Keller Karsten, Haghi Seyed Hamed Rastguye, Hahad Omar, Schmidtmann Irene, Chowdhury Sourangsu, Lelieveld Jos, Münzel Thomas, Hobohm Lukas
Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany; Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, Heidelberg, Germany.
Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.
Thromb Res. 2023 May;225:116-125. doi: 10.1016/j.thromres.2023.03.006. Epub 2023 Mar 22.
A growing body of evidence suggests that air pollution exposure is associated with an increased risk for cardiovascular diseases. Data regarding the impact of long-term air pollution exposure on ischemic stroke mortality are sparse.
The German nationwide inpatient sample was used to analyse all cases of hospitalized patients with ischemic stroke in Germany 2015-2019, which were stratified according to their residency. Data of the German Federal Environmental Agency regarding average values of air pollutants were assessed from 2015 to 2019 at district-level. Data were combined and the impact of different air pollution parameters on in-hospital case-fatality was analyzed.
Overall, 1,505,496 hospitalizations of patients with ischemic stroke (47.7% females; 67.4 % ≥70 years old) were counted in Germany 2015-2019, of whom 8.2 % died during hospitalization. When comparing patients with residency in federal districts with high vs. low long-term air pollution, enhanced levels of benzene (OR 1.082 [95%CI 1.034-1.132],P = 0.001), ozone (O OR 1.123 [95%CI 1.070-1.178],P < 0.001), nitric oxide (NO, OR 1.076 [95%CI 1.027-1.127],P = 0.002) and PM fine particulate matter concentrations (OR 1.126 [95%CI 1.074-1.180],P < 0.001) were significantly associated with increased case-fatality independent from age, sex, cardiovascular risk-factors, comorbidities, and revascularization treatments. Conversely, enhanced carbon monoxide, nitrogen dioxide, PM and sulphur dioxide (SO) concentrations were not significantly associated with stroke mortality. However, SOconcentrations were significantly associated with stroke-case-fatality rate of >8 % independent of residence area-type and area use (OR 1.518 [95%CI 1.012-2.278],P = 0.044).
Elevated long-term air pollution levels in residential areas in Germany, notably of benzene, O, NO, SO and PM, were associated with increased stroke mortality of patients.
Evidence before this study: Besides typical, established risk factors, increasing evidence suggests that air pollution is an important and growing risk factor for stroke events, estimated to be responsible for approximately 14 % of all stroke-associated deaths. However, real-world data regarding the impact of long-term exposure to air pollution on stroke mortality are sparse. Added value of this study: The present study demonstrates that the long-term exposure to the air pollutants benzene, O, NO, SO and PM are independently associated with increased case-fatality of hospitalized patients with ischemic stroke in Germany. Implications of all the available evidence: The results of our study support the urgent need to reduce the exposure to air pollution by tightening emission controls to reduce the stroke burden and stroke mortality.
越来越多的证据表明，接触空气污染与心血管疾病风险增加有关。关于长期接触空气污染对缺血性中风死亡率影响的数据很少。
利用德国全国住院患者样本分析了2015 - 2019年德国所有住院缺血性中风患者的病例，这些病例根据居住地进行了分层。德国联邦环境局关于空气污染物平均值的数据在2015年至2019年期间按地区级别进行了评估。将数据合并，并分析了不同空气污染参数对住院病死率的影响。
总体而言，2015 - 2019年德国共有1,505,496例缺血性中风患者住院（47.7%为女性；67.4%年龄≥70岁），其中8.2%在住院期间死亡。当比较居住在长期空气污染程度高与低的联邦地区的患者时，苯（比值比[OR]1.082[95%置信区间（CI）1.034 - 1.132]，P = 0.001）、臭氧（OR 1.123[95%CI 1.070 - 1.178]，P < 0.001）、一氧化氮（NO，OR 1.076[95%CI 1.027 - 1.127]，P = 0.002）和细颗粒物（PM）浓度（OR 1.126[95%CI 1.074 - 1.180]，P < 0.001）的升高与病死率增加显著相关，且不受年龄、性别、心血管危险因素、合并症和血运重建治疗的影响。相反，一氧化碳、二氧化氮、PM和二氧化硫（SO）浓度的升高与中风死亡率无显著关联。然而，SO浓度与中风病死率>8%显著相关，且与居住地区类型和区域用途无关（OR 1.518[95%CI 1.012 - 2.278]，P = 0.044）。
德国居民区长期空气污染水平升高，尤其是苯、臭氧、NO、SO和PM，与患者中风死亡率增加有关。
本研究之前的证据：除了典型的、已确定的危险因素外，越来越多的证据表明，空气污染是中风事件的一个重要且不断增加的危险因素，估计约占所有中风相关死亡的14%。然而，关于长期接触空气污染对中风死亡率影响的实际数据很少。本研究的附加值：本研究表明，长期接触空气污染物苯、臭氧、NO、SO和PM与德国住院缺血性中风患者的病死率增加独立相关。所有现有证据的意义：我们的研究结果支持迫切需要通过加强排放控制来减少空气污染暴露，以减轻中风负担和降低中风死亡率。
