1. : Epidemiology of Morbidity and Mortality from Particles and Co-Pollutants: Respiratory, Cardiovascular, and Cancer Douglas W. Dockery Harvard School of Public Health

2. Estimated Effect of Each 10  g/m 3 Increase in PM 10 Total Respiratory Cardiovascular

3. PM 10 and Elderly Hospital Admissions: Detroit Schwartz & Morris, Am J Epi 1995 l l Daily hospital admissions of elderly (65+ yrs) for 1986-89 Medicare files 32  g/m 3 PM 10 associated with +1.8% Ischemic HD +2.4% Heart Failure +1.9% Dysrythmias l l CO also associate with Heart Failure

4. PM Air Pollution and Cardiovascular Hospital Admissions Schwartz, Epidemiology1998 l l Hospital admission for CVD (ICD9 390-429) l l Eight metropolitan counties with PM10 measurements (1988- 1990) l l Overall effect of 25  g/m 3 PM 10 2.5%(95%CI 1.8%,3.2%)

5. Does PM Pollution Induce Hypoxemia? Pope et al, AJRCCM 1999 l l Do PM episodes produce transient drops in blood oxygenation? l l Two panels of elderly adults at high altitude – –52 retired BYU faculty and spouses – –38 retirement home residents l Measured oxygen saturation in morning and evening with pulse oximeter l PM 10, CO, and NO 2 measured at 3 sites within valley l Four winter months 1995-96

7. Utah Valley Oximetry Study

8. l l Expected association between S pO2 and barometric pressure l l No association between S pO2 and PM 10 l l Unexpected positive association between heart rate and PM 10 l l Seen in other studies (Peters, 1999). Autonomic link?

9. Heart Rate Variability (HRV) l l HRV indicator of autonomic tone l l SDNN - standard deviation of time intervals between normal beats l l SDNN decreases with age, lower in illness l Low SDNN associated with risk of sudden death l Decreased SDNN associated with poor cardiovascular prognosis –Framingham Study: lower SDNN associated with higher risk of death (Tsui, Circ 1994)

10. Utah Valley Ambulatory ECG Pilot Pope et al, AHJ 1999 l l Panel of 6 Emeritus BYU faculty, Winter 1995/96 l l 24 hour ambulatory ECG monitoring l l Three occasions - before, during and after PM episode l l Conclusions – –Decreased heart rate variability (SDNN) following episodes – –Participants unwilling to repeat measurement

11. HRV and PM Air Pollution l l Panel studies of elderly – –Ambulatory EKG monitoring – –Controlled conditions (5-30 minutes) – –Repeated every other day to weekly l l Reported  HRV associated with  PM 10 – –Baltimore, MD (Liao et al, EHP 1999) – –Boston, MA (Gold et al, Circ 2000) – –Baltimore, Md (Creason et al, JEAEE2000)

12. Implantable Cardioverter (ICD) Devices Implantable Cardioverter Defibrillators (ICD) Devices l l Implanted under skin with electrodes and leads attached to heart l l Monitor cardiac rhythm abnormalities l l On detecting potentially fatal arrhythmia, triggers cardioverter shock l l Records date and time of all detected arrhythmias and therapies

13. Abstracted Arrhythmia Data Date& Time of Arrhythmia Result of Therapy Therapy Initiated Type of Arrhythmia Identifier Interval

14. Air Pollution and Incidence of Cardiac Arrhythmias Peters et al, Epidemiology 2000 l l 100 patients with Implanted Cardioverter Defibrillators (ICDs) l l Lived in eastern Massachusetts l l Followed 1995-1997, median 644 days l l Abstracted ICD Discharges – –223 events – –33 patients with any discharge, 6 with 10+ l Daily air pollution measurements –PM 10, PM 2.5, black carbon, –CO, O 3, NO 2 and SO 2 l Weather –Temperature and humidity l Regression of ICD discharges against air pollution

15. Air Pollution and Incidence of Cardiac Arrhythmias Peters et al, Epidemiology 2000 l l OR for ICD Discharge associated with PM 2.5, Black Carbon, and NO 2 l l Stronger associations among 6 patients with 10+ events (effect of 5%-95% air pollution) – –PM 2.5 1.22 (0.7,2.0) – –BC 2.16 (1.0,4.9) – –NO 2 3.13 (1.8,5.6)

16. Determinants of MI Onset Study l l “Determinants of Myocardial Infarction Onset Study” designed to study triggers of myocardial infarction such as exercise (Mittleman et al., NEJM 1993). l l Subset of 833 patients with myocardial infarction interviewed in the greater Boston area between 1995 and 1996. l l Hourly PM 2.5 data available during this period (24h-average: 12.1 µg/m 3 ; max: 47.4 µg/m 3 ).

17. Acute Triggers of Myocardial Infarction? l l A case-crossover study provides a framework to study triggers (Maclure, AJE 1991; Mittleman et al., AJE 1995) time (days)

18. Hourly PM 2.5 and onset of myocardial infarction

19. 24h-average PM 2.5 and onset of myocardial infarction

20. OR for MI Onset for Both Time Scales Simultaneously

21. Onset Study - Conclusions l l Increased risk of MI with increased PM 2.5 two hours and twenty four hours prior. l l Two time scales independent and additive. l l Multivariate adjustments for season, temperature and relative humidity slightly increased estimates. l l Stronger effects observed for PM 2.5 than for gaseous pollutants such as CO, NO 2 or SO 2.

22. PM Episode & CRP Acute Phase Response MONICA - Augsburg Study Peters et al, 2000 l l 631 men 45-64 yrs, tested 1984/85 and 1987/88 l l C Reactive Protein (CRP) – –Imflamation, tissue damage, infection l l Jan 85 pollution episode l l % with CRP >5.7 mg/L – –episode (17%) – – nonepisode (11%) – – follow-up (8%)

23. Population Studies of PM-Induced Changes in Cardiac Function l l Time Series studies – –  Cardiovascular mortality – –  Cardiovascular hospital admissions l l Autonomic cardiac function in elderly – –  Pulse Rate and  Heart Rate Variability l l Implanted Cardiac Defibrillators – –  Cardiac arrhythmias (VF) l l  Onset of myocardial infarction l l  Inflammatory markers (CRP)