Cardiovascular Mortality and Exposure to Heat in an Inherently Hot Region
2020; Lippincott Williams & Wilkins; Volume: 141; Issue: 15 Linguagem: Inglês
10.1161/circulationaha.119.044860
ISSN1524-4539
AutoresBarrak Alahmad, Haitham Khraishah, Ahmed F. Shakarchi, Mazen Albaghdadi, Sanjay Rajagopalan, Petros Koutrakis, Farouc A. Jaffer,
Tópico(s)Thermal Regulation in Medicine
ResumoHomeCirculationVol. 141, No. 15Cardiovascular Mortality and Exposure to Heat in an Inherently Hot Region Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBCardiovascular Mortality and Exposure to Heat in an Inherently Hot RegionImplications for Climate Change Barrak Alahmad, MBChB, MPH, Haitham Khraishah, MD, Ahmed F. Shakarchi, MBChB, MPH, Mazen Albaghdadi, MD, Sanjay Rajagopalan, MD, Petros Koutrakis, PhD and Farouc A. Jaffer, MD, PhD Barrak AlahmadBarrak Alahmad Barrak Alahmad, MBChB, MPH, Department of Environmental Health, Harvard T.H. Chan School of Public Health, 401 Park Dr, Landmark Center Rm 410, Boston, MA 02115. Email E-mail Address: [email protected] https://orcid.org/0000-0002-9523-9537 Environmental Health Department, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA (B.A., P.K.). Environmental and Occupational Health Department, Faculty of Public Health, Kuwait University, Kuwait City (B.A.). , Haitham KhraishahHaitham Khraishah Cardiovascular Research Center, Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (H.K.. M.A., F.A.J.). Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (H.K.). , Ahmed F. ShakarchiAhmed F. Shakarchi Wilmer Eye Institute, Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, MD (A.F.S.). , Mazen AlbaghdadiMazen Albaghdadi Cardiovascular Research Center, Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (H.K.. M.A., F.A.J.). , Sanjay RajagopalanSanjay Rajagopalan University Hospitals, Harrington Heart & Vascular Institute, Department of Medicine, Case Western Reserve University, Cleveland, OH (S.R.). , Petros KoutrakisPetros Koutrakis Environmental Health Department, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA (B.A., P.K.). and Farouc A. JafferFarouc A. Jaffer Cardiovascular Research Center, Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (H.K.. M.A., F.A.J.). Originally published30 Mar 2020https://doi.org/10.1161/CIRCULATIONAHA.119.044860Circulation. 2020;141:1271–1273Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: March 30, 2020: Ahead of Print Cardiovascular disease (CVD) remains the leading cause of death worldwide. Although clinicians appropriately treat established CVD risk factors, the potential CVD risks from climate change warrant further investigation. With ongoing climate change, the intensity and duration of heatwaves and temperature extremes will likely escalate over the coming decades. As a specific example, the Arabian Peninsula is an inherently hot and hyperarid region where temperatures are already soaring to unprecedented levels,1 yet to date, scant data are available regarding the relationship between climate change and CVD mortality in this region. Kuwait is a representative country in the corner of the Arabian Peninsula, where the highest temperature on earth in the last 76 years was recently recorded.1 Should emissions of greenhouse gases continue at the present rate, the projected temperatures in the Arabian Peninsula will exceed the threshold of human adaptability by the end of this century.2 In this investigation, we specifically assessed the effects of extreme ambient temperatures in Kuwait on CVD mortality over a 7-year period.We applied a time-series design to measure cardiovascular-specific daily mortality in Kuwait from 2010 to 2016, as well as the 24-hour average ambient temperatures across the country.3 The population of Kuwait is approximately 4.1 million. Cause-specific mortality data were obtained from the Department of Vital Statistics, Ministry of Health, Kuwait. Cardiovascular mortality was defined using International Classification of Diseases, Tenth Revision codes from death certificates (I00–I99). We used distributed lag nonlinear models to capture delayed effects of temperature on mortality over a span of 30 days. The distributed lag nonlinear models allow the estimation of nonlinear effects at specific time lags and across all lags. We modeled the lag using a cubic natural spline with 3 degrees of freedom placed equally on the log scale. Negative binomial regression was used to account for overdispersion. All results were adjusted for air pollutants (ozone and particles with aerodynamic diameter <10 μm [PM10]), relative humidity, and other factors that can confound the relationship in a time-series design (time trends, seasonality, and day of the week) as