Abstract
To investigate the associations between particulate matter (PM) and hospital admissions for stroke and its subtypes among hypertension patients. We proposed a new modifier named high-concentration duration (HCD). Data on daily hospital admissions, air pollution, and meteorological factors were collected from 2014 to 2018 in Beijing, China. We included all patients with hypertension who were admitted to hospitals of secondary-level and above for stroke. Time-series analysis was conducted by fitting a generalized additive model. An interaction term of daily concentration and an HCD stratum indicator were included in the model. Sex subgroup analysis was performed in four age groups to detect vulnerable populations. A total of 358,577 admissions were identified. The PM was significantly associated with stroke admissions in patients with hypertension. The maximum excess risk (ER) (%) per 10 μg/m3 increase in fine particulate matter (PM2.5) was 0.23% (95% confidence interval (CI): 0.15%, 0.31%) for overall stroke, 0.25% (95% CI: 0.16%, 0.33%) for ischemic stroke (IS). The maximum ER (%) per 10 μg/m3 increase in inhalable particle (PM10) was 0.14% (95% CI: 0.06%, 0.23%) for overall stroke, 0.15% (95% CI: 0.06%, 0.23%) for IS. For hemorrhagic stroke, significant associations were also observed among males and patients < 55 years. ER (%) in long-HCD strata was significantly larger than that in short-HCD strata. The effects of PM2.5 were significant in long-HCD strata, but insignificant in short-HCD strata. HCD might be a modifier in the association between air pollution and health effects. While controlling the daily average concentration, it is also important to reduce HCD on a given day.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
Data availability
The datasets and code generated and analyzed during the current study are not publicly available due to the confidentiality agreement.
Abbreviations
- PM:
-
Particulate matter
- IS:
-
Ischemic stroke
- HS:
-
Hemorrhagic stroke
- HCD:
-
High-concentration duration
- GAM:
-
Generalized additive model
- ER:
-
Excess risk
- CI:
-
Confidence interval
- PM2.5 :
-
Fine particulate matter
- PM10 :
-
Inhalable particle
- DALYs:
-
Disability-adjusted life years
- DECH:
-
Daily excessive concentration hours
- SO2 :
-
Sulfur dioxide
- NO2 :
-
Nitrogen dioxide
- CO:
-
Carbon monoxide
- O3 :
-
Ozone
- CO2 :
-
Carbon dioxide
- DOW:
-
Day of the week
- df:
-
Degree of freedom
- RR:
-
Relative risk
References
Alsaber AR, Pan J, Al-Hurban A (2021) Handling complex missing data using random forest approach for an air quality monitoring dataset: a case study of Kuwait environmental data (2012 to 2018). Int J Environ Res Public Health 18:1333. https://doi.org/10.3390/ijerph18031333
Bao J, Yang X, Zhao Z, Wang Z, Yu C, Li X (2015) The spatial-temporal characteristics of air pollution in China from 2001–2014. Int J Environ Res Public Health 12:15875–15887. https://doi.org/10.3390/ijerph121215029
Byrne CP, Bennett KE, Hickey A, Kavanagh P, Broderick B, O’Mahony M, Williams DJ (2020) Short-term air pollution as a risk for stroke admission: a time-series analysis. Cerebrovasc Dis 49:404–411. https://doi.org/10.1159/000510080
Cai B, Xia T, Qian Y, Lu H, Cai R, Wang C (2020) Association between fine particulate matter and fatal hemorrhagic stroke incidence: a time stratified case-crossover study in Shanghai, China. J Occup Environ Med 62:916–921. https://doi.org/10.1097/JOM.0000000000001973
Chang CH, Chen SH, Liu PH, Huang KC, Chiu IM, Pan HY, Cheng FJ (2022) Ambient air pollution and risk for stroke hospitalization: impact on susceptible groups. Toxics 10:350. https://doi.org/10.3390/toxics10070350
