Published ahead of print on June 30, 2005, doi:10.1164/rccm.200412-1726OC
Am. J. Respir. Crit. Care Med., Volume 172, Number 12, December 2005, 1549-1555
A more recent version of this article appeared on December 15, 2005
Submitted on December 22, 2004
Accepted on June 27, 2005
A Case-crossover Analysis of Out-of-Hospital Coronary Deaths and Air pollution in Rome, Italy
Francesco Forastiere1*, Massimo Stafoggia1, Sally Picciotto1, Tom Bellander2, Daniela D'Ippoliti1, Timo Lanki3, Stephanie von Klot4, Fredrik Nyberg5, Pentti Paatero6, Annette Peters4, Juha Pekkanen3, Jordi Sunyer7, and Carlo A Perucci1
1 Department of Epidemiology, Rome E Local Health Authority, Rome, Italy,
2 Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Occupational and Environmental Health, Stockholm County Council, Stockholm, Sweden,
3 Unit of Environmental Epidemiology, KTL-National Public Health Institute, Kuopio, Finland,
4 GSF-National Research Center for Environment and Health, Neuherberg, Germany,
5 Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; AstraZeneca R and D Molndal, Molndal, Sweden,
6 Department of Physical Sciences, University of Helsinki, Helsinki, Finland,
7 IMIM-Municipal Institute for Medical Research, Barcelona, Spain
* To whom correspondence should be addressed. E-mail: forastiere{at}asplazio.it.
Rationale. Out-of-hospital coronary heart disease death is a major public health problem but the association with air pollution is not well understood.
Objectives. We evaluated the association between daily ambient air pollution levels (Particle Number Concentration (PNC), a proxy for ultrafine particles (diameter <0.1 µm), mass of particles <10 µm (PM10), CO, NO2, and O3) and the occurrence of fatal non-hospitalized coronary events.
Methods. Subjects were 5,144 out-of-hospital fatalities (410-414, ICD-9) (years 1998-2000) among Rome residents. Hospitalizations during the three years before death were considered to identify comorbidities (e.g. diabetes, hypertension, heart failure, dysrhythmia, chronic obstructive pulmonary disease). Statistical analyses were performed using a case-crossover design.
Measurements and Main Results. The association with out-of-hospital coronary deaths was statistically significant for PNC, PM10 and CO. Air pollution on the day of death had strongest effect, e.g. 7.6 % increase (95% CI 2.0 - 13.6%) for an interquartile range of PNC (27,790 particles/cm3). The age groups 65-74 and 75+ years were at higher risk than the 35-64 age group, and there was a suggestion of effect modification for people with hypertension and COPD.
Conclusions. Air pollutants originating from combustion processes, including ultrafine particles, are related to fatal non-hospitalized coronary events. The effect is stronger among people above 65 years of age but is not limited to a group with a specific comorbidity.
Key words: coronary heart disease, myocardial infarction, particulate matter, sudden cardiac death, ultrafine particles.
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