Short-term association between ambient temperature and acute myocardial infarction hospitalizations for diabetes mellitus patients: A time series study

PLoS Med. 2018 Jul 17;15(7):e1002612. doi: 10.1371/journal.pmed.1002612. eCollection 2018 Jul.


Background: Acute myocardial infarction (AMI) is the leading cause of death among people with diabetes mellitus (DM) and has been found to occur more frequently with extreme temperatures. With the increasing prevalence of DM and the rising global mean temperature, the number of heat-related AMI cases among DM patients may increase. This study compares excess risk of AMI during periods of extreme temperatures between patients with DM and without DM.

Methods: Distributed lag nonlinear models (DLNMs) were used to estimate the short-term association between daily mean temperature and AMI admissions (International Classification of Diseases 9th revision [ICD-9] code: 410.00-410.99), stratified by DM status (ICD-9: 250.00-250.99), to all public hospitals in Hong Kong from 2002 to 2011, adjusting for other meteorological variables and air pollutants. Analyses were also stratified by season, age group, gender, and admission type (first admissions and readmissions). The admissions data and meteorological data were obtained from the Hong Kong Hospital Authority (HA) and the Hong Kong Observatory (HKO).

Findings: A total of 53,769 AMI admissions were included in the study. AMI admissions among DM patients were linearly and negatively associated with temperature in the cold season (cumulative relative risk [cumRR] [95% confidence interval] in lag 0-22 days (12 °C versus 24 °C) = 2.10 [1.62-2.72]), while those among patients without DM only started increasing when temperatures dropped below 22 °C with a weaker association (cumRR = 1.43 [1.21-1.69]). In the hot season, AMI hospitalizations among DM patients started increasing when the temperature dropped below or rose above 28.8 °C (cumRR in lag 0-4 days [30.4 versus 28.8 °C] = 1.14 [1.00-1.31]), while those among patients without DM showed no association with temperature. The differences in sensitivity to temperature between patients with DM and without DM were most apparent in the group <75 years old and among first-admission cases in the cold season. The main limitation of this study was the unavailability of data on individual exposure to ambient temperature.

Conclusions: DM patients had a higher increased risk of AMI admissions than non-DM patients during extreme temperatures. AMI admissions risks among DM patients rise sharply in both high and low temperatures, with a stronger effect in low temperatures, while AMI risk among non-DM patients only increased mildly in low temperatures. Targeted health protection guidelines should be provided to warn DM patients and physicians about the dangers of extreme temperatures. Further studies to project the impacts of AMI risks on DM patients by climate change are warranted.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Climate Change
  • Cold Temperature / adverse effects*
  • Diabetes Mellitus / diagnosis
  • Diabetes Mellitus / epidemiology*
  • Diabetes Mellitus / mortality
  • Diabetes Mellitus / therapy
  • Environmental Exposure / adverse effects*
  • Female
  • Hong Kong / epidemiology
  • Hospital Mortality
  • Hospitals, Public
  • Hot Temperature / adverse effects*
  • Humans
  • Male
  • Myocardial Infarction / diagnosis
  • Myocardial Infarction / epidemiology*
  • Myocardial Infarction / mortality
  • Myocardial Infarction / therapy
  • Patient Admission*
  • Patient Readmission
  • Retrospective Studies
  • Risk Assessment
  • Risk Factors
  • Seasons*
  • Time Factors

Grant support

This study was supported by the Health and Medical Research Fund granted by the Food and Health Bureau, Hong Kong SAR (project code: 12130241) received by WG ( The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.