A cohort study evaluating the risk of stroke associated with long-term exposure to ambient fine particulate matter in Taiwan

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Abstract

Background

Evidences have shown that the stroke risk associated with long-term exposure to particulate matter with an aerodynamic diameter of ≤2.5 μm (PM _2.5) varies among people in North America, Europe and Asia, but studies in Asia rarely evaluated the association by stroke type. We examined whether long-term exposure to PM _2.5 is associated with developing all strokes, ischemic stroke and hemorrhagic stroke.

Methods

The retrospective cohort study consisted of 1,362,284 adults identified from beneficiaries of a universal health insurance program in 2011. We obtained data on air pollutants and meteorological measurements from air quality monitoring stations across Taiwan in 2010–2015. Annual mean levels of all environmental measurements in residing areas were calculated and assigned to cohort members. We used Cox proportional hazards models to estimate hazard ratio (HR) and 95% confidence interval (CI) of developing stroke associated with 1-year mean levels of PM _2.5 at baseline in 2010, and yearly mean levels from 2010 to 2015 as the time-varying exposure, adjusting for age, sex, income and urbanization level.

Results

During a median follow-up time of 6.0 years, 12,942 persons developed strokes, 9919 (76.6%) were ischemic. The adjusted HRs (95% CIs) per interquartile range increase in baseline 1-year mean PM _2.5 were 1.03 (1.00–1.06) for all stroke, 1.06 (1.02–1.09) for ischemic stroke, and 0.95 (0.89–1.10) for hemorrhagic stroke. The concentration-response curves estimated in the models with and without additional adjustments for other environmental measurements showed a positively linear association between baseline 1-year mean PM _2.5 and ischemic stroke at concentrations greater than 30 μg/m ³, under which no evidence of association was observed. There was an indication of an inverse association between PM _2.5 and hemorrhagic stroke, but the association no longer existed after controlling for nitrogen dioxide or ozone. We found similar shape of the concentration-response association in the Cox regression models with time-varying PM _2.5 exposures.

Conclusion

Long-term exposure to PM _2.5 might be associated with increased risk of developing ischemic stroke. The association with high PM _2.5 concentrations remained significant after adjustment for other environmental factors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12940-022-00854-y.

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Most cited references 43

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Particulate matter air pollution and cardiovascular disease: An update to the scientific statement from the American Heart Association.

Robert D Brook, Sanjay Rajagopalan, C. Pope … (2010)

In 2004, the first American Heart Association scientific statement on "Air Pollution and Cardiovascular Disease" concluded that exposure to particulate matter (PM) air pollution contributes to cardiovascular morbidity and mortality. In the interim, numerous studies have expanded our understanding of this association and further elucidated the physiological and molecular mechanisms involved. The main objective of this updated American Heart Association scientific statement is to provide a comprehensive review of the new evidence linking PM exposure with cardiovascular disease, with a specific focus on highlighting the clinical implications for researchers and healthcare providers. The writing group also sought to provide expert consensus opinions on many aspects of the current state of science and updated suggestions for areas of future research. On the basis of the findings of this review, several new conclusions were reached, including the following: Exposure to PM <2.5 microm in diameter (PM(2.5)) over a few hours to weeks can trigger cardiovascular disease-related mortality and nonfatal events; longer-term exposure (eg, a few years) increases the risk for cardiovascular mortality to an even greater extent than exposures over a few days and reduces life expectancy within more highly exposed segments of the population by several months to a few years; reductions in PM levels are associated with decreases in cardiovascular mortality within a time frame as short as a few years; and many credible pathological mechanisms have been elucidated that lend biological plausibility to these findings. It is the opinion of the writing group that the overall evidence is consistent with a causal relationship between PM(2.5) exposure and cardiovascular morbidity and mortality. This body of evidence has grown and been strengthened substantially since the first American Heart Association scientific statement was published. Finally, PM(2.5) exposure is deemed a modifiable factor that contributes to cardiovascular morbidity and mortality.

