. 2023 Jan 3;147(1):35-46.

doi: 10.1161/CIRCULATIONAHA.122.061832. Epub 2022 Dec 12.

Associations Between Extreme Temperatures and Cardiovascular Cause-Specific Mortality: Results From 27 Countries

Barrak Alahmad^{1

2}, Haitham Khraishah³, Dominic Royé⁴, Ana Maria Vicedo-Cabrera^{5

6

7}, Yuming Guo⁸, Stefania I Papatheodorou⁹, Souzana Achilleos^{10

11}, Fiorella Acquaotta¹², Ben Armstrong⁷, Michelle L Bell¹³, Shih-Chun Pan¹⁴, Micheline de Sousa Zanotti Stagliorio Coelho¹⁵, Valentina Colistro¹⁶, Tran Ngoc Dang¹⁷, Do Van Dung¹⁷, Francesca K De' Donato¹⁸, Alireza Entezari¹⁹, Yue-Liang Leon Guo¹⁴, Masahiro Hashizume²⁰, Yasushi Honda²¹, Ene Indermitte²², Carmen Íñiguez^{23

24}, Jouni J K Jaakkola^{25

26

27}, Ho Kim²⁸, Eric Lavigne²⁹, Whanhee Lee^{13

30}, Shanshan Li^{8

31}, Joana Madureira^{32

33

34}, Fatemeh Mayvaneh¹⁹, Hans Orru²², Ala Overcenco³⁵, Martina S Ragettli^{36

37}, Niilo R I Ryti²⁷, Paulo Hilario Nascimento Saldiva³⁸, Noah Scovronick³⁹, Xerxes Seposo⁴⁰, Francesco Sera⁴¹, Susana Pereira Silva⁴², Massimo Stafoggia¹⁸, Aurelio Tobias^{40

