Figure 1
Patient flow chart.
Table 1
Baseline characteristics of patients stratified by major adverse cardiac and cerebrovascular events (MACCE) (n = 22,188).
| VARIABLE | OVERALL MEAN (SD) | NO MACCE (n = 15,806) | MACCE* (n = 6,382) | P-VALUE |
|---|---|---|---|---|
| PM2.5 (μg/m3) | 0.555# | |||
| Mean (SD) | 3.28 (9.94) | 3.37 (10.45) | 3.04 (8.52) | |
| Median (Q1, Q3) | 0.26 (0, 2.29) | 0.26 (0, 2.25) | 0.28 (0, 2.38) | |
| Quarters, n (%) | 0.623 | |||
| Q1 (January to March) | 5,227 (23.56) | 3,761 (71.95) | 1,466 (28.05) | |
| Q2 (April to June) | 5,579 (25.14) | 3,962 (71.02) | 1,617 (28.98) | |
| Q3 (July to September) | 6,367 (28.70) | 4,527 (71.10) | 1,840 (28.90) | |
| Q4 (October to December) | 5,015 (22.60) | 3,556 (70.91) | 1,459 (29.09) | |
| Age group, n (%) | <0.001 | |||
| < 65 | 11,620 (52.4) | 8,688 (54.9) | 2,932 (45.9) | |
| ≥ 65 | 10,568 (47.6) | 7,118 (45.0) | 3,450 (54.1) | |
| Gender, n (%) | <0.001 | |||
| Female | 6,882 (31.0) | 4,757 (30.1) | 2,125 (33.3) | |
| Male | 15,306 (68.9) | 11,049 (69.9) | 4,257 (66.7) | |
| BMI class, n (%) | <0.001 | |||
| <18.0 Kg/m2 | 1,446 (6.5) | 925 (5.9) | 521 (8.2) | |
| 18.0–22.9 Kg/m2 | 7,314 (32.9) | 5,086 (32.2) | 2,228 (34.9) | |
| 23.0–24.9 Kg/m2 | 4,898 (22.1) | 3,554 (22.5) | 1,344 (21.1) | |
| 25.0–29.9 Kg/m2 | 6,555 (29.5) | 4,823 (30.5) | 1,732 (27.1) | |
| ≥ 30.0 Kg/m2 | 1,975 (8.9) | 1,418 (8.9) | 557 (8.7) | |
| Diabetes mellitus, n (%) | <0.001 | |||
| Yes | 9,814 (44.2) | 6,555 (41.5) | 3,259 (51.1) | |
| No | 12,374 (55.8) | 9,251 (58.5) | 3,123 (48.9) | |
| Hypertension, n (%) | <0.001 | |||
| Yes | 14,900 (67.2) | 10,241 (64.8) | 4,659 (73.0) | |
| No | 7,288 (32.8) | 5,565 (35.2) | 1,723 (26.9) | |
| Dyslipidemia, n (%) | <0.001 | |||
| Yes | 14,450 (65.1) | 10,054 (63.6) | 4,396 (68.9) | |
| No | 7,738 (34.9) | 5,752 (36.4) | 1,986 (31.1) | |
| Chronic kidney disease, n (%) | <0.001 | |||
| Yes | 7,250 (32.7) | 4,554 (28.8) | 2,696 (42.2) | |
| No | 14,938 (67.3) | 11,252 (71.2) | 3,686 (57.8) | |
| Family history of premature CAD, n (%) | 0.160 | |||
| Yes | 2,019 (9.1) | 1,411 (8.9) | 608 (9.5) | |
| No | 20,169 (90.9) | 14,395 (91.1) | 5,774 (90.5) | |
| Prior myocardial infarction, n (%) | 0.217 | |||
| Yes | 5,214 (23.5) | 3,679 (23.3) | 1,535 (24.1) | |
| No | 16,974 (76.5) | 12,127 (76.7) | 4,847 (75.9) | |
| Cerebrovascular disease, n (%) | <0.001 | |||
| Yes | 1,264 (5.7) | 764 (4.8) | 500 (7.8) | |
| No | 20,924 (94.3) | 15,042 (95.2) | 5,882 (92.2) | |
| Prior PCI, n (%) | <0.001 | |||
| Yes | 6,538 (29.5) | 4,867 (30.8) | 1,671 (26.2) | |
| No | 15,650 (70.5) | 10,939 (69.2) | 4,711 (73.8) | |
