 (n = 1450) and 2000-2004 (n = 2088). RESULTS: The increase in numbers of AMI in the last period was mainly, but not exclusively driven by NSTEMI cases. Evidence-based pharmacological therapy increased steeply over time. Invasive procedures increased mainly in the last period with percutaneous coronary intervention and coronary artery bypass graft performed in 30% and 15% in 1998 and 66.0% and 22%, respectively, in 2004. In-hospital complications and 28-day-case fatality decreased significantly from period 1 to period 4 in all patients with AMI. Marked reductions in 28-day-case fatality were mostly seen in BBB patients during the last period (25.3% vs. 10.3%, P < 0.001). Of interest, the odds in 28-day-case fatality reduction was diminished after correction for recanalization therapy (from 0.35, 95% CI: 0.16-0.74 to 0.52, 95% CI: 0.19-1.45). CONCLUSIONS: Over the past 20 years, there were substantial changes in pharmacological and interventional therapies in AMI accompanied by reductions in in-hospital complications and 28-day-case fatality in all infarction types with marked reductions in 28-day-case fatality in BBB patients. The latter observation may mainly be because of the increased use of interventional therapy.

Influence of antihypertensive therapy and blood pressure control on left ventricular geometry and function in subjects with type II diabetes: The Augsburg Diabetes Family Study.

Cross-sectional data often fail to show beneficial effects of antihypertensive therapy in patients with hypertension. We, therefore, examined the influence of hypertension control on left ventricular (LV) structure in diabetic persons separated into those having and not having any known cardiovascular disease (CVD) symptoms. The study population consisted of 394 subjects with type II diabetes. According to the presence of CVD, subjects were classified as symptomatic (N=181) or asymptomatic (N=213). In addition, three groups were differentiated: controlled hypertensives (CHs), that is, known hypertension with normal blood pressure (BP), uncontrolled hypertensives (UHs), that is, elevated BP regardless of antihypertensive medication, and normotensives (Ns). Symptomatic subjects showed a significantly higher prevalence of LV hypertrophy (LVH) (34.5 vs 23.4%, P<0.02). In contrast to symptomatic subjects where hypertension control status had no further significant impact on LV geometry, a considerable impact on preservation of normal LV geometry was observed in asymptomatic persons (LVH of 30, 15 and 18% in UH, CH and N, respectively, P<0.001). Control of hypertension in early diabetes seems especially to prevent the development of concentric hypertrophy (24 vs 11% in UH vs CH, P<0.04). In conclusion, in subjects with diabetes and CVD, the prevalence of LV structural abnormalities is very high. Although in this population-based study setting, in the latter group BP control does not seem to positively influence LV mass and function, hypertension control in still asymptomatic diabetic persons is beneficial and has a considerable impact on preservation of normal LV geometry.

[Distribution, determinants and reference values of left ventricular parameters in the general population--results of the MONICA/KORA echocardiography studies]. / Verteilung, Determinanten und Referenzwerte linksventrikulärer Parameter in der Allgemeinbevölkerung -- Resultate der MONICA/KORA-Echokardiographiestudien.

For successful fighting against the burden of cardiovascular disease in the community a comprehensive knowledge about the prevalence and the impact of underlying risk factors is important. The present paper summarises some studies undertaken on more than 2000 persons from the MONICA/KORA-studies (parts of S1 and S3) where left ventricular mass (LVM) and other left ventricular parameters were determined by echocardiography. We especially investigated the associations of LVM with blood pressure and obesity. A special focus was on sex-specific factors in the determination of LVM and the influence of different indices of body size when normalising LVM. It could be shown that hypertension and obesity are major determinants of LV hypertrophy. Especially women with both hypertension and obesity on showed a high prevalence of concentric hypertrophy, significantly more than men. We also showed that the prevalence of LV hypertrophy in a representative sample of the general population (25 to 74 years) is 17.5 % for men, and 18.5 % for women. This underscores the need for primary and secondary prevention regarding the development of LV hypertrophy. Finally, our data in a selected group of normal subjects (reference sample) may be used for the development of reference values for left ventricular parameters in the general German population.

Cardiovascular phenotypes and functional parameters in the general population--results of the MONICA/KORA studies.

