Association of Fine Particulate Matter Exposure With Bystander-Witnessed Out-of-Hospital Cardiac Arrest of Cardiac Origin in Japan

Primary Prevention of Coronary and Other Cardiovascular Diseases: A Focused Review

In 2022, the Japan Atherosclerosis Society (JAS) updated its prevention guidelines, the "Japan Atherosclerosis Society (JAS) Guidelines for Prevention of Atherosclerotic Cardiovascular Diseases 2022" (JAS2022GL), expanding its scope from coronary artery disease (CAD) to atherosclerotic cardiovascular diseases (ASCVDs), including atherothrombotic stroke. The following year, the Japanese Circulation Society (JCS) updated its guidelines for primary prevention entitled "JCS 2023 Guideline on the Primary Prevention of Coronary Artery Disease" (JCS2023GL). Since those publications, scientific advancements in relevant fields have continued. This review article outlines the current recommendations provided by the guidelines, provides background information supporting these recommendations, introduces scientific findings subsequent to prior publications, and discusses future directions on select topics for the primary prevention of CVD. The topics covered in this review are traditional risk factors, including dyslipidemia and hypertension, the application of comprehensive risk stratification or risk scoring systems, patient-specific topics, salt and alcohol, and environmental factors. These topics were deliberate and selected by the authors, who were involved in the compilation of either or both JAS2022GL and JCS2023GL. This review not only emphasizes the pivotal role of continuously updated guidelines in shaping clinical practice but also stresses the urgent need for ongoing research to bridge existing knowledge and practice gaps.

Agonal breathing upon hospital arrival as a prognostic factor in patients experiencing out-of-hospital cardiac arrest

Background

Agonal breathing is a relatively common symptom that follows cardiac arrest when the brainstem function is preserved. Agonal breathing is associated with favorable survival in patients experiencing out-of-hospital cardiac arrest (OHCA). While previous studies focused on agonal breathing observed in the pre-hospital setting for all study subjects, we focused on agonal breathing observed upon hospital arrival. In this multicenter prospective study, we aimed to assess the prognosis of patients exhibiting agonal breathing upon hospital arrival were compared. We hypothesized that agonal breathing at hospital arrival would be associated with favorable neurological outcomes among patients with OHCA.

Methods

The data on incidence of agonal breathing were prospectively collected for all evaluable participants in a multicenter, observational study in Japan (SOS-KANTO [Survey of Survivors after Out-of-Hospital Cardiac Arrest in Kanto Area] 2017 Study). Groups with and without agonal breathing were compared upon hospital arrival. Propensity-score with inverse probability of treatment weighting (IPTW) analysis was performed to adjust for confounding factors. The primary outcome was a favorable neurological outcome (Cerebral Performance Category 1-2) at 1 month.

Results

A total of 6,457 participants out of the 9,909 registered in SOS-KANTO 2017 (in which 42 facilities participated) were selected for the current study. There were 128 patients (2.0%) in the with-agonal breathing group and 6,329 (98.0%) in the withoutagonal breathing group. The primary outcome was 1.1% in the with-agonal breathing group and 0.6% in the without-agonal breathing group (risk difference, 0.55; 95% confidence interval, 0.23-0.87) after IPTW analysis.

Conclusion

In this multicenter prospective study, agonal breathing at hospital arrival was significantly associated with better neurological outcomes and increased survival at 1 month. Thus, agonal breathing at hospital arrival may be a useful prognostic predictor for patients experiencing OHCA.

Air Pollution and Cardiac Arrest: A More Significant Intermediate Role of COPD than Cardiac Events