| Prior CABG, % | 0.164 | |||
| Yes | 362 (1.6) | 246 (1.6) | 116 (1.8) | |
| No | 21,826 (98.4) | 15,560 (98.4) | 6,266 (98.2) | |
| Smoking, n (%) | <0.001 | |||
| Never | 9,963 (44.9) | 6,989 (44.2) | 2,974 (46.6) | |
| Former | 7,051 (31.8) | 5,012 (31.7) | 2,039 (31.9) | |
| Current | 5,174 (23.3) | 3,805 (24.1) | 1,369 (21.5) | |
| Heart Failure, n (%) | <0.001 | |||
| Yes | 2,714 (12.2) | 1,655 (10.5) | 1,059 (16.6) | |
| No | 19,474 (87.8) | 14,151 (89.5) | 5,323 (83.4) | |
| Cardiogenic Shock, n (%) | <0.001 | |||
| Yes | 1,763 (7.9) | 1,133 (7.2) | 630 (9.9) | |
| No | 20,425 (92.1) | 14,673 (92.8) | 5,752 (90.1) | |
| Arrhythmia, n (%) | <0.001 | |||
| Yes | 1,056 (4.8) | 647 (4.1) | 409 (6.4) | |
| No | 21,132 (95.2) | 15,159 (95.9) | 5,973 (93.6) | |
| Types of CAD, n (%) | <0.001 | |||
| Stable | 9,298 (41.9) | 6,812 (43.1) | 2,486 (38.9) | |
| NSTEMI/Unstable Angina | 6,630 (29.9) | 4,567 (28.9) | 2,063 (32.3) | |
| STEMI | 6,260 (28.2) | 4,427 (28.0) | 1,833 (28.7) | |
| Lesion location, n (%) | <0.001 | |||
| Left Main | 2,627 (11.8) | 1,711 (10.8) | 916 (14.4) | |
| Others vessel disease | 19,561 (88.2) | 14,095 (89.2) | 5,466 (85.6) | |
| Number of stent(s) used, n (%) | <0.001 | |||
| 0 stent | 1,728 (7.8) | 1,017 (6.4) | 711 (11.1) | |
| 1 stent | 11,388 (51.3) | 8,613 (54.5) | 2,775 (43.5) | |
| 2 stents | 6,264 (28.2) | 4,297 (27.2) | 1,967 (30.8) | |
| ≥ 3 stents | 2,808 (12.7) | 1,879 (11.9) | 929 (14.6) | |
| Number of lesion(s), n (%) | 0.162 | |||
| 1 lesion | 17,626 (79.4) | 12,597 (79.7) | 5,029 (78.8) | |
| 2 lesions | 3,826 (17.2) | 2,678 (16.9) | 1,148 (17.9) | |
| ≥3 lesions | 736 (3.3) | 531 (3.4) | 205 (3.2) | |
| Follow up time during COVID-19 period | <0.001 | |||
| Yes+ | 10,156 (45.8) | 7,830 (49.5) | 2,326 (36.4) | |
| No++ | 12,032 (54.2) | 7,976 (50.5) | 4,056 (63.6) |
[i] Abbreviations: BMI: body mass index; CAD: coronary artery disease; CVA: cerebrovascular accident; PCI: percutaneous coronary intervention; CABG: coronary artery bypass graft surgery; NSTEMI: non-ST-segment elevation myocardial infarction; UA: unstable angina; ST-segment elevation myocardial infarction; LM: left main; MACCE: major adverse cardiac and cerebrovascular events.
*MACCE occurrence at least one time during one-year follow-up; # Wilcoxon’s rank-sum test; + During years 2020–2022; ++ During years 2018–2020.
Figure 2
Monthly average concentration of PM2.5 exposure of Thai adults who underwent percutaneous coronary intervention during 2018–2019.
Abbreviations: PM2.5: particulate matter with diameter of less than 2.5 micron.
