Short term effects of temperature on risk of myocardial infarction in England and Wales: time series regression analysis of the Myocardial Ischaemia National Audit Project (MINAP) registry

Abstract

Objective: To examine the short term relation between ambient temperature and risk of myocardial infarction.

Design: Daily time series regression analysis.

Setting: 15 conurbations in England and Wales.

Participants: 84,010 hospital admissions for myocardial infarction recorded in the Myocardial Ischaemia National Audit Project during 2003-6 (median 57 events a day).

Main outcome measures: Change in risk of myocardial infarction associated with a 1 degrees C difference in temperature, including effects delayed by up to 28 days.

Results: Smoothed graphs revealed a broadly linear relation between temperature and myocardial infarction, which was well characterised by log-linear models without a temperature threshold: each 1 degrees C reduction in daily mean temperature was associated with a 2.0% (95% confidence interval 1.1% to 2.9%) cumulative increase in risk of myocardial infarction over the current and following 28 days, the strongest effects being estimated at intermediate lags of 2-7 and 8-14 days: increase per 1 degrees C reduction 0.6% (95% confidence interval 0.2% to 1.1%) and 0.7% (0.3% to 1.1%), respectively. Heat had no detrimental effect. Adults aged 75-84 and those with previous coronary heart disease seemed more vulnerable to the effects of cold than other age groups (P for interaction 0.001 or less in each case), whereas those taking aspirin were less vulnerable (P for interaction 0.007).

Conclusions: Increases in risk of myocardial infarction at colder ambient temperatures may be one driver of cold related increases in overall mortality, but an increased risk of myocardial infarction at higher temperatures was not detected. The risk of myocardial infarction in vulnerable people might be reduced by the provision of targeted advice or other interventions, triggered by forecasts of lower temperature.

Fig 1 Estimated relative risk of myocardial infarction by temperature in 15 conurbations combined, from a model including all five lag periods for temperature (0-1, 2-7, 8-14, 15-21, and 22-28 days) and adjusted for calendar time (stratified by conurbation), relative humidity (average of lags 0-3), day of week, public holiday, influenza, respiratory syncytial virus, PM10 level (lags 0-3), and ozone level (lags 0-3). Reference value for relative risk estimates is mean value of daily mean temperature across all days included

Fig 2 Estimated relative risk of myocardial infarction per 1°C reduction in temperature by conurbation. Estimates from a combined model including five temperature terms (lag days 0-1, 2-7, 8-14, 15-21, and 28), adjusted for calendar time (stratified by conurbation), and fixed effects across conurbations of relative humidity (average of lags 0-3), day of week, public holiday, influenza, respiratory syncytial virus, PM10 level (lags 0-3), and ozone level (lags 0-3)

Fig 3 Estimated relative risk of myocardial infarction per 1°C reduction in temperature: effect modification by age, sex, history, and aspirin use. Graph shows estimated effect of temperature (average of lag days 0-28), adjusted for calendar time (stratified by conurbation), and fixed effects across conurbations of relative humidity (average lags 0-3), day of week, public holiday, influenza, respiratory syncytial virus, PM10 levels (lags 0-3), and ozone levels (lags 0-3)