No prior studies have linked long-term air pollution exposure to incident sudden cardiac arrest (SCA) or its possible development trajectories. We aimed to investigate the association between long-term exposure to air pollution and SCA, as well as possible intermediate diseases. Based on the UK Biobank cohort, Cox proportional hazard model was applied to explore associations between air pollutants and SCA. Chronic obstructive pulmonary disease (COPD) and major adverse cardiovascular events (MACE) were selected as intermediate conditions, and multistate model was fitted for trajectory analysis. During a median follow-up of 13.7 years, 2884 participants developed SCA among 458 237 individuals. The hazard ratios (HRs) for SCA were 1.04-1.12 per interquartile range increment in concentrations of fine particulate matter, inhalable particulate matter, nitrogen dioxide, and nitrogen oxides. Most prominently, air pollutants could induce SCA through promoting transitions from baseline health to COPD (HRs: 1.06-1.24) and then to SCA (HRs: 1.16-1.27). Less importantly, SCA could be developed through transitions from baseline health to MACE (HRs: 1.02-1.07) and further to SCA (HRs: 1.12-1.16). This study provides novel and compelling evidence that long-term exposure to air pollution could promote the development of SCA, with COPD serving as a more important intermediate condition than MACE.

Heatwave characteristics complicate the association between PM2.5 components and schizophrenia hospitalizations in a changing climate: Leveraging of the individual residential environment

BACKGROUND

In the era characterized by global environmental and climatic changes, understanding the effects of PM2.5 components and heatwaves on schizophrenia (SCZ) is essential for implementing environmental interventions at the population level. However, research in this area remains limited, which highlights the need for further research and effort. We aim to assess the association between exposure to PM2.5 components and hospitalizations for SCZ under different heatwave characteristics.

METHODS

We conducted a 16 municipalities-wide, individual exposure-based, time-stratified, case-crossover study from January 1, 2017, to December 31, 2020, encompassing 160736 hospitalizations in Anhui Province, China. Daily concentrations of PM2.5 components were obtained from the Tracking Air Pollution in China dataset. Conditional logistic regression models were used to investigate the association between PM2.5 components and hospitalizations. Additionally, restricted cubic spline models were used to identify protective thresholds of residential environment in response to environmental and climate change.

RESULTS

Our findings indicate a positive correlation between PM2.5 and its components and hospitalizations. Significantly, a 1 μg/m3 increase in black carbon (BC) was associated with the highest risk, at 1.58% (95%CI: 0.95-2.25). Exposure to heatwaves synergistically enhanced the impact of PM2.5 components on hospitalization risks, and the interaction varied with the intensity and duration of heatwaves. Under the 99th percentile heatwave events, the impact of PM2.5 and its components on hospitalizations was most pronounced, which were PM2.5 (2-4d: 4.59%, 5.09%, and 5.09%), sulfate (2-4d: 21.73%, 23.23%, and 25.25%), nitrate (2-4d: 17.51%, 16.93%, and 20.31%), ammonium (2-4d: 27.49%, 31.03%, and 32.41%), organic matter (2-4d: 32.07%, 25.42%, and 24.48%), and BC (2-4d: 259.36%, 288.21%, and 152.52%), respectively. Encouragingly, a protective effect was observed when green and blue spaces comprised more than 17.6% of the residential environment.

DISCUSSION

PM2.5 components and heatwave exposure were positively associated with an increased risk of hospitalizations, although green and blue spaces provided a mitigating effect.

Air Pollution and Temperature: a Systematic Review of Ubiquitous Environmental Exposures and Sudden Cardiac Death

PURPOSE OF REVIEW

Environmental exposures have been associated with increased risk of cardiovascular mortality and acute coronary events, but their relationship with out-of-hospital cardiac arrest (OHCA) and sudden cardiac death (SCD) remains unclear. SCD is an important contributor to the global burden of cardiovascular disease worldwide.

RECENT FINDINGS

Current literature suggests a relationship between environmental exposures and cardiovascular disease, but their relationship with OHCA/SCD remains unclear. A literature search was conducted in PubMed, Embase, Web of Science, and Global Health. Of 5138 studies identified by our literature search, this review included 30 studies on air pollution, 42 studies on temperature, 6 studies on both air pollution and temperature, and 1 study on altitude exposure and OHCA/SCD. Particulate matter air pollution, ozone, and both hot and cold temperatures are associated with increased risk of OHCA/SCD. Pollution and other exposures related to climate change play an important role in OHCA/SCD incidence.

