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Effects of Asian Dust-Derived Particulate Lee et al. BMC Public Health (2021) 21:68 https://doi.org/10.1186/s12889-020-10067-y RESEARCH ARTICLE Open Access Effects of Asian dust-derived particulate matter on ST-elevation myocardial infarction: retrospective, time series study Suji Lee1, Whanhee Lee2, Eunil Lee3, Myung Ho Jeong4, Seung-Woon Rha5, Chong-Jin Kim6, Shung Chull Chae7,8, Hyo-Soo Kim9, Hyeon-Cheol Gwon10 and Ho Kim1,2* Abstract Background: Dust storms affect human health by impairing visibility and promoting interactions with microscopic organisms, such as bacteria and fungi. Although ST-elevation MI (STEMI) and non-ST-elevation MI (NSTEMI) differ mechanistically, few studies have investigated the incidence of cardiovascular diseases according to infarction type; these studies have yielded inconsistent findings. This study aimed to examine whether PM size (< 2.5 μm (PM2.5) and < 10 μm (PM10)) modifies the effect of Asian dust on acute myocardial infarction (AMI), with separate analyses for STEMI and NSTEMI. Methods: MI-related data from 9934 emergency visits were collected from the Korea AMI Registry from 2005 to 2017. Asian dust events were defined as days with visibility of ≤10 km. Generalized linear models were used to analyze data with natural cubic splines. To examine potential modifiers, analyses were stratified by age, smoking status, and body mass index (BMI). Results: No significant associations were observed between Asian dust and AMI. By adjusting for different lag structures, a significant effect was exclusively observed in STEMI. For moving average lags, the largest value at lag 5 (relative risk [RR] 1.083; 95% confidence interval [CI], 1.007–1.166) for single and lags 0–7 (RR 1.067; 95% CI: 1.002– 1.136) was observed for PM2.5; for PM10, the largest significant effect was observed at lag 4 (RR 1.075; 95% CI: 1.010– 1.144) for single and lags 0–7 (RR 1.067; 95% CI: 1.002–1.136). RRs were significantly higher in < 65-year-olds than in ≥65-year-olds. Additionally, RRs between the BMI < 25 and BMI ≥ 25 groups were not different; statistically significant effects were observed for concentration at lags 0–5 (RR: 1.073; 95% CI: 1.002–1.150) and lags 0–6 (RR: 1.071; 95% CI: 1.001–1.146) in the BMI < 25 group. A negative exposure-response association was observed between daily average visibility-adjusted PM and STEMI and daily average visibility-adjusted PM in < 65-year-olds. Conclusions: Reducing PM2.5 and PM10 emissions, particularly during the days of Asian dust, may be crucial and reduce STEMI and AMI incidence among < 65-year-olds. These results indicate that the Asian dust alarm system needs revision to protect vulnerable populations. Keywords: Particulate matter, Myocardial infarction, Asian dust, Air pollution, Health effect * Correspondence: [email protected] 1Institute of Health and Environment, Seoul National University, Gwanak-ro, Seoul 08826, Republic of Korea 2Department of Biostatistics and Epidemiology, Graduate School of Public Health, Seoul National University, Gwanak-gu, Seoul 00826, Republic of Korea Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This 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. Lee et al. BMC Public Health (2021) 21:68 Page 2 of 10 Background hospitals that collects data using a standardized case re- Dust storms affect human health by impairing visibility port form. The rationale and design of this nationwide and promoting interactions with microscopic organisms, mandatory registration have been previously explained such as bacteria and fungi [1]. They have recently been [18]. This study included patients from the KAMIR who associated with diseases and adverse health effects and presented with AMI to the Seoul hospital emergency are being recognized as a health risk. Considerable epi- rooms between 2005 and 2017 and for whom PM2.5 data demiological research has been published on cardiovas- were available. Of these, patients with inadequate infor- cular impacts of dust storms in East Asian countries, mation were excluded. The first medical contact time such as China [2] and Japan [3, 4], as well as southern was defined as the time of the primary manifestation of Europe [5] and North America [6]. These adverse health AMI symptoms. In addition, stratified analyses were per- effects include asthma, respiratory diseases, cardiovascu- formed by age, smoking status, and MI status (STEMI lar diseases, and mortality [2, 4–6]. By contrast, some and NSTEMI). studies