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(Stroke. 1998;29:1562-1566.)
© 1998 American Heart Association, Inc.

Original Contributions

Incidence and Risk Factors for Stroke in an Occupational Cohort

The PROCAM Study

K. Berger, MD, MPH; H. Schulte, PhD; F. Stögbauer, MD; G. Assmann, MD, PhD

From the Institute of Atherosclerosis Research (K.B., H.S., G.A.), the Institute of Epidemiology and Social Medicine (K.B.), and the Department of Neurology (K.B., F.S.), University of Muenster, Muenster, Germany.

Correspondence to Klaus Berger, MD, MPH, MSc, Institute of Epidemiology and Social Medicine, Muenster University, Domagkstr 3, 48129 Muenster, Germany. E-mail bergerk{at}uni-muenster.de

	Abstract

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Background and Purpose—The purpose of this study was to assess the incidence of stroke and the magnitude of classic stroke risk factors in an occupational cohort of white-collar and blue-collar workers.

Methods—We studied a prospective cohort of 12 866 male employees, aged 30 to 65 years, in 52 companies in northwestern Germany, with an average follow-up of 7.2 years. Participants were free of self-reported stroke, transient ischemic attack, and myocardial infarction at baseline. Physical examination, blood tests, and a face-to-face interview to assess presence of various risk factors were performed at the workplace. Follow-up was done by standardized mailed questionnaire. Main outcome measure was first stroke occurrence.

Results—Overall stroke incidence was 42.4 per 100 000 person-years, increasing from 10.1 per 100 000 person-years in the age category 30 to 39 years to 33.6, 80.6, and 159.2 per 100 000 person-years in the age categories 40 to 49, 50 to 59, and 60 years and older, respectively. After adjustment for potential confounders, the relative risks of total stroke associated with systolic blood pressure 120, 121 to 140, and 141 mm Hg were 1.00 (reference), 2.99 (95% confidence interval, 0.85 to 10.49), and 5.56 (1.56 to 19.88). The risks associated with smoking status of never/past, 20 cigarettes per day, and >20 cigarettes per day) were 1.00 (reference), 1.65 (0.62 to 4.42), and 3.56 (1.78 to 7.15), respectively. A history of hypertension at baseline (yes versus no) was independently associated with a relative risk of 2.37 (1.20 to 4.71) for total stroke and a history of diabetes mellitus (yes versus no) with a risk of 2.21 (1.00 to 4.87). A comparison of risk factor levels with a general population study revealed only small differences.

Conclusions—This occupational cohort had a 2-fold lower stroke incidence than that observed in cohorts of the general population. In the absence of a strong healthy-worker effect, moderate differences in behavioral risk factors and a higher treatment rate for hypertension contribute to the explanation of this favorable stroke incidence.

Key Words: cerebrovascular disorders • epidemiology • incidence • occupation • risk factors • stroke

	Introduction

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Occupational cohorts differ in many aspects of morbidity from cohorts based on the general population. Disease incidences are in general lower and risk factor profiles more favorable among working populations,^{1 2} unless work-related factors represent risks for specific diseases. The aim of most studies conducted in occupational cohorts is to evaluate potential associations between these work-related factors and certain diseases of interest. The rare chance to prospectively assess cardiovascular and cerebrovascular diseases in an occupational cohort offers an opportunity to contrast incidence rates and risk factor profiles with those from general populations.

Stroke is a leading cause of disabling morbidity and death in many countries of the world.^{3 4 5} Stroke events in actively employed individuals often cause death or premature retirement because of disease-related disability. Because of a strong age dependency, stroke events are not as frequent in working as in general populations but still have considerable socioeconomic impact. Incidence data on stroke are available from only 2 registers^{6 7} in Germany. The Prospective Cardiovascular Muenster Study (PROCAM) offered the first opportunity to evaluate stroke occurrence and magnitude of stroke risk factors in a German prospective cohort study.