Short-Term Ambient Air Pollution Exposure and Risk of Out-of-Hospital Cardiac Arrest in Sweden: A Nationwide Case-Crossover Study

Background Air pollution is one of the main risk factors for cardiovascular disease globally, but its association with out-of-hospital cardiac arrest at low air pollution levels is unclear. This nationwide study in Sweden aims to investigate if air pollution is associated with a higher risk of out-of-hospital cardiac arrest in an area with relatively low air pollution levels. Methods and Results This study was a nationwide time-stratified case-crossover study investigating the association between short-term air pollution exposures and out-of-hospital cardiac arrest using data from the SRCR (Swedish Registry for Cardiopulmonary Resuscitation) between 2009 and 2019. Daily air pollution levels were estimated in 1×1-km grids for all of Sweden using a satellite-based machine learning model. The association between daily air pollutant levels and out-of-hospital cardiac arrest was quantified using conditional logistic regression adjusted for daily air temperature. Particulate matter <2.5 μm exposure was associated with a higher risk of out-of-hospital cardiac arrest among a total of 29 604 cases. In a multipollutant model, the association was most pronounced for intermediate daily lags, with an increased relative risk of 6.2% (95% CI, 1.0-11.8) per 10 μg/m3 increase of particulate matter <2.5 μm 4 days before the event. A similar pattern of association was observed for particulate matter <10 μm. No clear association was observed for O3 and NO2. Conclusions Short-term exposure to air pollution was associated with higher risk of out-of-hospital cardiac arrest. The findings add to the evidence of an adverse effect of particulate matter on out-of-hospital cardiac arrest, even at very low levels below current regulatory standards.

Fine and coarse particulate air pollution and out-of-hospital cardiac arrest onset: a nationwide case-crossover study in China

Out-of-hospital cardiac arrest (OHCA) is a global public health concern. Nationwide studies on the effects of short-term exposure to particulate matter (PM) on OHCA risk are rare in regions with high PM levels, and evidence for coarse PM (PM_2.5-10) is limited and inconsistent. To evaluate the associations between fine PM (PM_2.5) and PM_2.5-10 and OHCA onset, a time-stratified case-crossover study was conducted on 77,261 patients with cardiac OHCA in 26 cities across China in 2020. Daily PM_2.5 and PM_2.5-10 concentrations were assessed with high-resolution and full-coverage PM estimations. Conditional logistic regression models were applied in analyses. Each interquartile range of PM increase in 3-day moving average was associated with an increased risk of cardiac OHCA onset of 2.37% (95% CI, 1.20-3.56%) for PM_2.5 and 2.12% (95% CI, 0.70-3.56%) for PM_2.5-10. Stratified analyses showed higher susceptibility in patients over 75 years for PM_2.5 exposure and with diabetes for PM_2.5-10. This first nationwide study in region with high PM levels and great PM variability found not only PM_2.5 but also PM_2.5-10 were associated with a higher risk of OHCA onset, which could add powerful epidemiological evidence to this field and provide new evidence for the formulation of air quality guidelines.

Overview of PM2.5 and health outcomes: Focusing on components, sources, and pollutant mixture co-exposure

PM_2.5 varies in source and composition over time and space as a complicated mixture. Consequently, the health effects caused by PM_2.5 varies significantly over time and generally exhibit significant regional variations. According to numerous studies, a notable relationship exists between PM_2.5 and the occurrence of many diseases, such as respiratory, cardiovascular, and nervous system diseases, as well as cancer. Therefore, a comprehensive understanding of the effect of PM_2.5 on human health is critical. The toxic effects of various PM_2.5 components, as well as the overall toxicity of PM_2.5 are discussed in this review to provide a foundation for precise PM_2.5 emission control. Furthermore, this review summarizes the synergistic effect of PM_2.5 and other pollutants, which can be used to draft effective policies.

Inferior STEMI Electrocardiogram in a Young Postpartum Female with Sickle Cell Trait with Chest Pain - A Case Report

This is a case of a 35-year-old postpartum female presenting to the emergency department (ED) with acute onset chest pain and dyspnea with initial concern for acute ST-segment elevation myocardial infarct (STEMI). Her electrocardiogram (ECG) showed ST segment elevations in the lateral leads and inferior leads with depressions in the high lateral and septal leads. Given her post-partum status, spontaneous coronary artery dissection (SCAD) was part of the differential as well as other emergent processes. Upon cardiac catheterization, the patient was found to have 50% vasospasm in the left circumflex coronary artery. Her post-catheterization echocardiogram showed a normal ejection fraction (EF) without regional wall abnormalities. This is an interesting case of chest pain in a younger patient, without typical acute coronary syndrome (ACS) risk factors, presenting with a concerning ECG likely due to coronary vasospasm. We will discuss other atypical causes of STEMI patterns that should be considered in the differential and management of such patients.

