title: Effect of cold spells and their modifiers on cardiovascular disease events: Evidence from two prospective studies.
abstract: OBJECTIVE
  To investigate effects of cold weather spells on incidence of cardiovascular disease (CVD), and potential effect modification of socio-demographic, clinical, behavioural and environmental exposures.
  
  
  METHODS
  Data from two prospective studies were analysed: the British Regional Heart Study (BRHS), a population-based study of British men aged 60-79years, followed for CVD incidence from 1998-2000 to 2012; and the PROSPER study of men and women aged 70-82 recruited to a trial of pravastatin vs placebo from 1997 to 9 (followed until 2009). Cold spells were defined as at least three consecutive days when daily mean temperature fell below the monthly 10th percentile specific to the closest local weather station. A time-stratified case-crossover approach was used to estimate associations between cold spells and CVD events.
  
  
  RESULTS
  921 of 4252 men from BRHS and 760 of 2519 participants from PROSPER suffered a first CVD event during follow-up. More CVD events were registered in winter in both studies. The risk ratio (RR) associated with cold spells was statistically significant in BRHS (RR=1.86, 95% CI 1.30-2.65, p<0.001), and independent of temperature level: results were similar whether events were fatal or non-fatal. Increased risk was particularly marked in BRHS for ever-smokers (RR of 2.44 vs 0.99 for never-smokers), in moderate/heavy drinkers (RR 2.59 vs 1.41), and during winter months (RR 3.28 vs 1.25). No increased risk was found in PROSPER.
  
  
  CONCLUSIONS
  Although CVD risks were higher in winter in both BRHS and PROSPER prospective studies, cold spells increased risk of CVD events, independently of cold temperature, in the BRHS only.
authors.affiliation: Department of Primary Care & Population Health, University College London, Rowland Hill Street, NW3 2PF London. UK. Electronic address: c.sartini@ucl.ac.uk.
authors.forename: Claudio
authors.initials: C
authors.lastname: Sartini
authors.affiliation: Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, Robertson Centre for Biostatistics, Boyd Orr Building, Level 11 University of Glasgow, Glasgow G12 8QQ, UK.
authors.forename: Sarah J E
authors.initials: SJE
authors.lastname: Barry
authors.affiliation: Department of Primary Care & Population Health, University College London, Rowland Hill Street, NW3 2PF London. UK.
authors.forename: S Goya
authors.initials: SG
authors.lastname: Wannamethee
authors.affiliation: Population Health Research Institute, St George's University of London, Cranmer Terrace, London SW17 0RE, UK.
authors.forename: Peter H
authors.initials: PH
authors.lastname: Whincup
authors.affiliation: Department of Primary Care & Population Health, University College London, Rowland Hill Street, NW3 2PF London. UK.
authors.forename: Lucy
authors.initials: L
authors.lastname: Lennon
authors.affiliation: Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, Robertson Centre for Biostatistics, Boyd Orr Building, Level 11 University of Glasgow, Glasgow G12 8QQ, UK.
authors.forename: Ian
authors.initials: I
authors.lastname: Ford
authors.affiliation: School of Social & Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Rd, Bristol BS8 2PS, UK.
authors.forename: Richard W
authors.initials: RW
authors.lastname: Morris
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002318:Cardiovascular Diseases / Q000453:epidemiology*; D003080:Cold Temperature; D004781:Environmental Exposure / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D011446:Prospective Studies
keywords: Cardiovascular disease; Cold spell; Older people; Outdoor temperature; Prospective study; Winter deaths