The impact of low ambient temperature on cardiovascular health

Guoqing Zhang; Cuiqing Liu; Qinghua Sun

doi:10.2478/fzm-2023-0021

The impact of low ambient temperature on cardiovascular health

doi: 10.2478/fzm-2023-0021

Guoqing Zhang^{1, 2},
Cuiqing Liu^{1, 2
, ,},
Qinghua Sun^{1, 2
, ,}

1.
School of Public Health and Joint China-US Research Center for Environment and Pulmonary Diseases, Zhejiang Chinese Medical University, Hangzhou 310053, China
2.
Zhejiang International Science and Technology Cooperation Base of Air Pollution and Health, Hangzhou 310053, China

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Corresponding author: Cuiqing Liu, E-mail address: liucuiqing@zcmu.edu.cn; Qinghua Sun, E-mail address: qhsun@zcmu.edu.cn

摘要

Abstract: Extreme weather events and climate change have witnessed a substantial increase in recent years, leading to heightened concerns. The rise in abnormal ambient temperatures, both in intensity and frequency, directly and indirectly impacts cardiovascular health. While the impact of high ambient temperatures on cardiovascular response is a common concern in the context of global warming, the significance of low temperatures cannot be overlooked. The challenges posed by low temperatures contribute to increased cardiovascular morbidity and mortality, posing a significant threat to global public health. This review aims to provide an overview of the relationship between low ambient temperature and cardiovascular health, encompassing the burden of cardiovascular outcomes and underlying mechanisms. Additionally, the review explores strategies for cold adaptation and cardioprotection. We posit that to optimize cold adaptation strategies, future research should delve deeper into the underlying mechanisms of cardiovascular health in response to low ambient temperature exposure.
- low ambient temperature /
- cardiovascular health /
- cold adaptation

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Figure 1. Potential mechanisms linking low ambient temperature to cardiovascular morbidity and mortality

PA, pulmonary arterial; BAT, brown adipose tissue; SNS, sympathetic nervous system; RAS, renin-angiotensin system.

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Table 1. Summary of selected studies on low ambient temperature and CVD mortality

Authors (year of publication)	Study region	Study period	Population size	Outcome variables	Main outcome	Reference
Carder et al. (2005)	3 large cities in Scottish	1981–2001	1, 652, 000	Cardiorespiratory mortality	For temperatures below 11℃, a 1℃ drop in the daytime mean temperature on any day was associated with an increase in mortality of 3.4% (95% CI: 2.6, 4.1) over the following month for CVD disease.	[47]
Zeka et al. (2014)	Ireland	1984–2007	1, 057, 046	CVD mortality	CVD mortality showed the greatest increase associated with temperatures in the preceding week; the impact of cold temperature on mortality was slightly weakened, but lasted up to 4 weeks prior to death.	[49]
Wang et al. (2015)	Beijing and Shanghai, China	2007–2009	none	CVD mortality	People with hypertensive disease were particularly susceptible to extremely low temperature in Beijing. People with ischemic heart disease in Shanghai showed greater susceptibility to extremely cold temperature.	[48]
Yang et al. (2015)	15 cities in China	2007–2013	1, 936, 116	CVD mortality	Cold weather was responsible for temperature-related CVD death burden with a fraction of 15.8% (95% CI: 13.1%, 17.9%), corresponding to 305902 deaths.	[34]
Zhang et al. (2016)	Wuhan, China	2003–2010	32, 721	CVD mortality	For cold effects over lag 0–21 days, a 1℃ decrease in mean temperature below the cold thresholds was associated with a 3.65% (95% CI: 2.62, 4.69) increase in CVD mortality.	[46]
Fu et al. (2018)	India	2001–2013	40, 003	Ischemic heart disease death	Moderately cold temperature (13.8℃) was estimated to have higher attributable risks (9.7% [95% CI: 3.7, 15.3]) for ischemic heart disease death than extreme cold one.	[38]
Zhang et al. (2018)	Yinchuan, China	2010–2015	26, 097	CVD mortality	Cold temperature was associated with significantly delayed CVD mortality.	[27]
Chen et al. (2018)	272 main Chinese cities	2013–2015	1, 826, 186	CVD mortality	Compared to the minimum mortality temperatures, extreme cold temperature had larger relative risks (1.92 [95% CI: 1.75, 2.10]) than extreme hot temperature (RR: 1.22 [95% CI: 1.16, 1.28]) on CVD mortality.	[23]
Lv et al. (2020)	Hunan, China	2013–2017	none	YLL rate	Cold temperature was responsible for most of the YLL for cardiovascular death, with an overall estimate of 15.94% (8.82%, 23.05%).	[43]
Cheng et al. (2021)	Hong Kong, China	2000–2016	67, 157	YLL	Cold was estimated to cause life expectancy loss of 0.9 years in total cardiovascular disease.	[41]
Hu et al. (2021)	364 locations across China	2006–2017	none	YLL	An average of 1.07 (95% CI: 1.00, 1.15) years life loss per CVD death was associated with cold temperature.	[26]
Liu et al. (2021)	364 locations across China	2013–2017	none	YLL rate	A mean of 1.1 (95% CI: 0.67, 1.37) YLL per CVD death was attributable to cold temperature.	[44]
Lv et al. (2022)	Hunan, China	2013–2017	711, 484	YLL rates	Life loss per death of cardiovascular diseases attributable to cold temperature was 1.13 (95% CI: 0.89, 1.37), particularly moderate cold (1.00, 95% CI: 0.78, 1.23).	[19]
Xu et al. (2022)	Jiangsu, China	2015–2019	1, 000, 014	CVD mortality	Exposure to extreme cold (−0.6℃) was significantly associated with increased odds of mortality (1.79, 95% CI: 1.73, 1.85).	[20]
CVD, cardiovascular disease; CI, confidence interval; eCI, empirical confidence interval; RR, relative risk; YLL, years of life lost.