Chen C, Liu X, Wang X, Qu W, Li W, Dong L (2020) Effect of air pollution on hospitalization for acute exacerbation of chronic obstructive pulmonary disease, stroke, and myocardial infarction. Environ Sci Pollut Res Int 27:3384–3400. https://doi.org/10.1007/s11356-019-07236-x
Chen H, Cheng Z, Li M, Luo P, Duan Y, Fan J, Xu Y, Pu K, Zhou L (2021) Ambient air pollution and hospitalizations for ischemic stroke: a time series analysis using a distributed lag nonlinear model in Chongqing China. Frontiers In Public Health 9:762597. https://doi.org/10.3389/fpubh.2021.762597
Cipolla MJ, Liebeskind DS, Chan S-L (2018) The importance of comorbidities in ischemic stroke: impact of hypertension on the cerebral circulation. J Cereb Blood Flow Metab 38:2129–2149. https://doi.org/10.1177/0271678X18800589
Darrow LA, Klein M, Sarnat JA, Mulholland JA, Strickland MJ, Sarnat SE, Russell AG, Tolbert PE (2011) The use of alternative pollutant metrics in time-series studies of ambient air pollution and respiratory emergency department visits. J Expo Sci Environ Epidemiol 21:10–19. https://doi.org/10.1038/jes.2009.49
Delfino RJ, Zeiger RS, Seltzer JM, Street DH, McLaren CE (2002) Association of asthma symptoms with peak particulate air pollution and effect modification by anti-inflammatory medication use. Environ Health Perspect 110:A607–A617. https://doi.org/10.1289/ehp.021100607
Goldman GT, Mulholland JA, Russell AG, Strickland MJ, Klein M, Waller LA, Tolbert PE (2011) Impact of exposure measurement error in air pollution epidemiology: effect of error type in time-series studies. Environ Health 10:61. https://doi.org/10.1186/1476-069X-10-61
Hamanaka RB, Mutlu GM (2018) Particulate matter air pollution: effects on the cardiovascular system. Front Endocrinol (lausanne) 9:680. https://doi.org/10.3389/fendo.2018.00680
Ho AFW, Zheng H, De Silva DA, Wah W, Earnest A, Pang YH, Xie Z, Pek PP, Liu N, Ng YY, Wong TH, Foo LL, Ong MEH (2018) The relationship between ambient air pollution and acute ischemic stroke: a time-stratified case-crossover study in a city-state with seasonal exposure to the Southeast Asian haze problem. Ann Emerg Med 72:591–601. https://doi.org/10.1016/j.annemergmed.2018.06.037
Huang W, Wang G, Lu SE, Kipen H, Wang Y, Hu M, Lin W, Rich D, Ohman-Strickland P, Diehl SR, Zhu P, Tong J, Gong J, Zhu T, Zhang J (2012) Inflammatory and oxidative stress responses of healthy young adults to changes in air quality during the Beijing Olympics. Am J Respir Crit Care Med 186:1150–1159. https://doi.org/10.1164/rccm.201205-0850OC
Huang K et al (2019a) Long-term exposure to fine particulate matter and hypertension incidence in China. Hypertension 73:1195–1201. https://doi.org/10.1161/HYPERTENSIONAHA.119.12666
Huang K et al (2019b) Long term exposure to ambient fine particulate matter and incidence of stroke: prospective cohort study from the China-PAR project. BMJ 367:l6720. https://doi.org/10.1136/bmj.l6720
Humphrey JD (2008) Mechanisms of arterial remodeling in hypertension: coupled roles of wall shear and intramural stress. Hypertension 52:195–200. https://doi.org/10.1161/HYPERTENSIONAHA.107.103440
Hurn PD, Macrae IM (2000) Estrogen as a neuroprotectant in stroke. J Cereb Blood Flow Metab 20:631–652. https://doi.org/10.1097/00004647-200004000-00001
Jiao A, Xiang Q, Ding Z, Cao J, Ho HC, Chen D, Cheng J, Yang Z, Zhang F, Yu Y, Zhang Y (2020) Short-term impacts of ambient fine particulate matter on emergency department visits: Comparative analysis of three exposure metrics. Chemosphere 241:125012. https://doi.org/10.1016/j.chemosphere.2019.125012
Kim T, Chelluboina B, Chokkalla AK, Vemuganti R (2019) Age and sex differences in the pathophysiology of acute CNS injury. Neurochem Int 127:22–28. https://doi.org/10.1016/j.neuint.2019.01.012