Table 2
Univariable and multivariable multi-level Cox PH models of risk factors for major adverse cardiac and cerebrovascular events (MACCE), stratified by PM2.5 exposure.
| VARIABLE | PERSON-MONTH | INCIDENCE RATE | HR (95%CI) | P-VALUE | ADJUSTED HR (95%CI) | P-VALUE |
|---|---|---|---|---|---|---|
| PM2.5 (μg/m3)# | – | – | 1.00 (0.99, 1.00) | 0.012 | 1.45 (1.37, 1.54) | <0.001 |
| Quarters | ||||||
| Q1 | 63,000.0 | 0.028 (0.026, 0.029) | 0.95 (0.89, 1.01) | 0.108 | 1.18 (1.09, 1.27) | <0.001 |
| Q2 | 60,966.9 | 0.028 (0.026, 0.029) | 0.94 (0.88, 1.01) | 0.078 | 1.17 (1.09, 1.28) | <0.001 |
| Q3 | 63,423.5 | 0.031 (0.029, 0.032) | 1 | – | 1 | – |
| Q4 | 64,046.2 | 0.028 (0.027, 0.029) | 0.96 (0.90, 1.03) | 0.252 | 0.97 (0.90, 1.03) | 0.322 |
| Age (Y) | ||||||
| < 65 | 134,696.5 | 0.024 (0.023, 0.025) | 1 | <0.001 | 1 | <0.001 |
| ≥ 65 | 116,740.1 | 0.033 (0.032, 0.034) | 1.36 (1.30, 1.43) | 1.13 (1.07, 1.19) | ||
| Gender | ||||||
| Female | 76,705.9 | 0.032 (0.030, 0.033) | 1.16 (1.11, 1.22) | <0.001 | – | – |
| Male | 174,730.7 | 0.027 (0.026, 0.028) | 1 | |||
| BMI (Kg/m2) | ||||||
| <18.0 | 15,191.9 | 0.040 (0.037, 0.043) | 1.29 (1.18, 1.42) | <0.001 | 1.27 (1.16, 1.39) | <0.001 |
| 18.0–22.9 | 81,714.8 | 0.031 (0.030, 0.032) | 1 | 1 | 1 | – |
| 23.0–24.9 | 55,967.6 | 0.027 (0.026, 0.028) | 0.87 (0.82, 0.93) | <0.001 | 0.90 (0.84, 0.96) | 0.001 |
| 25.0–29.9 | 75,772.0 | 0.025 (0.024, 0.027) | 0.83 (0.78, 0.88) | <0.001 | 0.85 (0.80, 0.90) | <0.001 |
| ≥ 30.0 | 22,790.3 | 0.027 (0.025, 0.029) | 0.87 (0.80, 0.95) | 0.003 | 0.87 (0.79, 0.95) | 0.003 |
| Diabetes mellitus, n (%) | ||||||
| Yes | 109,785.6 | 0.034 (0.033, 0.035) | 1.38 (1.31, 1.44) | <0.001 | 1.19 (1.13, 1.25) | <0.001 |
| No | 141,651.0 | 0.024 (0.024, 0.025) | 1 | 1 | ||
| Hypertension, n (%) | ||||||
| Yes | 168,150.1 | 0.031 (0.030, 0.032) | 1.35 (1.28, 1.43) | <0.001 | 1.18 (1.11, 1.26) | <0.001 |
| No | 83,286.5 | 0.023 (0.022, 0.024) | 1 | 1 | ||
| Dyslipidemia, n (%) | ||||||
| Yes | 164,958.8 | 0.030 (0.029, 0.031) | 1.16 (1.11, 1.23) | <0.001 | 1.13 (1.07, 1.20) | <0.001 |
| No | 86,477.8 | 0.025 (0.024, 0.026) | 1 | 1 | ||
| CKD, n (%) | ||||||
| Yes | 78,128.0 | 0.040 (0.038, 0.041) | 1.67 (1.59, 1.75) | <0.001 | 1.39 (1.32, 1.47) | <0.001 |
| No | 173,308.6 | 0.023 (0.023, 0.024) | 1 | 1 | ||
| CVA, n (%) | ||||||
| Yes | 13,681.0 | 0.043 (0.040, 0.047) | 1.52 (1.40, 1.66) | <0.001 | 1.29 (1.18, 1.41) | <0.001 |
| No | 237,755.6 | 0.028 (0.027, 0.028) | 1 | 1 | ||
| Prior PCI, n (%) | ||||||
| Yes | 75,238.6 | 0.025 (0.024, 0.026) | 0.80 (0.76, 0.85) | <0.001 | 0.79 (0.74, 0.84) | <0.001 |
| No | 176,198.0 | 0.030 (0.029, 0.031) | 1 | 1 | ||
| Prior CABG, n (%) | ||||||
| Yes | 4,045.0 | 0.035 (0.029, 0.041) | 1.19 (1.00, 1.41) | 0.045 | – | – |
| No | 247,391.6 | 0.028 (0.028, 0.029) | 1 | |||
