Association of Fine Particulate Matter Exposure With Bystander-Witnessed Out-of-Hospital Cardiac Arrest of Cardiac Origin in Japan | Cardiology | JAMA Network Open | JAMA Network
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    Original Investigation
    Global Health
    April 17, 2020

    Association of Fine Particulate Matter Exposure With Bystander-Witnessed Out-of-Hospital Cardiac Arrest of Cardiac Origin in Japan

    Author Affiliations
    • 1Department of General Internal Medicine 3, Kawasaki Medical School General Medical Center, Okayama, Japan
    • 2Department of Environmental and Occupational Health, School of Medicine, Toho University, Ota-ku, Tokyo, Japan
    • 3Department of General Medicine, Kumamoto University Hospital, Kumamoto, Japan
    • 4National Cerebral and Cardiovascular Center, Suita, Japan
    • 5Centre for Health and Environmental Risk Research, National Institute for Environmental Studies, Tsukuba, Japan
    • 6Centre for Regional Environmental Research, National Institute for Environmental Studies, Tsukuba, Japan
    • 7Environmental Health Sciences, Kyoto University Graduate School of Global Environmental Studies, Sakyo-ku, Kyoto, Japan
    • 8Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
    • 9Department of Neuropsychopharmacology, National Center of Neurology and Psychiatry, Kodaira, Japan
    • 10Intensive Care Center, Shizuoka General Hospital, Shizuoka, Japan
    • 11Department of Cardiovascular Center, Nihon University Hospital, Chiyoda-ku, Tokyo, Japan
    • 12Department of Cardiovascular Medicine, Toho University Faculty of Medicine, Ota-ku, Tokyo, Japan
    • 13Department of Cardiovascular Medicine, Kawaguchi Cardiovascular and Respiratory Hospital, Kawaguchi, Japan
    • 14Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
    JAMA Netw Open. 2020;3(4):e203043. doi:10.1001/jamanetworkopen.2020.3043
    Key Points español 中文 (chinese)

    Question  What is the association of short-term exposure to fine particulate matter (with a diameter of ≤2.5 μm [PM2.5]) with bystander-witnessed out-of-hospital cardiac arrests of cardiac origin and with the development of initial cardiac arrest rhythm?

    Findings  In this case-control study of 103 189 bystander-witnessed out-of-hospital cardiac arrests, every 10 μg/m3 increase in PM2.5 levels was associated with a 1.6% increase in out-of-hospital cardiac arrests and with a 1.4% increase in out-of-hospital cardiac arrests initially presenting with a nonshockable rhythm.

    Meaning  Results of this study support the implementation of measures to reduce PM2.5 exposure for the prevention of out-of-hospital cardiac arrests of cardiac origin.


    Importance  Out-of-hospital cardiac arrests (OHCAs) are a major public health concern and a leading cause of death worldwide. Exposure to ambient air pollution is associated with increases in morbidity and mortality and has been recognized as a leading contributor to global disease burden.

    Objective  To examine the association between short-term exposure to particulate matter with a diameter of 2.5 μm or smaller (PM2.5) and the incidence of OHCAs of cardiac origin and with the development of initial cardiac arrest rhythm.

    Design, Setting, and Participants  This case-control study used data from cases registered between January 1, 2005, and December 31, 2016, in the All-Japan Utstein Registry, a prospective, nationwide, population-based database for OHCAs across all 47 Japanese prefectures. These OHCA cases included patients who had bystander-witnessed OHCAs and for whom emergency medical services responders initiated resuscitation before hospital transfer. A case-crossover design was employed for the study analyses. A prefecture-specific, conditional logistic regression model to estimate odds ratios was applied, and a random-effects meta-analysis was used to obtain prefecture-specific pooled estimates. All analyses were performed from May 7, 2019, to January 23, 2020.

    Main Outcomes and Measures  The main outcome was the association of short-term PM2.5 exposure with the incidence of bystander-witnessed OHCAs of cardiac origin. The differences in the distribution of initial cardiac arrest rhythm in OHCAs among those with exposure to PM2.5 were also examined.

    Results  In total, 103 189 OHCAs witnessed by bystanders were included in the final analysis. Among the patients who experienced such OHCAs, the mean (SD) age was 75 (15.5) years, and 62 795 (60.9%) were men. Point estimates of the percentage increase for a 10-μg/m3 increase in PM2.5 at lag0-1 (difference in mean PM2.5 concentrations measured on the case day and 1 day before) demonstrated a statistically significantly higher incidence of OHCA across most of the 47 prefectures, without significant heterogeneity (I2 = 20.1%; P = .12). A stratified analysis found an association between PM2.5 exposure and OHCAs (% increase, 1.6; 95% CI, 0.1%-3.1%). An initial shockable rhythm, such as ventricular fibrillation or pulseless ventricular tachycardia (% increase, 0.6; 95% CI, –2.0% to 3.2%), was not associated with PM2.5 exposure. However, an initial nonshockable rhythm, such as pulseless electrical activity and asystole, was associated with PM2.5 exposure (% increase, 1.4; 95% CI, 0.1%-2.7%).

    Conclusions and Relevance  Findings from this study suggest that increased PM2.5 concentration is associated with bystander-witnessed OHCA of cardiac origin that commonly presents with nonshockable rhythm. The results support measures to reduce PM2.5 exposure to prevent OHCAs of cardiac origin.