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HomeStrokeAhead of PrintExtreme Temperatures and Stroke Mortality: Evidence From
a Multi-Country Analysis
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EXTREME TEMPERATURES AND STROKE MORTALITY: EVIDENCE FROM A MULTI-COUNTRY
ANALYSIS

 * Barrak Alahmad
   ,
 * Haitham Khraishah
   ,
 * Meghana Kamineni
   ,
 * Dominic Royé
   ,
 * Stefania I. Papatheodorou
   ,
 * Ana Maria Vicedo-Cabrera
   ,
 * Yuming Guo
   ,
 * Eric Lavigne
   ,
 * Ben Armstrong
   ,
 * Francesco Sera
   ,
 * Aaron S. Bernstein
   ,
 * Antonella Zanobetti
   ,
 * Eric Garshick
   ,
 * Joel Schwartz
   ,
 * Michelle L. Bell
   ,
 * Fahd Al-Mulla
   ,
 * Petros Koutrakis
   and
 * Antonio Gasparrini

Barrak Alahmad
Barrak Alahmad



Correspondence to: Barrak Alahmad, MD, PhD, Harvard T.H. Chan School of Public
Health, 401 Park Dr, 4th floor, Room 412G, Boston, MA 02115. Email

E-mail Address: balahmad@hsph.harvard.edu



https://orcid.org/0000-0002-9523-9537

Environmental Health Department, Harvard T.H. Chan School of Public Health,
Boston, MA. (B.A., A.S.B., A.Z., J.S., P.K.)

Dasman Diabetes Institute, Kuwait City, Kuwait (B.A., F.A.-M.).

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,
Haitham Khraishah
Haitham Khraishah





https://orcid.org/0000-0003-0003-5089

Cardiology Division, University of Maryland Medical Center, University of
Maryland, Baltimore (H.K.).

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,
Meghana Kamineni
Meghana Kamineni





https://orcid.org/0000-0002-6698-5151

Harvard Medical School, Boston, MA (M.K.).

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,
Dominic Royé
Dominic Royé





https://orcid.org/0000-0002-5516-6396

Climate Research Foundation, Madrid, Spain (D.R.).

CIBER de Epidemiología y Salud Pública, Madrid, Spain (D.R.).

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,
Stefania I. Papatheodorou
Stefania I. Papatheodorou





https://orcid.org/0000-0002-9451-9094

Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston,
MA. (S.I.P.)

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,
Ana Maria Vicedo-Cabrera
Ana Maria Vicedo-Cabrera





Institute of Social and Preventive Medicine, University of Bern, Switzerland.
(A.M.V.-C.)

Oeschger Center for Climate Change Research, University of Bern, Switzerland.
(A.M.V.-C.)

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,
Yuming Guo
Yuming Guo





Climate, Air Quality Research Unit, School of Public Health and Preventive
Medicine, Monash University, Melbourne, Australia (Y.G.).

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,
Eric Lavigne
Eric Lavigne





https://orcid.org/0000-0001-6146-9839

School of Epidemiology & Public Health, Faculty of Medicine, University of
Ottawa, Canada (E.L.).

Environmental Health Science and Research Bureau, Health Canada, Ottawa (E.L.).

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,
Ben Armstrong
Ben Armstrong





https://orcid.org/0000-0003-4407-0409

Department of Public Health Environments and Society, London School of Hygiene &
Tropical Medicine, United Kingdom. (B.A.)

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,
Francesco Sera
Francesco Sera





https://orcid.org/0000-0002-8890-6848

Department of Statistics, Computer Science and Applications G. Parenti,
University of Florence, Italy (F.S.).

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,
Aaron S. Bernstein
Aaron S. Bernstein





https://orcid.org/0000-0003-1703-1041

Environmental Health Department, Harvard T.H. Chan School of Public Health,
Boston, MA. (B.A., A.S.B., A.Z., J.S., P.K.)

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,
Antonella Zanobetti
Antonella Zanobetti





https://orcid.org/0000-0001-8170-4736

Environmental Health Department, Harvard T.H. Chan School of Public Health,
Boston, MA. (B.A., A.S.B., A.Z., J.S., P.K.)

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,
Eric Garshick
Eric Garshick





https://orcid.org/0000-0001-5931-5638

Pulmonary, Allergy, Sleep and Critical Care Medicine Section, Department of
Medicine, Veterans Affairs Boston Healthcare System, West Roxbury, MA (E.G.).

Channing Division of Network Medicine, Department of Medicine, Brigham and
Women’s Hospital, Harvard Medical School, Boston, MA (E.G.).