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Table 2. Summary of selected studies on low ambient temperature and CVD morbidity

Authors (year of publication)	Study region	Study period	Population size	Outcome variables	Main outcome	Reference
Sartini et al. (2016)	British	1998–2012	none	CVD morbidity	CVD risks were higher in winter.	[55]
Bai et al. (2016)	Ontario, Canada	1996–2013	395, 840	Hospitalizations from hypertensive diseases and arrhythmia	Compared to the temperature with minimum risk of morbidity, cold temperatures (1^st percentile) were associated with a 37% (95% CI: 5%, 78%) increase in hypertension-related hospitalizations. Arrhythmia was not linked to temperatures.	[32]
Hensel et al. (2017)	Hamburg, Germany	2010–2014	510, 389	CVD emergencies	Coronary artery disease, cardiac pulmonary edema and hypertensive urgency were increased at low temperatures, particularly below 10℃.	[33]
Ponjoan et al. (2017)	Catalan	2006–2013	22, 611	CVD emergency hospitalization	The overall incidence of CVD hospitalization was significantly increased during cold spells (IRR = 1.120; 95% CI: 1.10, 1.30) and the effect was even stronger in the 7 days subsequent to the cold spell (IRR = 1.29; 95% CI: 1.22, 1.36).	[59]
Bai et al. (2018)	Ontario, Canada	1996–2013	1, 389, 057	Coronary heart disease hospitalization	On cold days with temperature corresponding to the 1^st percentile of temperature distribution, a 9% increase in daily hospitalizations for coronary heart disease (95% CI: 1%, 16%), 29% increase for myocardial infarction (95% CI: 15%, 45%) and 11% increase for stroke (95% CI: 1%, 22%) relative to the days with an optimal temperature.	[29]
Zhao et al. (2018)	Ningxia, China	2012–2015	158, 733	Clinical visit	Cold effect on cardiovascular visits appeared at the lag 6^th day and persisted until the 22nd day, resulting in a cumulative relative risk (RR) 1.55 (95% CI: 1.26, 1.92), compared to the minimum-clinical visit temperature.	[40]
Liu et al. (2018)	Beijing, China	2013–2016	81, 029	Acute myocardial infarction (AMI) hospitalization	Compared to the 10^th percentile temperature measured by daily mean temperature (T mean), daily minimum temperature (T min) and daily minimum apparent temperature (AT min), the cumulative RR at 1^st percentile of T mean, T min and AT min for AMI hospitalization were 1.15 (95% CI: 1.02, 1.30), 1.24 (95% CI: 1.11, 1.38) and 1.41 (95% CI: 1.18, 1.68), respectively.	[51]
Mohammadi et al. (2018)	Tehran, Iran	2013–2016	15, 835	AMI hospitalization	Cold temperatures increased the risk of AMI admissions.	[53]
Xu et al. (2019)	Suzhou, China	2013–2016	100	Blood pressure	The systolic blood pressure, diastolic blood pressure, pulse pressure, and mean arterial pressure decreased with hourly temperature decreased.	[56]
Cui et al. (2019)	Hefei, China	2015–2017	35, 096	Hospital admission	Compared to the 25^th percentile of temperature (10.3℃), the cumulative RR of extremely low temperature (1^st percentile of temperature, 0.075℃) over lag 0–27 days was 0.616 (95% CI: 0.423, 0.891), and the cumulative RR of moderate low temperature (10^th percentile of temperature, 5.16℃) was 1.081 (95% CI: 1.019, 1.147) over lag 0–7 days.	[54]
Tian et al. (2020)	Hong Kong, China	2005–2012	521, 575	Emergency CVD hospitalization	Compared to the identified optimal temperature at 23.0℃, the cumulative relative risk during 0 to 21 lag days was 1.69 (95% CI: 1.56, 1.82) for extreme cold (1^st percentile) and 1.22 (95% CI: 1.15, 1.29) for moderate cold temperature (10^th percentile).	[39]
Kang et al. (2020)	31 provinces in China	2012–2015	451, 770	Blood pressure	An overall 10℃ decrease in ambient temperature was statistically associated with 0.74 mmHg (95% CI: 0.69, 0.79) and 0.60 mmHg (95% CI: −0.63, −0.57) rise in systolic and diastolic blood pressure, respectively.	[52]
Lavigne et al. (2021)	Toronto, Canada	2002–2010	292, 666	CVD morbidity	The effect of extreme cold temperatures (1^st percentile of temperature distribution vs. 25^th percentile) on CVD emergency room visits was stronger for individuals with comorbid cardiac (REM = 1.47; 95% CI: 1.06, 2.23) and kidney diseases (REM = 2.43; 95% CI: 1.59, 8.83).	[58]
Fonseca-Rodríguez et al. (2021)	Sweden	1991–2014	1, 630, 189	CVD hospitalization	Moist and very cold weather was related to a delayed increase in cardiovascular hospitalizations.	[21]
CVD, cardiovascular disease; CI, confidence interval; RR, relative risk; YLL, years of life lost; IRR, Incidence rate ratios; REM, relative effect modification.

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