Koellhoffer EC, McCullough LD (2013) The effects of estrogen in ischemic stroke. Transl Stroke Res 4:390–401. https://doi.org/10.1007/s12975-012-0230-5
Kroll ME, Green J, Beral V, Sudlow CL, Brown A, Kirichek O, Price A, Yang TO, Reeves GK, Million Women Study C (2016) Adiposity and ischemic and hemorrhagic stroke: Prospective study in women and meta-analysis. Neurology 87:1473–1481. https://doi.org/10.1212/WNL.0000000000003171
Lavigne E, Yasseen AS 3rd, Stieb DM, Hystad P, van Donkelaar A, Martin RV, Brook JR, Crouse DL, Burnett RT, Chen H, Weichenthal S, Johnson M, Villeneuve PJ, Walker M (2016) Ambient air pollution and adverse birth outcomes: differences by maternal comorbidities. Environ Res 148:457–466. https://doi.org/10.1016/j.envres.2016.04.026
Li R, Wang Z, Cui L, Fu H, Zhang L, Kong L, Chen W, Chen J (2019) Air pollution characteristics in China during 2015–2016: spatiotemporal variations and key meteorological factors. Sci Total Environ 648:902–915. https://doi.org/10.1016/j.scitotenv.2018.08.181
Lin H, Ma W, Qiu H, Wang X, Trevathan E, Yao Z, Dong GH, Vaughn MG, Qian Z, Tian L (2017) Using daily excessive concentration hours to explore the short-term mortality effects of ambient PM2.5 in Hong Kong. Environ Pollut 229:896–901. https://doi.org/10.1016/j.envpol.2017.07.060
Lin H, Wang X, Qian ZM, Guo S, Yao Z, Vaughn MG, Dong G, Liu T, Xiao J, Li X, Zeng W, Xu Y, Ma W (2018) Daily exceedance concentration hours: a novel indicator to measure acute cardiovascular effects of PM2.5 in six Chinese subtropical cities. Environ Int 111:117–123. https://doi.org/10.1016/j.envint.2017.11.022
Liu H, Tian Y, Xu Y, Zhang J (2017) Ambient particulate matter concentrations and hospitalization for stroke in 26 Chinese cities: a case-crossover study. Stroke 48:2052–2059. https://doi.org/10.1161/STROKEAHA.116.016482
Liu X, Li Z, Guo M, Zhang J, Tao L, Xu X, Deginet A, Lu F, Luo Y, Liu M, Liu M, Sun Y, Li H, Guo X (2021) Acute effect of particulate matter pollution on hospital admissions for stroke among patients with type 2 diabetes in Beijing, China, from 2014 to 2018. Ecotoxicol Environ Saf 217:112201. https://doi.org/10.1016/j.ecoenv.2021.112201
Luo K, Li R, Wang Z, Zhang R, Xu Q (2017) Effect modification of the association between temperature variability and daily cardiovascular mortality by air pollutants in three Chinese cities. Environ Pollut 230:989–999. https://doi.org/10.1016/j.envpol.2017.07.045
Meng Y, Lu Y, Xiang H, Liu S (2021) Short-term effects of ambient air pollution on the incidence of influenza in Wuhan, China: a time-series analysis. Environ Res 192:110327. https://doi.org/10.1016/j.envres.2020.110327
Muller M, van der Graaf Y, Visseren FL, Mali WPTM, Geerlings MI (2012) Hypertension and longitudinal changes in cerebral blood flow: the SMART-MR study. Ann Neurol 71:825–833. https://doi.org/10.1002/ana.23554
Qian Y, Yu H, Cai B, Fang B, Wang C (2019) Association between incidence of fatal intracerebral hemorrhagic stroke and fine particulate air pollution. Environ Health Prev Med 24:38. https://doi.org/10.1186/s12199-019-0793-9
Rapsomaniki E, Timmis A, George J, Pujades-Rodriguez M, Shah AD, Denaxas S, White IR, Caulfield MJ, Deanfield JE, Smeeth L, Williams B, Hingorani A, Hemingway H (2014) Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1.25 million people. Lancet 383:1899–1911. https://doi.org/10.1016/S0140-6736(14)60685-1
Rhinehart ZJ, Kinnee E, Essien UR, Saul M, Guhl E, Clougherty JE, Magnani JW (2020) Association of fine particulate matter and risk of stroke in patients with atrial fibrillation. JAMA Netw Open 3:e2011760. https://doi.org/10.1001/jamanetworkopen.2020.11760