described previously.3 By design, individual characteristics including age, sex, body mass index, smoking, and others cannot confound the observed relationship because (1) they do not vary from day to day, and (2) they cannot be associated with the daily fluctuations of ambient temperatures. However, these factors can be important effect modifiers. Our analysis was repeated for overall, sex-specific, and age group–specific cardiovascular mortality. The work described in this article has been approved by the Standing Committee for Coordination of Health and Medical Research, Ministry of Health, Kuwait. The work was carried out in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki).Across the entire country, a total of 15 609 cardiovascular deaths occurred over the study period of 2532 days (1.4% missing) with an average rate of 6.2±2.7 cardiovascular deaths per day. The 24-hour average ambient temperature in Kuwait was 27.9±9.5°C (82.2±49.1°F); the minimum mortality temperature (temperature associated with lowest mortality) was 34.7°C (94.5°F), and the extreme temperature (99th percentile) was 42.7°C (108.9°F). The average concentration of particles with aerodynamic diameter <10 μm [PM10]) and ozone levels were 190.7±201.2 µg/m3 and 0.023±0.008 ppm, respectively. The relative risk of dying from a cardiovascular cause at the extreme temperature compared with the minimum mortality temperature was 3.09 (95% CI, 1.72–5.55). Similarly, the relative risks of dying from a cardiovascular cause among males and females were 3.53 (1.74–7.16) and 2.36 (0.83–6.66), respectively. Those aged 15 to 64 years had a relative risk of 3.84 (1.57–7.70), whereas adults over 65 had a relative risk of 2.29 (0.96–5.48). The CVD temperature–mortality relationship at specific lags is shown in the 3-dimensional plot (Figure, A). Across all lags, the exposure–response relationship was U-shaped, and the risk of adjusted CVD mortality increased with increasing temperature beyond the minimum mortality temperature (Figure, B).Download figureDownload PowerPointFigure. Effects of rising temperature on cardiovascular mortality in Kuwait.A, Three-dimensional (3D) plot of adjusted temperature–mortality relationship at specific time lags from distributed lag nonlinear models. The z axis shows the relative risk of cardiovascular disease mortality with respect to the minimum mortality temperature (34.7°C [94.5°F]), and the other axes represent 24-hour average temperature (°C) and lag period (days). The 3D plot only shows the general pattern of the relationship without the CIs around the estimates. B, Two-dimensional plot of adjusted temperature–mortality relationship for a cumulative distributive lag of 30 days with 95% CI.The association between high ambient temperatures and cardiovascular mortality has been demonstrated in vulnerable subgroups in several parts of the world.4 However, in Kuwait, the average temperature is notably higher than other regions in the world previously studied.3 In this study, we specifically assessed the effects of heat on cardiovascular mortality and found that the relative risks of cardiovascular death in Kuwait at extreme temperatures were remarkably high, with a doubling to tripling of CVD mortality.Possible pathophysiologic mechanisms implicated in CVD mortality from heat include exaggerated thermoregulatory mechanisms and systemic inflammation. During high ambient temperatures, thermoregulatory mechanisms augment blood flow to the skin to ameliorate heat, requiring an increase in cardiac output and potentially precipitating myocardial ischemia in susceptible individuals. When thermoregulatory processes become exhausted, core body temperature may rise precipitously. A rising core temperature may trigger a homeostatic but misaligned systemic inflammatory response, ultimately resulting in endothelial dysfunction and direct cytotoxic effects,5 which may provoke acute coronary syndromes.In summary, we provide new evidence from one of the hottest regions in the world that higher ambient temperatures associate with higher CVD mortality, with higher relative risks not observed in previous studies. Urgent public health interventions by the international community, including heightened awareness among clinicians (specifically cardiologists) is warranted.Sources of FundingThis publication was made possible by United States Environmental Protection Agency (US EPA) Grant RD-835872. Its contents are solely the responsibility of the grantee and do not necessarily represent the official views of the US EPA. Further, the US EPA does not endorse the purchase of any commercial products or services mentioned in the publication. The project was also funded by Kuwait