Topics

Sickle cell trait, STEMI, postpartum, vasospasm, ECG, cardiology.

Effect modification by sex for associations of fine particulate matter (PM2.5) with cardiovascular mortality, hospitalization, and emergency room visits: systematic review and meta-analysis

Particulate matter with aerodynamic diameter no larger than 2.5 μm (PM2.5) has been linked to cardiovascular diseases (CVDs) but evidence for vulnerability by sex remains unclear. We performed systematic review and meta-analysis to synthesize the state of scientific evidence on whether cardiovascular risks from PM2.5 differ for men compared to women. The databases Pubmed, Scopus, Embase, and GreenFILE were searched for studies published Jan. 1995 to Feb. 2020. Observational studies conducting subgroup analysis by sex for impacts of short-term or long-term exposure to PM2.5 on target CVDs were included. Data were independently extracted in duplicate and pooled with random-effects meta-regression. Risk ratios (RRs) for long-term exposure and percent changes in outcomes for short-term exposure were calculated per 10 μg/m3 PM2.5 increase. Quality of evidence of risk differences by sex was rated following Grading of Recommendations Assessment, Development and Evaluation (GRADE). A total of 12,502 articles were screened, with 61 meeting inclusion criteria. An additional 32 studies were added from citation chaining. RRs of all CVD mortality for long-term PM2.5 for men and women were the same (1.14; 95% CI: 1.09, 1.22) indicating no statistically different risks. Men and women did not have statistically different risks of daily CVD mortality, hospitalizations from all CVD, ischemic heart disease, cardiac arrest, acute myocardial infarction, and heart failure from short-term PM2.5 exposure (difference in % change in risk per 10 μg/m3 PM2.5: 0.04 (95% CI, -0.42 to 0.51); -0.05 (-0.47 to 0.38); 0.17 (-0.90, 1.24); 1.42 (-1.06, 3.97); 1.33 (-0.05, 2.73); and -0.48 (-1.94, 1.01), respectively). Analysis using GRADE found low or very low quality of evidence for sex differences for PM2.5-CVD risks. In conclusion, this meta-analysis and quality of evidence assessment of current observational studies found very limited evidence of the effect modification by sex for effects of PM2.5 on CVD outcomes in adults, which can inform clinical approaches and policies.

Association of ambient air pollution with risk of out of hospital cardiac arrest in the United States

Objective

We assessed the association of acute exposure to ambient air particulate matter < 2.5 μm (PM2.5) and Ozone with risk of out of hospital cardiac arrest (OHCA).

Methods

We used data from the Cardiac Arrest Registry to Enhance Survival (CARES), a prospective multicenter registry of patients with OHCA in the U.S. Environmental data was obtained from publicly available data and linked with each patient. A case-crossover design was used to estimate association of acute exposure to ambient air PM2.5 and Ozone with risk of OHCA. Case day was defined as the day of the OHCA, and control days were same days of the week from preceding two weeks.

Results

Of 187,047 patients with OHCA, mean age was 61.5 ± 19.9 years, 59.7 % were males and 47.1 % were of White race. Mean daily PM2.5 concentration on case day was 9.2 ± 4.9 μg/m3 and mean averaged 8-hour Ozone concentration was 36.9 ± 12.1 ppb. Each 5 μg/m3 increase in PM2.5 concentration (case day vs. control day) was not associated with risk of OHCA (OR 0.99 [95 % CI 0.998, 1.017] p = 0.72). In contrast, there was an association of exposure to Ozone with risk of OHCA with every 12 ppb increase in Ozone associated with a higher risk for OHCA on case day (OR 1.011 [95 % CI 1.003, 1.019] p = 0.01).