Roberts S (2004) Interactions between particulate air pollution and temperature in air pollution mortality time series studies. Environ Res 96:328–337. https://doi.org/10.1016/j.envres.2004.01.015
Roy-O’Reilly M, McCullough LD (2018) Age and sex are critical factors in ischemic stroke pathology. Endocrinology 159:3120–3131. https://doi.org/10.1210/en.2018-00465
Schenker N, Gentleman JF (2001) On judging the significance of differences by examining the overlap between confidence intervals. Am Stat 55:182–186
Shah AS, Lee KK, McAllister DA, Hunter A, Nair H, Whiteley W, Langrish JP, Newby DE, Mills NL (2015) Short term exposure to air pollution and stroke: systematic review and meta-analysis. BMJ 350:h1295. https://doi.org/10.1136/bmj.h1295
Sun S, Cao P, Chan KP, Tsang H, Wong CM, Thach TQ (2015) Temperature as a modifier of the effects of fine particulate matter on acute mortality in Hong Kong. Environ Pollut 205:357–364. https://doi.org/10.1016/j.envpol.2015.06.007
Tang C, Chen Y, Song Q, Ma J, Zhou Y, Gong L, Chen X, Qu J, Luo Y (2021) Short-term exposure to air pollution and occurrence of emergency stroke in Chongqing, China. Int Arch Occup Environ Health 94:69–76. https://doi.org/10.1007/s00420-020-01557-y
Tian L, Liang F, Guo Q, Chen S, Xiao S, Wu Z, Jin X, Pan X (2018a) The effects of interaction between particulate matter and temperature on mortality in Beijing, China. Environ Sci Process Impacts 20:395–405. https://doi.org/10.1039/c7em00414a
Tian Y, Liu H, Zhao Z, Xiang X, Li M, Juan J, Song J, Cao Y, Wang X, Chen L, Wei C, Hu Y, Gao P (2018b) Association between ambient air pollution and daily hospital admissions for ischemic stroke: a nationwide time-series analysis. PLoS Med 15:e1002668. https://doi.org/10.1371/journal.pmed.1002668
Tian Y, Liu H, Wu Y, Si Y, Song J, Cao Y, Li M, Wu Y, Wang X, Chen L, Wei C, Gao P, Hu Y (2019) Association between ambient fine particulate pollution and hospital admissions for cause specific cardiovascular disease: time series study in 184 major Chinese cities. BMJ 367:l6572. https://doi.org/10.1136/bmj.l6572
Tibuakuu M, Michos ED, Navas-Acien A, Jones MR (2018) Air pollution and cardiovascular disease: a focus on vulnerable populations worldwide. Curr Epidemiol Rep 5:370–378. https://doi.org/10.1007/s40471-018-0166-8
Tsai DH, Amyai N, Marques-Vidal P, Wang JL, Riediker M, Mooser V, Paccaud F, Waeber G, Vollenweider P, Bochud M (2012) Effects of particulate matter on inflammatory markers in the general adult population. Part Fibre Toxicol 9:24. https://doi.org/10.1186/1743-8977-9-24
Verhoeven JI, Allach Y, Vaartjes ICH, Klijn CJM, de Leeuw FE (2021) Ambient air pollution and the risk of ischaemic and haemorrhagic stroke. Lancet Planet Health 5:e542–e552. https://doi.org/10.1016/S2542-5196(21)00145-5
Wang C et al (2018) Prevalence and risk factors of chronic obstructive pulmonary disease in China (the China Pulmonary Health [CPH] study): a national cross-sectional study. Lancet 391:1706–1717. https://doi.org/10.1016/S0140-6736(18)30841-9
Wang N, Mengersen K, Tong S, Kimlin M, Zhou M, Wang L, Yin P, Xu Z, Cheng J, Zhang Y, Hu W (2019) Short-term association between ambient air pollution and lung cancer mortality. Environmental Research 179:108748. https://doi.org/10.1016/j.envres.2019.108748
Wei J, Li Z, Guo J, Sun L, Huang W, Xue W, Fan T, Cribb M (2019) Satellite-derived 1-km-resolution PM1 concentrations from 2014 to 2018 across China. Environ Sci Technol 53:13265–13274. https://doi.org/10.1021/acs.est.9b03258
Wu J, Li J, Peng J, Li W, Xu G, Dong C (2015) Applying land use regression model to estimate spatial variation of PM2.5 in Beijing. China Environ Sci Pollut Res Int 22:7045–7061. https://doi.org/10.1007/s11356-014-3893-5