The MONICA/KORA surveys are characterized by a careful and broad investigation of multiple cardiovascular phenotypes. Particularly, repeated blinded measurements of blood pressure, comprehensive echocardiographic and electrocardiographic evaluations as well as differentiation between fat and fat-free body mass have led to manifold innovative observations. Specifically, genetic and serological markers of the renin angiotensin system could be associated with high blood pressure and left ventricular hypertrophy. The same applies to the importance of parameters of body composition as obesity and muscular mass. Moreover, the prevalence of heart failure in the general population could be determined for the first time in Germany. Additionally, the prevalence of left ventricular systolic and diastolic dysfunction could be obtained in the region of the survey, exemplarily for the Federal Republic of Germany. Finally, the surveys of the population random sample were used to define normal serum levels of natriuretic peptides. In summary, the evaluation of cardiovascular phenotypes in the MONICA/KORA surveys resulted in a -- in the European region unique -- documentation of cardiovascular functional parameters in the general population. Moreover, multiple epidemiological observations as to pathophysiologically relevant topics of heart and vascular diseases could be studied in extraordinary details.

[Sex specific trends of sudden cardiac death and acute myocardial infarction: results of the population-based KORA/MONICA-Augsburg register 1985 to 1998]. / Geschlechtsspezifische Trends von plötzlichem Herztod und akutem Herzinfarkt - Ergebnisse des bevölkerungsbasierten KORA1/MONICA Augsburg Herzinfarkt-Registers 1985 bis 1998 -

BACKGROUND AND AIM: Myocardial infarction (MI) is the main single cause of death in adult populations. For the MONICA Augsburg population, MI-morbidity, mortality, and 28-day case fatality and their determinants were assessed by gender, and suggestions for an intensified acute care program were presented. PATIENTS AND METHODS: From 1985 to 1998, 13 499 25- to 74-year-old MI cases (9537 men, 3962 women) were registered; 7873 cases (5300 men, 2573 women) died within 28 days. Cardiac deaths were identified by regional health departments; causes of death were validated by the last treating physician and the coroner (response > 90 %). Hospitalized patients were interviewed about history and circumstances of the acute event; treatment data were abstracted from hospital charts. The prehospital phase, the first and the 2nd to 28thday after hospitalization were analyzed separately. RESULTS: MI-morbidity per 100 000 population declined from 560 to 397 MI cases in men and from 161 to 145 in women; mortality decreased from 317 to 232 in men and from 101 to 96 in women. The decline in men was due to decreasing incident and recurrent MI whereas in women it was only due to a reduction of recurrent MI. One third died before hospitalization, mainly at home. Case fatality (CF) on the first day in hospital increased. In 24 hour survivors, evidence based treatment increased considerably, and was accompanied by decreasing 28-day-CF from 13.0 % to 8.4 % in men, and from 12.5 % to 10.7 % in women. CONCLUSION: Aggressive risk factor management and education of patients with cardiovascular risk factors concerning acute symptoms and the use of the emergency system will consequently improve pre-hospital and 28-day survival of the population.

What is the real hospital mortality from acute myocardial infarction? Epidemiological vs clinical view.

AIMS: To examine the general influence of the definition of fatal and non-fatal acute myocardial infarction and coronary deaths on the estimation of in-hospital case-fatality, and to show how the definition of acute myocardial infarction influences time-trends of hospital mortality over 11 years. METHODS AND RESULTS: As part of the World Health Organization's MONICA (multinational Monitoring of Trends and Determinants in Cardiovascular Disease) Project in Augsburg all patients aged 25-74 years with a suspected diagnosis of acute myocardial infarction who were hospitalized in the study region's major clinic were registered prospectively between 1985 to 1995 (n=4889). Patient information, including short-term survival status, was obtained from medical records, by interview of surviving patients, and municipal death certificate files which were validated by an extended identification and validation process. In-hospital case fatality was estimated according to different definitions which closely followed the international MONICA criteria. Epidemiological definitions comprised definite and possible acute myocardial infarction, and events with unclassifiable deaths, while the clinical definition was restricted to definite infarction. Overall, case fatality by the epidemiological definitions was 28 to 29.8% (23.5% of those treated in a coronary care unit) compared to 13.5% using the clinical definition. While over the 11 years, the reduction in case fatality according to the epidemiological definitions was modest, highly significant decreases were observed by applying the clinical definition (from 15.8% in 1985-1988 to 10.8% in 1993-1995, P<0.001 adjusted for age and sex). The discrepancy in case fatality between the definitions is explained by the high proportion of patients who die very early (about 70% of all fatal events during the first 24 h) with the consequence of missing data which may preclude a definite diagnosis of acute myocardial infarction. CONCLUSIONS: Applying a broader definition of acute myocardial infarction reveals that in-hospital mortality is higher than believed until now, and it implies that our efforts must be intensified to reduce overall in-hospital coronary heart disease mortality.