Conclusion

In the U.S., higher exposure to Ozone was associated with increased risk of OHCA.

Impact of ambient fine particulate matter on emergency department admissions for circulatory system disease in a city in Northeast China

The cardiovascular impact of fine particles has caused great concern worldwide. However, evidences on the impact of fine particulate matter (PM_2.5) on emergency department (ED) admissions for circulatory system disease in Northeast China is limited. We assessed the acute, lag, cumulative, and harvesting effects of PM_2.5 on ED admissions for circulatory system diseases and their exposure-response relationship. A total of 26,168 ED admissions, including those for hypertension, ischemic heart disease (IHD), arrhythmia, heart failure (HF), and cerebrovascular events (CVE), were collected from the Shenyang Emergency Center from 1 January 2017 to 31 December 2018. The relationship between PM_2.5 and ED admissions for circulatory system disease was estimated using a distributed lag non-linear model and a generalized additive quasi-Poisson model. We stratified the analyses by temperature. Air pollution was positively correlated with daily ED admissions for circulatory system disease or other cause-specific diseases under different lag structures. For every 10-μg/m³ increase in the PM_2.5 concentration, the relative risk of daily ED admissions for circulatory system disease was 1.007 [95% confidence interval (CI), 1.001-1.013] in lag0, 1.007 (95%CI, 1.000-1.013) in lag1, and 1.011 (95%CI, 1.002-1.021) in lag03. A lag effect was found in IHD, a cumulative effect was found in CVE, and both lag and cumulative effects were found in hypertension and arrhythmia. A harvesting effect was observed in daily ED admissions for circulatory system disease and HF. We found no interaction between pollutants and temperature. We observed a monotonic and almost linear exposure-response relationship between PM_2.5 and circulatory system disease with no threshold effect.PM_2.5 contributes to obvious acute, lag, cumulative, and harvesting effects on circulatory system disease. PM_2.5 was associated with the risk of daily ED admissions for circulatory system disease, hypertension, IHD, arrhythmia, HF, and CVE. Therefore, air quality management must be strengthened.

The influence of air pollution by PM2.5, PM10 and associated heavy metals on the parameters of out-of-hospital cardiac arrest

Out-of-hospital cardiac arrest (OHCA), defined as abrupt cessation of mechanical activity of the heart, is one of the most common causes of death in high-income countries. Cardiac arrest is most often a result of severe cardiovascular disease. New evidence shows that air pollutants such as heavy metals and atmospheric particulate matter have an impact on the pathophysiology of many cardiovascular diseases as well on incidences of OHCA. This retrospective analysis includes all OHCA cases that occurred in central Poland covering the area of 11.711 km² with the population density of 108 people per square kilometer. Among 2878 EMS-treated OHCA cases between 2013 and 2016, cardiopulmonary resuscitation (CPR) was attempted in 2076 (72%) patients. Concentrations of air pollutants were compared with temperature, humidity and clinical factors affecting the CPR. The study shows seasonal variation of PM 2.5 (p < 0.001), PM 10 (p < 0.001), As (p < 0.001) and Cd (p < 0.001) over the years. Air pollution has a significant effect on the parameters of pre-hospital evaluation in OHCA patients, especially with respect to the content of PM2.5/PM10 and heavy metals. Nickel exposure affects the incidence of initial shockable rhythm (IRR 0.92; p = 0.01) and effectiveness of CPR (IRR 0.94; p = 0.003). Arsenic has an impact on overall mortality (IRR 1.07; p = 0.01) and death upon the arrival of EMS team (IRR 1.15; p < 0.001). Overall mortality was also related to ambient levels of PM10 (IRR 1.004; p < 0.047).

Out-of-hospital cardiac arrest and ambient air pollution: A dose-effect relationship and an association with OHCA incidence

Background

Pollution has been suggested as a precipitating factor for cardiovascular diseases. However, data about the link between air pollution and the risk of out-of-hospital cardiac arrest (OHCA) are limited and controversial.