Xu W, Tian Y, Liu Y, Zhao B, Liu Y, Zhang X (2019) Understanding the spatial-temporal patterns and influential factors on air quality index: the case of North China. Int J Environ Res Public Health 16:2820. https://doi.org/10.3390/ijerph16162820
Yin P, Brauer M, Cohen AJ, Wang H, Li J, Burnett RT, Stanaway JD, Causey K, Larson S, Godwin W, Frostad J, Marks A, Wang L, Zhou M, Murray CJL (2020) The effect of air pollution on deaths, disease burden, and life expectancy across China and its provinces, 1990–2017: an analysis for the Global Burden of Disease Study 2017. Lancet Planet Health 4:e386–e398. https://doi.org/10.1016/S2542-5196(20)30161-3
Zhang L, Tian X, Zhao Y, Liu L, Li Z, Tao L, Wang X, Guo X, Luo Y (2021) Application of nonlinear land use regression models for ambient air pollutants and air quality index. Atmospheric Pollution Research 12:101186. https://doi.org/10.1016/j.apr.2021.101186
Zheng J, Dong S, Hu Y, Li Y (2020) Comparative analysis of the CO2 emissions of expressway and arterial road traffic: a case in Beijing. PLoS One 15:e0231536. https://doi.org/10.1371/journal.pone.0231536
Zhou M et al (2019) Mortality, morbidity, and risk factors in China and its provinces, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 394:1145–1158. https://doi.org/10.1016/S0140-6736(19)30427-1
Acknowledgements
We appreciate the Beijing Municipal Health Commission Information Center and the Beijing Air Pollution and Metrological Data Center.
Funding
This work was supported by the National Natural Science Foundation of China (grant number 81773512), Scientific Research Common Program of Beijing Municipal Commission of Education (grant number KM201810025008), and “Practical Training Plan” of Beijing Municipal Education Commission.
Author information
Authors and Affiliations
Contributions
Zemeng Zhao: conceptualization, methodology, software; writing—original draft, writing—review and editing; Moning Guo: data curation, resources, writing—review and editing; Peng Tan: data curation, conceptualization, writing—review and editing; Xue Tian: formal analysis, writing—review and editing; Yuhan Zhao: software; writing—review and editing; Lulu Liu: methodology, writing—review and editing; Lili Luo: writing—review and editing; Hui Luo: writing—review and editing; Xiaonan Wang: supervision, writing—review and editing; Xiangtong Liu: supervision, writing—review and editing; Xiuhua Guo: supervision, writing—review and editing; Yanxia Luo: funding acquisition, conceptualization, supervision, writing—review and editing, and project administration. All authors read and approved the final manuscript.
Corresponding author
Ethics declarations
Ethics approval
This is an observational study, so no ethical approval is required.
Consent to participate
This is an ecological study which does not involve individual participants, so no informed consent is required.
Consent for publication
This article does not contain any individual person’s data in any form.
Informed consent
This study does not involve human participants or animals, so informed consent and statement on welfare of animals is not required.
Competing interests
The authors declare no competing interests.
Additional information
Publisher's note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary Information
Below is the link to the electronic supplementary material.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Zhao, Z., Guo, M., Tan, P. et al. Effect modification by high-concentration duration in the association between particulate matters and stroke hospital admissions among hypertension patients in Beijing, China. Air Qual Atmos Health 16, 2325–2335 (2023). https://doi.org/10.1007/s11869-023-01412-2
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11869-023-01412-2