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Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study.

Martin O'Donnell, Denis Xavier, Lisheng Liu … (2010)

The contribution of various risk factors to the burden of stroke worldwide is unknown, particularly in countries of low and middle income. We aimed to establish the association of known and emerging risk factors with stroke and its primary subtypes, assess the contribution of these risk factors to the burden of stroke, and explore the differences between risk factors for stroke and myocardial infarction. We undertook a standardised case-control study in 22 countries worldwide between March 1, 2007, and April 23, 2010. Cases were patients with acute first stroke (within 5 days of symptoms onset and 72 h of hospital admission). Controls had no history of stroke, and were matched with cases for age and sex. All participants completed a structured questionnaire and a physical examination, and most provided blood and urine samples. We calculated odds ratios (ORs) and population-attributable risks (PARs) for the association of all stroke, ischaemic stroke, and intracerebral haemorrhagic stroke with selected risk factors. In the first 3000 cases (n=2337, 78%, with ischaemic stroke; n=663, 22%, with intracerebral haemorrhagic stroke) and 3000 controls, significant risk factors for all stroke were: history of hypertension (OR 2.64, 99% CI 2.26-3.08; PAR 34.6%, 99% CI 30.4-39.1); current smoking (2.09, 1.75-2.51; 18.9%, 15.3-23.1); waist-to-hip ratio (1.65, 1.36-1.99 for highest vs lowest tertile; 26.5%, 18.8-36.0); diet risk score (1.35, 1.11-1.64 for highest vs lowest tertile; 18.8%, 11.2-29.7); regular physical activity (0.69, 0.53-0.90; 28.5%, 14.5-48.5); diabetes mellitus (1.36, 1.10-1.68; 5.0%, 2.6-9.5); alcohol intake (1.51, 1.18-1.92 for more than 30 drinks per month or binge drinking; 3.8%, 0.9-14.4); psychosocial stress (1.30, 1.06-1.60; 4.6%, 2.1-9.6) and depression (1.35, 1.10-1.66; 5.2%, 2.7-9.8); cardiac causes (2.38, 1.77-3.20; 6.7%, 4.8-9.1); and ratio of apolipoproteins B to A1 (1.89, 1.49-2.40 for highest vs lowest tertile; 24.9%, 15.7-37.1). Collectively, these risk factors accounted for 88.1% (99% CI 82.3-92.2) of the PAR for all stroke. When an alternate definition of hypertension was used (history of hypertension or blood pressure >160/90 mm Hg), the combined PAR was 90.3% (85.3-93.7) for all stroke. These risk factors were all significant for ischaemic stroke, whereas hypertension, smoking, waist-to-hip ratio, diet, and alcohol intake were significant risk factors for intracerebral haemorrhagic stroke. Our findings suggest that ten risk factors are associated with 90% of the risk of stroke. Targeted interventions that reduce blood pressure and smoking, and promote physical activity and a healthy diet, could substantially reduce the burden of stroke. Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Canadian Stroke Network, Pfizer Cardiovascular Award, Merck, AstraZeneca, and Boehringer Ingelheim. Copyright 2010 Elsevier Ltd. All rights reserved.

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Stroke Risk Factors, Genetics, and Prevention.

Amelia K. Boehme, Charles Esenwa, Mitchell S. V. Elkind (2017)