Methods

By collecting data both in the OHCA registry and in the database of the regional agency for environmental protection (ARPA) of the Lombardy region, all medical OHCAs and the mean daily concentration of pollutants including fine particulate matter (PM₁₀, PM_2.5), benzene (C₆H₆), carbon monoxide (CO), nitrogen dioxide (NO₂), sulphur dioxide (SO₂), and ozone (O₃) were considered from January 1^st to December 31^st, 2019 in the southern part of the Lombardy region (provinces of Pavia, Lodi, Cremona and Mantua; 7863 km2; about 1550000 inhabitants). Days were divided into high or low incidence of OHCA according to the median value. A Probit dose-response analysis and both uni- and multivariable logistic regression models were provided for each pollutant.

Results

The concentrations of all the pollutants were significantly higher in days with high incidence of OHCA except for O₃, which showed a significant countertrend. After correcting for temperature, a significant dose-response relationship was demonstrated for all the pollutants examined. All the pollutants were also strongly associated with high incidence of OHCA in multivariable analysis with correction for temperature, humidity, and day-to-day concentration changes.

Conclusions

Our results clarify the link between pollutants and the acute risk of cardiac arrest suggesting the need of both improving the air quality and integrating pollution data in future models for the organization of emergency medical services.

Indoor air quality of 5,000 households and its determinants. Part A: Particulate matter (PM2.5 and PM10-2.5) concentrations in the Japan Environment and Children's Study

Exposure to particulate matter (PM) is one of the important risk factors for morbidity and mortality. Although PM concentrations have been assessed using air quality monitoring stations or modelling, few studies have measured indoor PM in large-scale birth cohorts. The Japan Environment and Children's Study (JECS) measured indoor and outdoor air quality in approximately 5000 households when the participating children were aged 1.5 and 3 years. PM was collected using portable pumps for 7 days (total of 24 h), inside and outside each home. Prediction models for indoor PM concentrations were built using data collected at age 1.5 years and post-validated against data collected at age 3 years. Median indoor/outdoor PM_2.5 and PM_10-2.5 concentrations at age 1.5 years [3 years] were 12.9/12.7 [12.5/11.3] μg/m³ and 5.0/6.3 [5.1/6.1] μg/m³, respectively. Random forest regression analysis found that the major predictors of indoor PM_2.5 were indoor PM_10-2.5, outdoor PM_2.5, indoor smoking, observable smoke and indoor/outdoor temperature. Indoor PM_2.5, outdoor PM_10-2.5, indoor humidity and opening room windows were important predictors of indoor PM_10-2.5 concentrations. Indoor benzene, acetaldehyde, ozone and nitrogen dioxide concentrations were also found to predict indoor PM_2.5 and PM_10-2.5 concentrations, possibly due to the formation of secondary organic aerosols. These findings demonstrate the importance of reducing outdoor PM concentrations, avoiding indoor smoking, using air cleaner in applicable and diminishing sources of VOCs that could form secondary organic aerosols, and the resulting models can be used to predict indoor PM concentrations for the rest of the JECS cohort.

Fine particulate matter and out-of-hospital cardiac arrest of respiratory origin

Exposure to ambient air pollution increases mortality and is a leading contributor to the global disease burden [1]. Epidemiological studies have elucidated a relationship between out-of-hospital cardiac arrests (OHCAs) and air pollutants, especially particulate matter (diameter ≤2.5 μm; PM_2.5) [2, 3]. The causes of OHCA are broadly categorised as cardiac and non-cardiac [4]. A 10 µg·m⁻³ increase in PM_2.5 exposure yielded a 1.6% increase in the incidence of cardiac origin OHCA [3, 5]. However, few studies on OHCAs of non-cardiac origin, including intrinsic respiratory diseases (COPD/pneumonia/asthma) are available. We examined the association between short-term exposure to PM_2.5 and bystander-witnessed respiratory origin OHCAs, including eventual prognosis. We also investigated differences between PM_2.5 exposure-related cardiac and respiratory origin OHCAs.

Particulate matter is a potential risk factor for out-of-hospital cardiac arrests (OHCAs) of respiratory origin. The percent increase in incidence of OHCA of respiratory origin is equivalent to that of PM_2.5 exposure-related OHCAs of cardiac origin.http://bit.ly/3tDXym0