Foundation for the Advancement of Sciences under the project code: CR19-13NH-01.DisclosuresDr. Jaffer has received sponsored research grants from Canon and Siemens; he is a consultant for Boston Scientific, Abbott Vascular, Siemens, Philips, Acrostak, Equity interest, and Intravascular Imaging Incorporated. Massachusetts General Hospital has a patent Licensing arrangement with Canon, and Dr. Jaffer has the right to receive royalties. The other authors report no conflicts.Footnoteshttps://www.ahajournals.org/journal/circData sharing: The data that support the findings of this study are available from the corresponding author upon reasonable request.Barrak Alahmad, MBChB, MPH, Department of Environmental Health, Harvard T.H. Chan School of Public Health, 401 Park Dr, Landmark Center Rm 410, Boston, MA 02115. Email b.[email protected]harvard.eduReferences1. Merlone A, Al-Dashti H, Faisal N, Cerveny RS, AlSarmi S, Bessemoulin P, Brunet M, Driouech F, Khalatyan Y, Peterson TC, et al. Temperature extreme records: World Meteorological Organization metrological and meteorological evaluation of the 54.0°C observations in Mitribah, Kuwait and Turbat, Pakistan in 2016/2017.Int J Climatol. 2019; 39:5154–5169.CrossrefGoogle Scholar2. Pal JS, Eltahir EAB. Future temperature in southwest Asia projected to exceed a threshold for human adaptability.Nat Clim Chang. 2015; 6;197.CrossrefGoogle Scholar3. Alahmad B, Shakarchi A, Alseaidan M, Fox M. The effects of temperature on short-term mortality risk in Kuwait: a time-series analysis.Environ Res. 2019; 171:278–284. doi: 10.1016/j.envres.2019.01.029CrossrefMedlineGoogle Scholar4. Basu R. High ambient temperature and mortality: a review of epidemiologic studies from 2001 to 2008.Environ Health. 2009; 8:40. doi: 10.1186/1476-069X-8-40CrossrefMedlineGoogle Scholar5. Epstein Y, Yanovich R. Heatstroke.N Engl J Med. 2019; 380:2449–2459. doi: 10.1056/NEJMra1810762CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Li C, Zhu Y, She K, Jia Y, Liu T, Han C, Fang Q, Cheng C, Han L, Liu Y, Zhang Y and Li X (2022) Modified effects of air pollutants on the relationship between temperature variability and hand, foot, and mouth disease in Zibo City, China, Environmental Science and Pollution Research, 10.1007/s11356-022-18817-8, 29:29, (44573-44581), Online publication date: 1-Jun-2022. Alahmad B, Vicedo-Cabrera A, Chen K, Garshick E, Bernstein A, Schwartz J and Koutrakis P (2022) Climate change and health in Kuwait: temperature and mortality projections under different climatic scenarios, Environmental Research Letters, 10.1088/1748-9326/ac7601, 17:7, (074001), Online publication date: 1-Jul-2022. Chaseling G, Iglesies-Grau J, Juneau M, Nigam A, Kaiser D and Gagnon D (2021) Extreme Heat and Cardiovascular Health: What a Cardiovascular Health Professional Should Know, Canadian Journal of Cardiology, 10.1016/j.cjca.2021.08.008, 37:11, (1828-1836), Online publication date: 1-Nov-2021. Feldman D, Dudum R, Alfaddagh A, Marvel F, Michos E, Blumenthal R and Martin S (2020) Summarizing 2019 in Cardiovascular Prevention using the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease’s ‘ABC’s Approach, American Journal of Preventive Cardiology, 10.1016/j.ajpc.2020.100027, 2, (100027), Online publication date: 1-Jun-2020. Alahmad B, Shakarchi A, Khraishah H, Alseaidan M, Gasana J, Al-Hemoud A, Koutrakis P and Fox M (2020) Extreme temperatures and mortality in Kuwait: Who is vulnerable?, Science of The Total Environment, 10.1016/j.scitotenv.2020.139289, 732, (139289), Online publication date: 1-Aug-2020. Alahmad B, Tomasso L, Al-Hemoud A, James P and Koutrakis P (2020) Spatial Distribution of Land Surface Temperatures in Kuwait: Urban Heat and Cool Islands, International Journal of Environmental Research and Public Health, 10.3390/ijerph17092993, 17:9, (2993) Khraishah H, Alahmad B, Ostergard R, AlAshqar A, Albaghdadi M, Vellanki N, Chowdhury M, Al-Kindi S, Zanobetti A, Gasparrini A and Rajagopalan S (2022) Climate change and cardiovascular disease: implications for global health, Nature Reviews Cardiology, 10.1038/s41569-022-00720-x Ohashi Y, Miyata A and Ihara T (2021) Mortality Sensitivity of Cardiovascular, Cerebrovascular, and Respiratory Diseases to Warm Season Climate in Japanese Cities, Atmosphere, 10.3390/atmos12121546, 12:12, (1546) April 14, 2020Vol 141, Issue 15 Advertisement Article InformationMetrics © 2020 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.119.044860PMID: 32223316 Originally publishedMarch 30, 2020 Keywordscardiovascular diseasestemperatureKuwaitMiddle Eastclimate changemortality rateenvironmental epidemiologyPDF download Advertisement SubjectsEpidemiologyPrimary PreventionRisk Factors
Referência(s)