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,
Joel Schwartz
Joel Schwartz





https://orcid.org/0000-0001-6168-378X

Environmental Health Department, Harvard T.H. Chan School of Public Health,
Boston, MA. (B.A., A.S.B., A.Z., J.S., P.K.)

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,
Michelle L. Bell
Michelle L. Bell





https://orcid.org/0000-0002-3965-1359

School of the Environment, Yale University, New Haven, CT (M.L.B.).

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,
Fahd Al-Mulla
Fahd Al-Mulla





Dasman Diabetes Institute, Kuwait City, Kuwait (B.A., F.A.-M.).

Search for more papers by this author

,
Petros Koutrakis
Petros Koutrakis





Environmental Health Department, Harvard T.H. Chan School of Public Health,
Boston, MA. (B.A., A.S.B., A.Z., J.S., P.K.)

Search for more papers by this author

and
Antonio Gasparrini
Antonio Gasparrini





https://orcid.org/0000-0002-2271-3568

Environment & Health Modelling (EHM) Lab, Department of Public Health
Environments and Society, London School of Hygiene & Tropical Medicine, United
Kingdom. (A.G.)

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and Multi-Country Multi-City (MCC) Network
Originally published22 May
2024https://doi.org/10.1161/STROKEAHA.123.045751Stroke. 2024;0


ABSTRACT


BACKGROUND:

Extreme temperatures contribute significantly to global mortality. While
previous studies on temperature and stroke-specific outcomes presented
conflicting results, these studies were predominantly limited to single-city or
single-country analyses. Their findings are difficult to synthesize due to
variations in methodologies and exposure definitions.




METHODS:

Within the Multi-Country Multi-City Network, we built a new mortality database
for ischemic and hemorrhagic stroke. Applying a unified analysis protocol, we
conducted a multinational case-crossover study on the relationship between
extreme temperatures and stroke. In the first stage, we fitted a conditional
quasi-Poisson regression for daily mortality counts with distributed lag
nonlinear models for temperature exposure separately for each city. In the
second stage, the cumulative risk from each city was pooled using mixed-effect
meta-analyses, accounting for clustering of cities with similar features. We
compared temperature-stroke associations across country-level gross domestic
product per capita. We computed excess deaths in each city that are attributable
to the 2.5% hottest and coldest of days based on each city’s temperature
distribution.




RESULTS:

We collected data for a total of 3 443 969 ischemic strokes and 2 454 267
hemorrhagic stroke deaths from 522 cities in 25 countries. For every 1000
ischemic stroke deaths, we found that extreme cold and hot days contributed 9.1
(95% empirical CI, 8.6–9.4) and 2.2 (95% empirical CI, 1.9–2.4) excess deaths,
respectively. For every 1000 hemorrhagic stroke deaths, extreme cold and hot
days contributed 11.2 (95% empirical CI, 10.9–11.4) and 0.7 (95% empirical CI,
0.5–0.8) excess deaths, respectively. We found that countries with low gross
domestic product per capita were at higher risk of heat-related hemorrhagic
stroke mortality than countries with high gross domestic product per capita
(P=0.02).




CONCLUSIONS:

Both extreme cold and hot temperatures are associated with an increased risk of
dying from ischemic and hemorrhagic strokes. As climate change continues to
exacerbate these extreme temperatures, interventional strategies are needed to
mitigate impacts on stroke mortality, particularly in low-income countries.

 * Download figure
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FOOTNOTES

For Sources of Funding and Disclosures, see page XXX.

*A list of all Multi-Country Multi-City (MCC) Network group authors is given in
the Appendix.

Supplemental Material is available at
https://www.ahajournals.org/doi/suppl/10.1161/STROKEAHA.123.045751.

Correspondence to: Barrak Alahmad, MD, PhD, Harvard T.H. Chan School of Public
Health, 401 Park Dr, 4th floor, Room 412G, Boston, MA 02115. Email
balahmad@hsph.harvard.edu



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 * © 2024 American Heart Association, Inc.



https://doi.org/10.1161/STROKEAHA.123.045751

PMID: 38776169

 * Manuscript receivedNovember 8, 2023
 * Manuscript acceptedApril 9, 2024
 * Originally publishedMay 22, 2024
 * Manuscript revisedMarch 27, 2024


Keywords
 * climate change
 * extreme cold
 * hemorrhagic stroke
 * ischemic stroke
 * temperature

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Subjects
 * Cerebrovascular Disease/Stroke
 * Epidemiology
 * Risk Factors


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