43}, Eric Garshick^{44

45}, Aaron S Bernstein^{46

47}, Antonella Zanobetti¹, Joel Schwartz¹, Antonio Gasparrini^{48

49}, Petros Koutrakis¹

Affiliations

¹ Environmental Health Department (B.Alahmad, A.Z., J.S., P.K.), Harvard T.H. Chan School of Public Health, Boston, MA.
² Environmental and Occupational Health Department, Faculty of Public Health, Kuwait University, Kuwait City (B.Alahmad).
³ Cardiology Division, University of Maryland Medical Center, University of Maryland, Baltimore (H.Khraishah).
⁴ Department of Geography, University of Santiago de Compostela, Spain (D.R.).
⁵ Institute of Social and Preventive Medicine (A.M.V-C.).
⁶ Oeschger Center for Climate Change Research, University of Bern, Switzerland (A.M.V-C.).
⁷ Department of Public Health Environments and Society (A.M.V-C., B.Armstrong), London School of Hygiene and Tropical Medicine, UK.
⁸ Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia (Y.G., S.L.).
⁹ Department of Epidemiology (S.I.P.), Harvard T.H. Chan School of Public Health, Boston, MA.
¹⁰ School of Health Sciences, Cyprus University of Technology, Limassol (S.A.).
¹¹ Department of Primary Care and Population Health, University of Nicosia Medical School, Cyprus (S.A.).
¹² Department of Earth Sciences, University of Torino, Turin, Italy (F.A.).
¹³ School of the Environment, Yale University, New Haven, CT (M.L.B., W.L.).
¹⁴ National Institute of Environmental Health Science, National Health Research Institutes, Zhunan, Taiwan (S-C.P., Y-L.L.G.).
¹⁵ Institute of Advanced Studies (M.S.Z.S.C.), University of São Paulo, Brazil.
¹⁶ Department of Quantitative Methods, School of Medicine, University of the Republic, Montevideo, Uruguay (V.C.).
¹⁷ Department of Environmental Health, Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam (T.N.D., D.V.D.).
¹⁸ Department of Epidemiology, Lazio Regional Health Service, Rome, Italy (F.K.D'D., M.S.).
¹⁹ Faculty of Geography and Environmental Sciences, Hakim Sabzevari University, Sabzevar, Iran (A.E., F.M.).
²⁰ Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, Japan (M.H.).
²¹ Center for Climate Change Adaptation, National Institute for Environmental Studies, Tsukuba, Japan (Y.H.).
²² Department of Family Medicine and Public Health, University of Tartu, Estonia (E.I., H.O.).
²³ CIBER de Epidemiología y Salud Pública, Madrid, Spain (D.R., C.Í.).
²⁴ Department of Statistics and Computational Research, Universitat de València, Spain (C.Í.).
²⁵ Center for Environmental and Respiratory Health Research (J.J.K.J.), University of Oulu, Finland.
²⁶ Medical Research Center Oulu (J.J.K.J.), University of Oulu, Finland.
²⁷ Biocenter Oulu (N.R.I.R., J.J.K.J.), University of Oulu, Finland.
²⁸ Graduate School of Public Health, Seoul National University, South Korea (H.Kim).
²⁹ School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Canada (E.L.).
³⁰ School of Biomedical Engineering, College of Information and Biomedical Engineering, Pusan National University, Yangsan, South Korea (W.L.).
³¹ Climate, Air Quality Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia (S.L.).
³² Department of Environmental Health, Instituto Nacional de Saúde Dr Ricardo Jorge, Porto, Portugal (J.M.).
³³ Epidemiology Research Unit (EPIUnit) (J.M.), Instituto de Saúde Pública, Universidade do Porto, Portugal.
³⁴ Laboratory for Integrative and Translational Research in Population Health (J.M.), Instituto de Saúde Pública, Universidade do Porto, Portugal.
³⁵ Laboratory of Management in Science and Public Health, National Agency for Public Health of the Ministry of Health, Chisinau, Moldova (A.O.).
³⁶ Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute (M.S.R.), Switzerland.
³⁷ University of Basel (M.S.R.), Switzerland.
³⁸ Department of Pathology, Faculty of Medicine (P.H.N.S.), University of São Paulo, Brazil.
³⁹ Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA (N.S.).
⁴⁰ School of Tropical Medicine and Global Health, Nagasaki University, Japan (X.S., A.T.).
⁴¹ Department of Statistics, Computer Science and Applications G. Parenti, University of Florence, Italy (F.S.).
⁴² Department of Epidemiology, Instituto Nacional de Saúde Dr Ricardo Jorge, Lisboa, Portugal (S.P.S.).
⁴³ Institute of Environmental Assessment and Water Research, Spanish Council for Scientific Research, Barcelona (A.T.).
⁴⁴ Pulmonary, Allergy, Sleep and Critical Care Medicine Section, Department of Medicine, Veterans Affairs Boston Healthcare System, Harvard Medical School, West Roxbury, MA (E.G.).
⁴⁵ Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital (E.G.), Harvard Medical School, MA.
⁴⁶ Center for Climate, Health and the Global Environment (A.S.B.), Harvard T.H. Chan School of Public Health, Boston, MA.
⁴⁷ Department of Pediatrics, Boston Children's Hospital (A.S.B.), Harvard Medical School, MA.
⁴⁸ Centre for Statistical Methodology (A.G.), London School of Hygiene and Tropical Medicine, UK.
⁴⁹ Centre on Climate Change and Planetary Health (A.G.), London School of Hygiene and Tropical Medicine, UK.

PMID: 36503273
PMCID: PMC9794133
DOI: 10.1161/CIRCULATIONAHA.122.061832

Associations Between Extreme Temperatures and Cardiovascular Cause-Specific Mortality: Results From 27 Countries

Barrak Alahmad et al. Circulation. 2023.

. 2023 Jan 3;147(1):35-46.

doi: 10.1161/CIRCULATIONAHA.122.061832. Epub 2022 Dec 12.