	Subjects and Methods

Top Abstract Introduction Subjects and Methods Results Discussion References

 
A detailed description of participants and methods of the PROCAM Study has previously been published.^{8 9} Briefly, 25 000 male and female blue- and white-collar employees, aged 16 to 65 years, in 52 companies and public authorities in the district of Muenster in the northwestern part of Germany were recruited for study participation on a voluntary basis from 1979 through 1990. Baseline examinations took place during paid working hours at the workplace and included face-to-face assessment of medical history using standardized questionnaires, standardized measurement of blood pressure and anthropometric data, a resting ECG, and collection of a blood sample after a 12-hour fast for the determination of various laboratory parameters. Participation rates in each company varied between 40% and 80%. Participation was free of charge, both to employees and to their employers. All findings were reported to the participants themselves and their general practitioners. The assessment of medical history included questions about current medical treatment; prior history of cardiovascular and cerebrovascular disease, hypertension, and diabetes mellitus; family history of cardiovascular disease; and information about smoking status, alcohol consumption, and physical activity. A participant was considered a current smoker if he or she smoked cigarettes daily within the last 12 months. The recommendations of the American and British Heart Associations were followed for blood pressure measurements.¹⁰ Systolic and diastolic readings were taken in the left arm with the subject seated and the arm at heart level. One measurement was taken at the start of the interview by the examining physician and one at its end. Only the second measurement was used in the analysis.

Blood was drawn from each participant in a sitting position. Levels of total cholesterol, triglycerides, and HDL cholesterol were measured using enzymatic assays¹¹ ; HDL cholesterol was measured with a precipitation method from Boehringer Mannheim¹² using a Hitachi 737 autoanalyzer.¹³ LDL cholesterol was calculated by the Friedewald formula if triglycerides were <400 mg/dL.¹⁴ A subject was considered to be glucose intolerant if a diagnosis of diabetes mellitus was known or if glucose in the specimen of whole fasting blood was 120 mg/dL. Laboratory analyses were carried out at the Institute of Atherosclerosis Research at the University of Muenster. The methods of laboratory analyses were validated by regular analyses of reference sera supplied by the national German INSTAND proficiency testing program and the international quality assurance program of the US Centers for Disease Control and Prevention.

During follow-up, participants were mailed a brief questionnaire every 2 years asking about the occurrence of new cardiovascular and cerebrovascular events, including myocardial infarction and stroke. Deaths were usually reported by families, and death certificates were reviewed in all cases. For all events, hospital records or records from the attending physician were requested, as well as an eyewitness account in case of death. The total follow-up was 96% after a maximum of 2 reminders by mail and phone.

A definite stroke was defined as a focal neurological deficit that lasted longer than 24 hours and was attributable to a vascular event. Strokes were classified into ischemic and hemorrhagic subtypes on the basis of mode of onset, clinical findings, and test results. The necessary information was extracted from all available medical records using a standardized stroke assessment form.¹⁵ The rate of MRI and/or CT scan performance in stroke cases was 83%. Because of the small number (n=6), hemorrhagic strokes are not presented separately in this analysis. Strokes were categorized as undetermined if clinical data, although consistent with stroke, did not allow a distinction between ischemic and hemorrhagic subtype. Severity of stroke at hospital discharge or at time of stabilization for patients who were not hospitalized was determined using the following 6-grade scale: no residual impairment (grade 1); minor nonfunctionally impairing deficit (grade 2); mild functional deficit with some restriction of lifestyle (grade 3); moderate deficit significantly interfering with activities of daily life (grade 4); dependent state requiring chronic care (grade 5); and fatality (grade 6).

All reported events were first independently classified by 2 study neurologists (K.B., F.S.) after review of medical records and all other available information. Interrater reliability (kappa statistic) was calculated to compare the 2 classifications. The interrater reliability was good (=0.74) for total stroke, good (=0.74) for ischemic subtype, and excellent (=1.0) for hemorrhagic subtype. In a second step, the 2 neurologists made an end-point decision by commonly confirming or not confirming each reported event.

For the analysis, only first stroke events were included. Because of the very small number of strokes among women and younger men, the analysis was limited to male participants aged 30 to 65 years without a prior history of myocardial infarction and stroke. Because of their ongoing working status, 29 pensioners aged 66 years and older with part-time work contracts were also included. The total number of participants was 12 866, contributing 92 093 person-years over an average follow-up of 7.2 years.

Statistical Analysis
Analysis was performed using the STATA Statistical Package. Comparisons between groups were based on Student's t test for continuous variables and the ² test for discrete variables. For the latter, Fisher's exact test was used for groups of <10 participants. Age-standardized rates of stroke occurrence were calculated using the age distribution of those participants who did not develop a stroke (noncases). Participants were classified in categories of the studied variables to determine incidence rates across risk factors. The Cox proportional hazards model¹⁶ was used to estimate the relative risks (RRs) of major stroke risk factors for total stroke, controlling for important confounders. The assumption of proportional hazards was evaluated for categories of systolic blood pressure. No significant change in RRs over time was found. Thus, stroke events that occurred during the complete follow-up period were included in the analysis. Tests of linear trend in RRs were calculated using the respective categories as an ordinal variable in the proportional hazards model. The RRs and 95% significance levels were calculated using the lowest category as reference. Separate models were calculated for systolic and diastolic blood pressures, since both risk factors were highly correlated.