Associations between homocysteine and coagulation factors--a cross-sectional study in two populations of central Europe.

Plasma homocysteine has been associated with vascular disease and mortality. Experimental studies and studies on patients with vascular disease have indicated a thrombogenic potential of raised homocysteine levels. Studies on community samples are rare. We investigated the associations between homocysteine levels and selected coagulation factors in population-based random samples of 187 men from Pardubice (Czech Republic) and 147 men from Augsburg (Germany), aged 45 to 64 years. Czech men had higher mean levels of plasma homocysteine (10.3 vs. 8.9 micromol/l, P<.001) and of fibrinogen, von Willebrand factor (vWF), prothrombin fragment 1+2 (F 1+2) and D-Dimer (each P<.05). Plasma homocysteine was positively correlated with fibrinogen (r=.34) and vWF (r=.23, each P<.001) only in Czechs, and with D-Dimer in both Czechs and Germans (r=.26 and.21, respectively). Formal testing for interaction regarding the intercountry differences in the relationship with homocysteine revealed significance only for fibrinogen (P<.01). In multivariate analyses, the association of homocysteine with D-Dimer remained statistically significant after adjustment for indicators of chronic inflammation and fibrinogen. No significant correlation was found with Factor VII (F VII) activity or F 1+2. Homocysteine levels were also unrelated to traditional risk factors. In conclusion, in these cross-sectional studies we found moderate to strong associations between homocysteine and components of the endogenous hemostatic and fibrinolytic systems. The associations were slightly different between Czech and German men. These findings may help to better understand the role of homocysteine in atherothrombotic diseases.

Determinants of short-period heart rate variability in the general population.

Decreased heart rate variability (HRV) is associated with a worse prognosis in a variety of diseases and disorders. We evaluated the determinants of short-period HRV in a random sample of 149 middle-aged men and 137 women from the general population. Spectral analysis was used to compute low-frequency (LF), high-frequency (HF) and total-frequency power. HRV showed a strong inverse association with age and heart rate in both sexes with a more pronounced effect of heart rate on HRV in women. Age and heart rate-adjusted LF was significantly higher in men and HF higher in women. Significant negative correlations of BMI, triglycerides, insulin and positive correlations of HDL cholesterol with LF and total power occurred only in men. In multivariate analyses, heart rate and age persisted as prominent independent predictors of HRV. In addition, BMI was strongly negatively associated with LF in men but not in women. We conclude that the more pronounced vagal influence in cardiac regulation in middle-aged women and the gender-different influence of heart rate and metabolic factors on HRV may help to explain the lower susceptibility of women for cardiac arrhythmias.

Indexation of left ventricular mass in adults with a novel approximation for fat-free mass.

BACKGROUND: Indexation to fat-free mass (FFM) seems to be the best option for adjusting left ventricular (LV) mass. However, measurements of FFM are frequently not available. OBJECTIVES: To define the relation of FFM with commonly available anthropometric measures in order to derive an approximation formula of FFM that can be used for valid indexation of LV mass. SUBJECTS AND METHODS: A total of 1,371 subjects from a community survey were examined by echocardiography to measure LV mass and by bioelectrical impedance analyses (BIA) for the determination of FFM. An approximation of FFM was generated in a healthy subgroup of 213 men and 291 women by non-linear regression techniques. RESULTS: Compared with body height, height2.0, height2.7, (the superscripts following weight and height are raised powers used as a more appropriate method for indexing LV mass) or body surface area, FFM measured by BIA in the healthy subgroups was best predicted by gender-specific equations of the form: FFM = 5.1 x height1.14 x weight0.41 for men and FFM = 5.34 x height1.47 x weight0.33 for women. In the healthy reference group, indexation of LV mass for BIA-determined FFM and approximated FFM (FFMa), respectively, equally eliminated gender differences in LV mass and markedly reduced the influence of body mass index without affecting the associations between blood pressure and LV mass. Validation of FFMa in two independent population-based samples, aged 52 to 67 years, of the same source population confirmed that LV mass indexed by FFMa produced results that were highly consistent with those obtained with indexation by BIA-determined FFM. CONCLUSIONS: We propose a novel approximation of FFM based on exponentials of body height and weight. It performed well in the indexation of LV mass in middle-aged men and women of this study. Evaluation of the equation in other populations should be awaited before its use is recommended in situations where direct determination of FFM is not possible.