Authors

Affiliations

¹ Environmental Health Department (B.Alahmad, A.Z., J.S., P.K.), Harvard T.H. Chan School of Public Health, Boston, MA.
² Environmental and Occupational Health Department, Faculty of Public Health, Kuwait University, Kuwait City (B.Alahmad).
³ Cardiology Division, University of Maryland Medical Center, University of Maryland, Baltimore (H.Khraishah).
⁴ Department of Geography, University of Santiago de Compostela, Spain (D.R.).
⁵ Institute of Social and Preventive Medicine (A.M.V-C.).
⁶ Oeschger Center for Climate Change Research, University of Bern, Switzerland (A.M.V-C.).
⁷ Department of Public Health Environments and Society (A.M.V-C., B.Armstrong), London School of Hygiene and Tropical Medicine, UK.
⁸ Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia (Y.G., S.L.).
⁹ Department of Epidemiology (S.I.P.), Harvard T.H. Chan School of Public Health, Boston, MA.
¹⁰ School of Health Sciences, Cyprus University of Technology, Limassol (S.A.).
¹¹ Department of Primary Care and Population Health, University of Nicosia Medical School, Cyprus (S.A.).
¹² Department of Earth Sciences, University of Torino, Turin, Italy (F.A.).
¹³ School of the Environment, Yale University, New Haven, CT (M.L.B., W.L.).
¹⁴ National Institute of Environmental Health Science, National Health Research Institutes, Zhunan, Taiwan (S-C.P., Y-L.L.G.).
¹⁵ Institute of Advanced Studies (M.S.Z.S.C.), University of São Paulo, Brazil.
¹⁶ Department of Quantitative Methods, School of Medicine, University of the Republic, Montevideo, Uruguay (V.C.).
¹⁷ Department of Environmental Health, Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam (T.N.D., D.V.D.).
¹⁸ Department of Epidemiology, Lazio Regional Health Service, Rome, Italy (F.K.D'D., M.S.).
¹⁹ Faculty of Geography and Environmental Sciences, Hakim Sabzevari University, Sabzevar, Iran (A.E., F.M.).
²⁰ Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, Japan (M.H.).
²¹ Center for Climate Change Adaptation, National Institute for Environmental Studies, Tsukuba, Japan (Y.H.).
²² Department of Family Medicine and Public Health, University of Tartu, Estonia (E.I., H.O.).
²³ CIBER de Epidemiología y Salud Pública, Madrid, Spain (D.R., C.Í.).
²⁴ Department of Statistics and Computational Research, Universitat de València, Spain (C.Í.).
²⁵ Center for Environmental and Respiratory Health Research (J.J.K.J.), University of Oulu, Finland.
²⁶ Medical Research Center Oulu (J.J.K.J.), University of Oulu, Finland.
²⁷ Biocenter Oulu (N.R.I.R., J.J.K.J.), University of Oulu, Finland.
²⁸ Graduate School of Public Health, Seoul National University, South Korea (H.Kim).
²⁹ School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Canada (E.L.).
³⁰ School of Biomedical Engineering, College of Information and Biomedical Engineering, Pusan National University, Yangsan, South Korea (W.L.).
³¹ Climate, Air Quality Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia (S.L.).
³² Department of Environmental Health, Instituto Nacional de Saúde Dr Ricardo Jorge, Porto, Portugal (J.M.).
³³ Epidemiology Research Unit (EPIUnit) (J.M.), Instituto de Saúde Pública, Universidade do Porto, Portugal.
³⁴ Laboratory for Integrative and Translational Research in Population Health (J.M.), Instituto de Saúde Pública, Universidade do Porto, Portugal.
³⁵ Laboratory of Management in Science and Public Health, National Agency for Public Health of the Ministry of Health, Chisinau, Moldova (A.O.).
³⁶ Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute (M.S.R.), Switzerland.
³⁷ University of Basel (M.S.R.), Switzerland.
³⁸ Department of Pathology, Faculty of Medicine (P.H.N.S.), University of São Paulo, Brazil.
³⁹ Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA (N.S.).
⁴⁰ School of Tropical Medicine and Global Health, Nagasaki University, Japan (X.S., A.T.).
⁴¹ Department of Statistics, Computer Science and Applications G. Parenti, University of Florence, Italy (F.S.).
⁴² Department of Epidemiology, Instituto Nacional de Saúde Dr Ricardo Jorge, Lisboa, Portugal (S.P.S.).
⁴³ Institute of Environmental Assessment and Water Research, Spanish Council for Scientific Research, Barcelona (A.T.).
⁴⁴ Pulmonary, Allergy, Sleep and Critical Care Medicine Section, Department of Medicine, Veterans Affairs Boston Healthcare System, Harvard Medical School, West Roxbury, MA (E.G.).
⁴⁵ Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital (E.G.), Harvard Medical School, MA.
⁴⁶ Center for Climate, Health and the Global Environment (A.S.B.), Harvard T.H. Chan School of Public Health, Boston, MA.
⁴⁷ Department of Pediatrics, Boston Children's Hospital (A.S.B.), Harvard Medical School, MA.
⁴⁸ Centre for Statistical Methodology (A.G.), London School of Hygiene and Tropical Medicine, UK.
⁴⁹ Centre on Climate Change and Planetary Health (A.G.), London School of Hygiene and Tropical Medicine, UK.