	Results

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Baseline characteristics of cohort members are given in Table 1. Stroke case subjects were significantly older and had higher systolic and diastolic blood pressure at baseline than noncases. They more often reported a history of hypertension but were less likely to be receiving current blood pressure treatment (47.0% versus 73.0%) if presence of hypertension was known. Of all study participants, 10.5% were newly diagnosed with hypertension, following the World Health Organization definition of hypertension (15.4% in cases, 10.5% in noncases) at baseline. Additionally, borderline isolated systolic hypertension (defined as systolic blood pressure between 140 to 159 mm Hg and diastolic blood pressure <90 mm Hg) was diagnosed in 10.3% of cases and 6.6% of noncases. Differences in smoking status, history of diabetes mellitus, and family history of stroke were of borderline significance. Considerable differences were also observed in lipid profiles of study participants. Those who subsequently developed a stroke had, in general, more unfavorable profiles than those who did not, most markedly with respect to total cholesterol.

View this table: [in this window] [in a new window]   Table 1. Baseline Characteristics of Participants (Men Aged 30–65 Years) in the PROCAM Study According to Stroke Case Status

To better demonstrate a potential healthy-worker effect, we compared participants of the PROCAM Study with those of a general population–based study (the Augsburg MONICA Survey, 1984/1985). The latter, conducted at about midpoint of the course of the PROCAM study, did not assess stroke and had a participation rate of 80.0%. Marked differences (Table 2) were observed in several variables such as obesity, alcohol consumption, and hypertension treatment rate. Additionally, small differences were found in systolic blood pressure, body mass index (BMI), and total cholesterol.

View this table: [in this window] [in a new window]   Table 2. Risk Factor Comparison1 Between Participants (Men Aged 30–65 Years) in the PROCAM Study (Occupational Cohort) and the Augsburg MONICA Survey 1984/1985 (General Population)

During an average of 7.2 years of follow-up, 39 total strokes were observed. Thirty-two were of ischemic, 6 of hemorrhagic, and 1 of undetermined subtype. The overall incidence of total stroke was 42.4 per 100 000 person-years in this cohort of 12 866 working men. Stroke occurrence showed an expected strong age dependency. The incidence increased from 10.1 per 100 000 person-years in the age category 30 to 39 years to 33.6, 80.6, and 159.2 per 100 000 person-years in the age categories 40 to 49, 50 to 59, and 60 years and older, respectively. Of the observed 39 strokes, 11 were fatal, 10 caused a major deficit, and 17 caused a minor functional deficit. No information on severity was available for 1 stroke. Differences in baseline characteristics were reflected in different rates of stroke in categories of major risk factors (Table 3). Prominent increases were especially observed for elevated systolic and diastolic blood pressure.

View this table: [in this window] [in a new window]   Table 3. Age-Adjusted Rates per 100 000 Person-Years for Total Stroke During 7.2 Years of Follow-Up in Different Categories of Major Stroke Risk Factors

In addition to age, 4 baseline risk factors were statistically significantly associated with incident stroke in both univariate and multivariate regression analyses (Table 4). In 2 different models, risks for systolic and diastolic blood pressure were calculated separately. Risk magnitudes were lower for diastolic blood pressure (RR, 2.20 [95% confidence interval, 0.89 to 5.48] for 81 to 90 mm Hg; RR, 3.59 [95% confidence interval, 1.39 to 9.26] for 91 mm Hg), whereas the risk magnitudes of the other variables in both models (smoking, history of hypertension, diabetes mellitus) did not change. Known history of hypertension at baseline was found to be an independent risk factor for total stroke of considerable magnitude. Significant trends of risk increase were observed across categories of systolic and diastolic blood pressure as well as smoking status.