Stroke is a heterogeneous syndrome, and determining risk factors and treatment depends on the specific pathogenesis of stroke. Risk factors for stroke can be categorized as modifiable and nonmodifiable. Age, sex, and race/ethnicity are nonmodifiable risk factors for both ischemic and hemorrhagic stroke, while hypertension, smoking, diet, and physical inactivity are among some of the more commonly reported modifiable risk factors. More recently described risk factors and triggers of stroke include inflammatory disorders, infection, pollution, and cardiac atrial disorders independent of atrial fibrillation. Single-gene disorders may cause rare, hereditary disorders for which stroke is a primary manifestation. Recent research also suggests that common and rare genetic polymorphisms can influence risk of more common causes of stroke, due to both other risk factors and specific stroke mechanisms, such as atrial fibrillation. Genetic factors, particularly those with environmental interactions, may be more modifiable than previously recognized. Stroke prevention has generally focused on modifiable risk factors. Lifestyle and behavioral modification, such as dietary changes or smoking cessation, not only reduces stroke risk, but also reduces the risk of other cardiovascular diseases. Other prevention strategies include identifying and treating medical conditions, such as hypertension and diabetes, that increase stroke risk. Recent research into risk factors and genetics of stroke has not only identified those at risk for stroke but also identified ways to target at-risk populations for stroke prevention.

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Author and article information

Contributors

Pei-Chun Chen:

ORCID: http://orcid.org/0000-0002-8713-8816

peichun@mail.cmu.edu.tw

Fung-Chang Sung: fcsung1008@yahoo.com

Journal

Journal ID (nlm-ta): Environ Health

Journal ID (iso-abbrev): Environ Health

Title: Environmental Health

Publisher: BioMed Central (London )

ISSN (Electronic): 1476-069X

Publication date (Electronic): 19 April 2022

Publication date PMC-release: 19 April 2022

Publication date Collection: 2022

Volume: 21

Affiliations

[1 ]GRID grid.254145.3, ISNI 0000 0001 0083 6092, Department of Public Health, , China Medical University College of Public Health, ; 100 Jingmao Rd Sec. 1, Taichung, 406040 Taiwan

[2 ]GRID grid.254145.3, ISNI 0000 0001 0083 6092, Department of Health Services Administration, , China Medical University College of Public Health, ; 100 Jingmao Rd Sec. 1, Taichung, 406040 Taiwan

[3 ]GRID grid.411508.9, ISNI 0000 0004 0572 9415, Management Office for Health Data, , China Medical University Hospital, ; Taichung, Taiwan

[4 ]GRID grid.252470.6, ISNI 0000 0000 9263 9645, Department of Food Nutrition and Health Biotechnology, , Asia University, ; Taichung, Taiwan

[5 ]GRID grid.410551.4, ISNI 0000 0001 0625 646X, University of Maryland Global Campus, ; Adelphi, MD USA

[6 ]GRID grid.264756.4, ISNI 0000 0004 4687 2082, School of Public Health, , Texas A&M University, ; College Station, TX USA

[7 ]GRID grid.27860.3b, ISNI 0000 0004 1936 9684, Department of Environmental Toxicology, , University of California, ; Davis, CA USA

[8 ]GRID grid.254145.3, ISNI 0000 0001 0083 6092, Graduate Institute of Biomedical Sciences, , China Medical University College of Public Health, ; Taichung, Taiwan

Article

Publisher ID: 854

DOI: 10.1186/s12940-022-00854-y

PMC ID: 9017007

SO-VID: 4069b53c-4b39-46be-9d53-20e3d94777ff

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Funding

Funded by: FundRef http://dx.doi.org/10.13039/501100004663, Ministry of Science and Technology, Taiwan;

Award ID: MOST 109-2321-B-039-002; MOST 110-2314-B-039 -030 -MY3; MOST 110-2629-B-039-001

Award Recipient : Pei-Chun Chen

Custom metadata

ScienceOpen disciplines: Public health

Keywords: ischemic stroke,hemorrhagic stroke,particulate matter,meteorological factors

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ScienceOpen disciplines: Public health

Keywords: ischemic stroke, hemorrhagic stroke, particulate matter, meteorological factors

A cohort study evaluating the risk of stroke associated with long-term exposure to ambient fine particulate matter in Taiwan

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Abstract

Background

Methods

Results

Conclusion

Supplementary Information

Related collections

Pneumonia, sex, and the environment

Most cited references 43

Particulate matter air pollution and cardiovascular disease: An update to the scientific statement from the American Heart Association.

Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study.

Stroke Risk Factors, Genetics, and Prevention.

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