| Smoking, n (%) | ||||||
| Never | 112,087.2 | 0.030 (0.029, 0.031) | 1 | – | – | – |
| Former | 80,709.3 | 0.028 (0.027, 0.029) | 0.94 (0.89, 0.99) | 0.018 | ||
| Current | 58,640.1 | 0.026 (0.025, 0.027) | 0.88 (0.82, 0.93) | <0.001 | ||
| Heart Failure, n (%) | ||||||
| Yes | 27,106.2 | 0.044 (0.042, 0.047) | 1.70 (1.60, 1.81) | <0.001 | 1.51 (1.38, 1.65) | <0.001 |
| No | 224,330.4 | 0.027 (0.026, 0.027) | 1 | 1 | ||
| Cardiogenic Shock, n (%) | ||||||
| Yes | 17,332.7 | 0.040 (0.037, 0.043) | 1.49 (1.37, 1.61) | <0.001 | 0.81 (0.72, 0.91) | <0.001 |
| No | 234,103.9 | 0.028 (0.027, 0.028) | 1 | 1 | ||
| Arrhythmia, n (%) | ||||||
| Yes | 10,743.4 | 0.042 (0.039, 0.046) | 1.51 (1.37, 1.67) | <0.001 | 1.19 (1.07, 1.32) | 0.002 |
| No | 240,693.2 | 0.028 (0.027, 0.029) | 1 | 1 | ||
| Types of CAD, n (%) | ||||||
| Stable | 107,637.5 | 0.026 (0.025, 0.027) | 1 | – | 1 | – |
| NSTEMI/UA | 74,898.2 | 0.031 (0.029, 0.032) | 1.23 (1.17, 1.31) | <0.001 | 1.08 (1.02, 1.15) | 0.014 |
| STEMI | 68,900.9 | 0.030 (0.029, 0.031) | 1.21 (1.14, 1.28) | <0.001 | 1.15 (1.07, 1.23) | <0.001 |
| Lesion location, n (%) | ||||||
| LM | 28,876.7 | 0.036 (0.034, 0.038) | 1.29 (1.21, 1.38) | <0.001 | 1.12 (1.05, 1.20) | 0.001 |
| Others | 222,559.9 | 0.028 (0.027, 0.028) | 1 | 1 | ||
| No. of stent(s) used, n (%) | ||||||
| 0 stent | 18,666.7 | 0.044 (0.041, 0.047) | 1 | – | 1 | – |
| 1 stent | 130,115.8 | 0.024 (0.023, 0.024) | 0.54 (0.50, 0.59) | <0.001 | 0.58 (0.54, 0.63) | <0.001 |
| 2 stents | 71,081.4 | 0.031 (0.030, 0.033) | 0.72 (0.66, 0.78) | <0.001 | 0.74 (0.68, 0.80) | <0.001 |
| ≥ 3 stents | 31,572.8 | 0.033 (0.031, 0.035) | 0.75 (0.68, 0.82) | <0.001 | 0.76 (0.69, 0.84) | <0.001 |
| Follow up time during COVID-19 period | ||||||
| Yes* | 37,794.1 | 0.009 (0.008, 0.010) | 0.42 (0.38, 0.47) | <0.001 | 0.39 (0.35, 0.44) | <0.001 |
| No** | 213,642.5 | 0.032 (0.031, 0.033) | 1 | – | 1 |
[i] Abbreviations: MACCE: major adverse cardiac and cerebrovascular events; BMI: body mass index; CKD: chronic kidney disease; CAD: coronary artery disease; MI: myocardial infarction; CVA: cerebrovascular accident; PCI: percutaneous coronary intervention; CABG: coronary artery bypass graft surgery; STEMI: ST-segment elevation myocardial infarction; NSTEMI: non-ST-segment elevation myocardial infarction; UA: unstable angina; LM: left main.
Q1 (January to March), Q2 (April to June), Q3 (July to September), and Q4 (October to December), which are not analyzed with interaction effect.
#Continuous variable, *During years 2020–2022, **During years 2018–2019.
Figure 3
Adjusted hazard ratio of PM2.5 exposure (per 1 µg/m3 increase) and quarters of the year for one-year major adverse cardiac and cerebrovascular (MACCE) outcome in Thai adults underwent PCI during 2018–2019.