Short-term exposure to ambient fine particulate matter and out-of-hospital cardiac arrest: a nationwide case-crossover study in Japan

Abstract

Background PM 2•5 is an important but modifiable environmental risk factor, not only for pulmonary diseases and cancers, but for cardiovascular health. However, the evidence regarding the association between air pollution and acute cardiac events, such as out-of-hospital cardiac arrest (OHCA), is inconsistent, especially at concentrations lower than the WHO daily guideline (25 µg/m³). This study aimed to determine the associations between exposure to ambient air pollution and the incidence of OHCA.Methods In this nationwide case-crossover study, we linked prospectively collected population-based registry data for OHCA in Japan from Jan 1, 2014, to Dec 31, 2015, with daily PM 2•5 , carbon monoxide (CO), nitrogen dioxide (NO 2 ), photochemical oxidants (O x ), and sulphur dioxide (SO 2 ) exposure on the day of the arrest (lag 0) or 1-3 days before the arrest (lags 1-3), as well as the moving average across days 0-1 and days 0-3. Daily exposure was calculated by averaging the measurements from all PM 2•5 monitoring stations in the same prefecture. The effect of PM 2•5 on risk of all-cause or cardiac OHCA was estimated using a time-stratified case-crossover design coupled with conditional logistic regression analysis, adjusted for daily temperature and relative humidity. Single-pollutant models were also investigated for the individual gaseous pollutants (CO, NO 2 , O x , and SO 2 ), as well as two-pollutant models for PM 2•5 with these gaseous pollutants. Subgroup analyses were done by sex and age. FindingsOver the 2 years, 249 372 OHCAs were identified, with 149 838 (60•1%) presumed of cardiac origin. The median daily PM 2•5 was 11•98 µg/m³ (IQR 8•13-17•44). Each 10 µg/m³ increase in PM 2•5 was associated with increased risk of all-cause OHCA on the same day (odds ratio [OR] 1•016, 95% CI 1•009-1•023) and at lags of up to 3 days, ranging from OR 1•015 (1•008-1•022) at lag 1 to 1•033 (1•023-1•043) at lag 0-3. Results for cardiac OHCA were similar (ORs ranging from 1•016 [1•007-1•025] at lags 1 and 2 to 1•034 [1•021-1•047] at lag 0-3). Patients older than 65 years were more susceptible to PM 2•5 exposure than younger age groups but no sex differences were identified. CO, O x , and SO 2 were also positively associated with OHCA while NO 2 was not. However, in two-pollutant models of PM 2•5 and gaseous pollutants, only PM 2•5 (positive association) and NO 2 (negative association) were independently associated with increased risk of OHCA. Interpretation Short-term exposure to PM 2•5 was associated with an increased risk of OHCA even at relatively low concentrations. Regulatory standards and targets need to incorporate the potential health gains from continual air quality improvement even in locations already meeting WHO standards.

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