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Particulate Matter and Temperature: Increased Risk of Adverse Clinical Outcomes in Patients With Atrial Fibrillation

  • José Miguel Rivera-Caravaca
    Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria, Murcia, Spain
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  • Vanessa Roldán
    Correspondence: Address to Vanessa Roldán, MD, PhD, Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, Avda. Marqués de los Vélez s/n 30008, Murcia, Spain.
    Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria, Murcia, Spain
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  • Vicente Vicente
    Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria, Murcia, Spain
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  • Gregory Y.H. Lip
    Liverpool Centre for Cardiovascular Science, University of Liverpool, and Liverpool Heart and Chest Hospital, Liverpool, UK

    Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
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  • Francisco Marín
    Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria, Murcia, Spain
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      To test the hypothesis that particulate matter with an aerodynamic diameter of less than 10 μm (PM10) and temperature are associated with an increased risk of adverse clinical outcomes in patients with atrial fibrillation (AF) taking vitamin K antagonists (VKAs).

      Patients and Methods

      We included patients with AF whose condition was stable while taking VKAs (international normalized ratio, 2.0 to 3.0) for 6 months seen in a tertiary hospital (recruitment from May 1, 2007, to December 1, 2007). During a median follow-up of 6.5 years (interquartile range, 4.3 to 7.9 years), ischemic strokes, major bleeding, adverse cardiovascular events, and mortality were recorded. From 2007 to 2016, data on average temperature and PM10 were compared with clinical outcomes.


      The study group included 1361 patients (663 [48.7%] male; median age, 76 years [interquartile range, 71 to 81 years]). High PM10 and low temperatures were associated with higher risk of major bleeding (adjusted hazard ratio [aHR], 1.44; 95% CI, 1.22 to 1.70 and aHR, 1.03; 95% CI, 1.01 to 1.05, respectively) and mortality (aHR, 1.50; 95% CI, 1.34 to 1.69 and aHR, 1.04; 95% CI, 1.02 to 1.06, respectively); PM10 was also associated with ischemic stroke and temperature with cardiovascular events. The relative risk (RR) for cardiovascular events and mortality increased in months in the lower quartile of temperature (RR, 1.12; 95% CI, 1.04 to 1.21 and RR, 1.41; 95% CI, 1.15 to 1.74, respectively). Comparing seasons, there were higher risks of cardiovascular events in spring, autumn, and winter than in summer, whereas the risk of mortality increased only in winter.


      In patients with AF taking VKAs, high PM10 and low temperature were associated with increased risk of ischemic stroke and cardiovascular events, respectively. Both factors increased major bleeding and mortality risks, which were higher during colder months and seasons.

      Abbreviations and Acronyms:

      AF (atrial fibrillation), aHR (adjusted hazard ratio), CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes, stroke, vascular disease, age 65-74 years, sex), HAS-BLED (hypertension, abnormal renal and/or liver function, stroke, bleeding, labile international normalized ratio, elderly, drugs or alcohol), HR (hazard ratio), IQR (interquartile range), IRR (incidence rate ratio), OAC (oral anticoagulation), PM (particulate matter), PM2.5 (PM with an aerodynamic diameter of 2.5 μm), PM10 (PM with an aerodynamic diameter <10 μm), RR (relative risk), sHR (subhazard ratio), VKA (vitamin K antagonist)
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