have observed no association between dust Climate data were obtained from the Korean Meteoro- storms and cardiovascular disease in either emergency logical Administration, including those on the daily department or hospital admissions [7]. mean temperature, humidity, sea level pressure, and visi- There is an increasing evidence that increased expos- bility from 2005 to 2017. Based on previous studies, we ure to particulate matter (PM) leads to cardiovascular defined Asian dust events as days when visibility was < disease, particularly among patients with a history of 10 km [3, 4]. PM10 data were obtained from the National myocardial infarction (MI) [8–11]. Although ST- Institute of Environmental Research in Korea, whereas elevation MI (STEMI) and non-ST-elevation MI (NSTE PM2.5 data were collected from 27 monitoring sites MI) differ mechanistically [12], few studies have investi- managed by the Seoul Research Institute of Public gated the incidence of cardiovascular diseases according Health and Environment. to infarction type; these studies have yielded inconsistent findings. A New York-based study initially suggested Statistical analysis that exposure to PM size < 2.5 μm (PM2.5) increased the The time-series data for this ecological study design risk of STEMI, unlike NSTEMI [9]. Moreover, studies were analyzed using generalized linear models to accom- from Belgium and Utah (US) reported consistent results modate the nonlinear relationships of emergency visits [8, 11]. Conversely, other studies failed to demonstrate for AMI. Natural cubic spline functions were used to the effect of PM2.5 on STEMI risk [13, 14]. consider non-linearity for time and weather variables. In The European project “MED-PARTICLES” underscored the basic model, single lag day effects of Asian dust were that the adverse health effect of the desert component of examined from the current day (lag 0) to the sixth day, PM can be affected by concentrations of anthropogenic- adjusting for meteorological effects that could affect derived PM size < 10 μm(PM10)[15]. However, past ap- AMI, including two-day moving average of temperature, proaches that investigated the health effects of PM and current day relative humidity, and sea level pressure (lag Asian dust separately analyzed each component, whereas 0), as covariates. In the evaluation of the hypothesis that few researches simultaneously studied the two effects. PM2.5 and PM10 would enhance MI risk on Asian dust 2+ 2+ Additionally, various natural crustal elements (Ca ,Mg , days, single- and moving average lags of PM2.5 and PM10 + + Na ,K), anthropogenic pollutants (Pb, As, NOx), micro- were included in the basic model. The largest lag days of organisms, fungal spores, chemical components, and gas- Asian dust in the basic model were used in the PM- eous pollutants can also be mixed and carried in the dust adjusted model. Similarly, stratified analyses were [16]. It is possible that dust event-associated health effects conducted by age, smoking status (never smoking/past involving PM are different from those associated with dust smoking/current smoking), and obesity to evaluate the events alone [17]; therefore, it is necessary to research the potential effect of the association between Asian dust health effects of dust storms with PM. and AMI. BMI was categorized into two categories based Therefore, this study aimed to evaluate the association on the standard definition as follows [19]: normal/under- between AMI and Asian dust with PM, and assess the weight (BMI < 25 kg/m2) and overweight/obese (BMI variation of the association according to infarction type ≥25 kg/m2). (STEMI and NSTEMI), age group, body mass index Finally, sensitivity analyses were performed to assess (BMI), and smoking status. the validity of the findings by modified different degrees of freedom for time trends and various temperature lag Methods structures. Additionally, because higher relative humidity Data collection could plausibly affect visibility, models were repeated to The KAMIR is a prospective study of approximately 37, include interaction terms between daily mean visibility 880 patients in 57 general emergency rooms of Korean and an indicator variable of high level of humidity days, Lee et al. BMC Public Health (2021) 21:68 Page 3 of 10 wherein relative humidity was higher than 70% or 80%, patients was observed on the current day (RR, 1.046; respectively. All statistical analyses were performed using 95% CI, 0.963–1.136).
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