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


Zhao, B and Johnston, FH and Salimi, F and Kurabayashi, M and Negishi, K, Short-term exposure to ambient fine particulate matter and out-of-hospital cardiac arrest: a nationwide case-crossover study in Japan, The Lancet Planetary Health, 4, (1) pp. e15-e23. ISSN 2542-5196 (2020) [Refereed Article]

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Copyright Statement

2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) (

DOI: doi:10.1016/S2542-5196(19)30262-1


Background: PM25 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 PM25, carbon monoxide (CO), nitrogen dioxide (NO2), photochemical oxidants (Ox), and sulphur dioxide (SO2) 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 PM25 monitoring stations in the same prefecture. The effect of PM25 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, NO2, Ox, and SO2), as well as two-pollutant models for PM25 with these gaseous pollutants. Subgroup analyses were done by sex and age.

Findings: Over the 2 years, 249 372 OHCAs were identified, with 149 838 (601%) presumed of cardiac origin. The median daily PM25 was 1198 μg/m3 (IQR 813-1744). Each 10 μg/m3 increase in PM25 was associated with increased risk of all-cause OHCA on the same day (odds ratio [OR] 1016, 95% CI 1009-1023) and at lags of up to 3 days, ranging from OR 1015 (1008-1022) at lag 1 to 1033 (1023-1043) at lag 0-3. Results for cardiac OHCA were similar (ORs ranging from 1016 [1007-1025] at lags 1 and 2 to 1034 [1021-1047] at lag 0-3). Patients older than 65 years were more susceptible to PM25 exposure than younger age groups but no sex differences were identified. CO, Ox, and SO2 were also positively associated with OHCA while NO2 was not. However, in two-pollutant models of PM25 and gaseous pollutants, only PM25 (positive association) and NO2 (negative association) were independently associated with increased risk of OHCA.

Interpretation: Short-term exposure to PM25 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.

Item Details

Item Type:Refereed Article
Research Division:Biomedical and Clinical Sciences
Research Group:Cardiovascular medicine and haematology
Research Field:Cardiology (incl. cardiovascular diseases)
Objective Division:Health
Objective Group:Clinical health
Objective Field:Clinical health not elsewhere classified
UTAS Author:Zhao, B (Miss Bing Zhao)
UTAS Author:Johnston, FH (Associate Professor Fay Johnston)
UTAS Author:Negishi, K (Dr Kazuaki Negishi)
ID Code:138884
Year Published:2020
Web of Science® Times Cited:12
Deposited By:Menzies Institute for Medical Research
Deposited On:2020-05-07
Last Modified:2021-03-17
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