Body composition and prevalence of left ventricular hypertrophy.

BACKGROUND: Fat-free mass (FFM) has been proposed as an optimal normalization of left ventricular (LV) mass to body size. We sought to evaluate the novel FFM-based criteria of LV hypertrophy (LVH). METHODS AND RESULTS: A population sample of 1371 men and women aged 25 to 74 years was examined by echocardiography and bioelectrical impedance analysis. Internal partition values for LVH were generated in a healthy population subgroup on the basis of LV mass divided by FFM and by the traditional indexations to body height, height(2.7), and body surface area. In contrast to the sex-specific criteria required by traditional indexations, the value of LV mass/FFM that divided individuals with and without LVH was identical for men and women (4.1 g/kg). Estimates of LVH prevalence varied significantly by type of indexation used, internally or externally derived cut points, and by population subgroups. Differences were pronounced among hypertensives and the obese. Thus, the application of LV mass/FFM more than halved the risk of LVH in obese versus nonobese women (odds ratio, 2.5; 95% confidence interval, 1.6 to 4.0) compared with criteria based on LV mass/height(2.7) (odds ratio, 5.5; 95% confidence interval, 3.6 to 8.3). Implications among hypertensives were less marked. CONCLUSIONS: Indexation of LV mass to FFM eliminates sex-specific LVH criteria. The proportion of individuals defined as having LVH using the new criteria deviate markedly from traditional indexations. Prospective investigations will be needed to identify the prognostic implications of different indexations, especially in subgroups such as the obese.

An ecological study of determinants of coronary heart disease rates: a comparison of Czech, Bavarian and Israeli men.

BACKGROUND: The large differences in cardiovascular disease rates between Eastern and Western Europe have largely developed over the last few decades, and are only partly explained by classical risk factors. This study was set up to identify other potential determinants of these differences. METHODS: This was an ecological study comparing random samples of men aged 45-64 years selected from three cities representing populations with different rates of cardiovascular mortality: Pardubice (Czech Republic), Augsburg (Bavaria, Germany), and Jerusalem (Israel). In total, 191 (response rate 70%), 153 (70%) and 162 (62%) men, respectively, participated. All centres followed the same study protocol. Lifestyle, anthropometry and biochemical risk factors were assessed by identical questionnaires, standardized medical examination, and central analyses of fasting blood samples. RESULTS: The mortality rates in the study populations, as well as the prevalence of coronary heart disease in study samples, were highest in Czech, intermediate in Bavarian and low in Israeli men. This pattern was replicated across the three samples by mean blood pressure (P < 0.001), cigarette smoking (not significant), triglycerides (P < 0.05), fibrinogen or D-dimer levels (P < 0.05). On the other hand, the prevalence of diabetes and obesity were similar; total and high density lipoprotein (HDL)-cholesterol, apolipoprotein B, lipoprotein (Lp(a)) and glucose did not differ between Czech and Bavarian men; and Czechs had particularly low levels of serum insulin and factor VIIc. Israelis had low fasting glucose and total cholesterol, as well as HDL-cholesterol levels and a high Lp(a) (each P < 0.001) compared with the two other samples. Striking differences were found for plasma homocysteine (10.5 in Czechs versus 8.9 mumol/l in Bavarians, P < 0.001) and for alpha-carotene (geometric mean in Czechs 16, Bavarians 21 and Israelis 30 micrograms/l), beta-carotene (60, 110 and 102 micrograms/l), and lycopene (84, 177 and 223 micrograms/l), respectively; all P-values < 0.001). Adjustment for obesity or smoking did not change these estimates. There were no differences in the levels of tocopherol and retinol. CONCLUSIONS: Czech men had high levels of blood pressure, triglycerides, fibrinogen and D-dimer but many other traditional risk factors, as well as indicators of metabolic disorders and vitamins A and E, did not differ between the study samples. The low levels of carotenoids and high concentrations of homocysteine in Czech men seem to reflect their low dietary intakes of fruit and vegetables. The results provide indirect support for the importance of dietary factors in the East-West morbidity and mortality divide.