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Extreme temperatures and out-of-hospital coronary deaths in six large Chinese cities
  1. Renjie Chen1,2,3,
  2. Tiantian Li4,
  3. Jing Cai1,2,3,
  4. Meilin Yan5,
  5. Zhuohui Zhao1,
  6. Haidong Kan1,2,3
  1. 1School of Public Health, Key Lab of Public Health Safety of the Ministry of Education, & Key Lab of Health Technology Assessment of the Ministry of Health, Fudan University, Shanghai, China
  2. 2Research Institute for the Changing Global Environment and Fudan Tyndall Centre, Fudan University, Shanghai, China
  3. 3Shanghai Key Laboratory of Atmospheric Particle Pollution and Prevention (LAP3), Fudan University, Shanghai, China
  4. 4Institute of Environmental Health and Related Product Safety, Chinese Center for Disease Control and Prevention, Beijing, China
  5. 5College of Environmental Sciences and Engineering, Peking University, Beijing, China
  1. Correspondence to
    Dr Haidong Kan, Department of Environmental Health, Fudan University, PO Box 249, 130 Dong-An Road, Shanghai 200032, China; haidongkan{at}


Background The seasonal trend of out-of-hospital coronary death (OHCD) and sudden cardiac death has been observed, but whether extreme temperature serves as a risk factor is rarely investigated. We therefore aimed to evaluate the impact of extreme temperatures on OHCDs in China. We obtained death records of 126 925 OHCDs from six large Chinese cities (Harbin, Beijing, Tianjin, Nanjing, Shanghai and Guangzhou) during the period 2009–2011.

Methods The short-term associations between extreme temperature and OHCDs were analysed with time-series methods in each city, using generalised additive Poisson regression models. We specified distributed lag non-linear models in studying the delayed effects of extreme temperature. We then applied Bayesian hierarchical models to combine the city-specific effect estimates.

Results The associations between extreme temperature and OHCDs were almost U-shaped or J-shaped. The pooled relative risks (RRs) of extreme cold temperatures over the lags 0–14 days comparing the 1st and 25th centile temperatures were 1.49 (95% posterior interval (PI) 1.26–1.76); the pooled RRs of extreme hot temperatures comparing the 99th and 75th centile temperatures were 1.53 (95% PI 1.27–1.84) for OHCDs. The RRs of extreme temperature on OHCD were higher if the patients with coronary heart disease were old, male and less educated.

Conclusions This multicity epidemiological study suggested that both extreme cold and hot temperatures posed significant risks on OHCDs, and might have important public health implications for the prevention of OHCD or sudden cardiac death.

  • Clinical epidemiology
  • Environmental epidemiology

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