PMID: 36503273
PMCID: PMC9794133
DOI: 10.1161/CIRCULATIONAHA.122.061832

Abstract

Background: Cardiovascular disease is the leading cause of death worldwide. Existing studies on the association between temperatures and cardiovascular deaths have been limited in geographic zones and have generally considered associations with total cardiovascular deaths rather than cause-specific cardiovascular deaths.

Methods: We used unified data collection protocols within the Multi-Country Multi-City Collaborative Network to assemble a database of daily counts of specific cardiovascular causes of death from 567 cities in 27 countries across 5 continents in overlapping periods ranging from 1979 to 2019. City-specific daily ambient temperatures were obtained from weather stations and climate reanalysis models. To investigate cardiovascular mortality associations with extreme hot and cold temperatures, we fit case-crossover models in each city and then used a mixed-effects meta-analytic framework to pool individual city estimates. Extreme temperature percentiles were compared with the minimum mortality temperature in each location. Excess deaths were calculated for a range of extreme temperature days.

Results: The analyses included deaths from any cardiovascular cause (32 154 935), ischemic heart disease (11 745 880), stroke (9 351 312), heart failure (3 673 723), and arrhythmia (670 859). At extreme temperature percentiles, heat (99th percentile) and cold (1st percentile) were associated with higher risk of dying from any cardiovascular cause, ischemic heart disease, stroke, and heart failure as compared to the minimum mortality temperature, which is the temperature associated with least mortality. Across a range of extreme temperatures, hot days (above 97.5th percentile) and cold days (below 2.5th percentile) accounted for 2.2 (95% empirical CI [eCI], 2.1-2.3) and 9.1 (95% eCI, 8.9-9.2) excess deaths for every 1000 cardiovascular deaths, respectively. Heart failure was associated with the highest excess deaths proportion from extreme hot and cold days with 2.6 (95% eCI, 2.4-2.8) and 12.8 (95% eCI, 12.2-13.1) for every 1000 heart failure deaths, respectively.

Conclusions: Across a large, multinational sample, exposure to extreme hot and cold temperatures was associated with a greater risk of mortality from multiple common cardiovascular conditions. The intersections between extreme temperatures and cardiovascular health need to be thoroughly characterized in the present day-and especially under a changing climate.

Keywords: climate change; cold temperature; heart failure; heat; hot temperature; myocardial ischemia; stroke.

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Figures

**Figure 1.**
**Map of all 567 locations.** Each city is represented with average annual temperature in °C.

**Figure 2.**
**Pooled exposure–response relationships.** Relationships are described as temperature percentiles and relative risk (RR) of different cardiovascular causes of death: all-cause cardiovascular (567 cities), ischemic heart disease (567 cities), stroke (567 cities), heart failure (524 cities), and arrhythmia (441 cities). Dashed line indicates the minimum mortality temperature. Dotted line indicates the 1st percentile (extreme cold) and the 99th percentile (extreme heat). X-axis was transformed from absolute temperatures (°C) to percentiles to enable a comparative application of the association. CVD indicates cardiovascular disease.

**Figure 3.**
**Relative risks of death from different cardiovascular-specific causes. A**, Relative risks of death from extreme heat comparing the 99th percentile to the minimum mortality temperature in each country as well as the pooled estimate. B, Relative risks (RR) of death from extreme cold comparing the 1st percentile to the minimum mortality temperature in each country, as well as the pooled estimate.

**Figure 4.**
**Excess deaths from different cardiovascular-specific causes. A**, Proportion of excess deaths associated with a range of extreme hot temperatures above the 97.5th percentile, expressed as number of deaths for each 1000 cardiovascular-specific deaths in each country as well as the pooled estimate. B, Proportion of excess deaths associated with a range of extreme cold temperatures below the 2.5th percentile, expressed as number of deaths for each 1000 cardiovascular-specific deaths in each country as well as the pooled estimate.

See this image and copyright information in PMC

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Associations Between Extreme Temperatures and Cardiovascular Cause-Specific Mortality: Results From 27 Countries

Affiliations

Associations Between Extreme Temperatures and Cardiovascular Cause-Specific Mortality: Results From 27 Countries

Authors

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Abstract

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References

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