View this table: [in this window] [in a new window]   Table 4. Major Risk Factors for Total Stroke During 7.2 Years of Follow-Up in the PROCAM Study

	Discussion

Top Abstract Introduction Subjects and Methods Results Discussion References

 
In this cohort of 12 866 working men from different industry branches and with different job training, a low overall incidence of stroke was observed. Strong increases in event rates across categories of various potential risk factors were found. Regression analysis revealed that systolic blood pressure and current smoking represented the strongest risks for total stroke, underscoring their known status as most important risk factors.^{17 18 19 20 21}

Compared with studies of the general population, the stroke incidence observed in this occupational cohort was about 2-fold lower. The 2 German population-based stroke registers also reported higher rates. Eisenblätter et al⁶ found an annual incidence of 88 per 100 000 men aged 25 to 64 years, which is twice as high. However, they report results from the MONICA stroke register in the former German Democratic Republic. Differences in methods and healthcare systems do not allow a true comparison. Kolominsky-Rabas et al⁷ describe an even higher overall annual incidence of 146 per 100 000 men in the community-based stroke register in Erlangen, Germany. This overall incidence rate is caused mainly by a high mean age (73.4 years) of stroke case subjects in this register. Also, age-specific incidence rates were higher in all age categories compared with those in the PROCAM Study.²² Again, differences in methods (community register versus prospective cohort study) do not allow a true comparison.

Other general population studies have found incidences among males of 30 per 100 000 person-years in the third decade of life to 320 per 100 000 person-years in the age group of 55 to 64 years.^{23 24 25 26} One study reported incidences among healthy men only in their fourth decade of age separately.²⁶ Their rate of 48 per 100 000 person-years is only half as high as the rate among all men of this age in this study and comes close to the rate in our study.

The lower overall incidence in our study may be explained by several factors. An initially expected healthy-worker effect is not among them, since the observed differences in known stroke risk factor levels compared with a German general population study are small. However, job status is an important factor of social class. Differences in incidences of cardiovascular and cerebrovascular diseases according to social class are well known.^{1 27} Participation at baseline was optional. This might have attracted health-conscious employees, since the chronically ill are less likely to volunteer for enrollment in any study.²⁸ Health consciousness includes motivation for initiation and adherence to treatment if diagnosed with a crucially elevated risk factor. The assessed treatment rate in the PROCAM Study among employees with hypertensive blood pressure values or aware of hypertension was almost twice as high as in the general population survey (44.3% versus 25.0%). In the absence of a marked difference in risk profiles, substantially higher treatment rates in addition to small differences in risk factor levels might help explain a low overall stroke incidence. Other behavioral factors that might contribute to an explanation were either not comparable because of different assessment methodology (physical activity) or remained insignificant (alcohol consumption). Nevertheless, having 1 or more classic risk factors for stroke is of special importance for those employees with high (140 mm Hg) systolic blood pressure. They had a 5-fold risk of stroke compared with those with pressure <120 mm Hg. This is remarkable because the former category included a considerable number (14%) of individuals with so-called borderline isolated systolic hypertension, for which only moderate risk magnitudes have been described.²⁹

This analysis is subject to a number of limitations. First, events were self-reported. Underreporting of stroke from case subjects, especially those left with a functional deficit, would result in an underestimation of stroke incidence in this cohort. However, since the number of reported events was considerably larger than the number of validated strokes, underreporting seems unlikely. Also, we observed the same strong age dependency and increases in event rates across categories of known stroke risk factors as in studies of general populations. This supports the internal validity of our data. The observed low stroke incidence is in accordance with a 30% lower overall mortality in this cohort³⁰ based on comparisons with German vital statistics (Federal Statistics Office). Self-reported stroke was validated by medical records. The validation procedure has been successfully applied to other studies before and was recently the subject of an interobserver agreement study¹⁵ and a review.³¹ Risk factor status was only measured once at baseline. Participants who changed smoking status, for example, during follow-up might have contributed to misclassification of exposure. However, since all information about risk factors status was assessed at baseline and before a stroke event, this misclassification would have been nondifferential.

In conclusion, we found that participants in our male working cohort had a very low incidence of stroke compared with those in general population studies. This finding cannot be explained by a healthy-worker effect. Carrying one of the classic stroke risk factors is of special importance in this group of employees because these individuals face high RR of stroke. Low incidence does not mean low severity. When a stroke occurred, only 43% of case subjects were left with a minor functional deficit or a better outcome. Because the risk magnitudes associated with hypertension and smoking are high,^{21 32} early and effective treatment of blood pressure, even at levels currently not strictly recommended for treatment, and avoidance of smoking should be encouraged by companies. This would contribute to a reduction of the burden of disease for employees, their families, and the companies themselves.

	Acknowledgments

 
The PROCAM Study is funded by the Ministry of Science and Research of Northrhine-Westfalia and the Public Health Insurance Societies of Westphalia and Rhineland.

Received February 18, 1998; revision received April 24, 1998; accepted May 14, 1998.

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Berger, K. Articles by Assmann, G. Search for Related Content PubMed PubMed Citation Articles by Berger, K. Articles by Assmann, G.