Effect modification by sex for associations of fine particulate matter (PM2.5) with cardiovascular mortality, hospitalization, and emergency room visits: systematic review and meta-analysis

Particulate matter with aerodynamic diameter no larger than 2.5 µ m (PM _2.5 ) has been linked to cardiovascular diseases (CVDs) but evidence for vulnerability by sex remains unclear. We performed systematic review and meta-analysis to synthesize the state of scientific evidence on whether cardiovascular risks from PM _2.5 differ for men compared to women. The databases Pubmed, Scopus, Embase, and GreenFILE were searched for studies published January 1995 to February 2020. Observational studies conducting subgroup analysis by sex for impacts of short-term or long-term exposure to PM _2.5 on target CVDs were included. Data were independently extracted in duplicate and pooled with random-effects meta-regression. Risk ratios (RRs) for long-term exposure and percent changes in outcomes for short-term exposure were calculated per 10 µ g m ^−3 PM _2.5 increase. Quality of evidence of risk differences by sex was rated following Grading of Recommendations Assessment, Development and Evaluation (GRADE). A total of 12 502 articles were screened, with 61 meeting inclusion criteria. An additional 32 studies were added from citation chaining. RRs of all CVD mortality for long-term PM _2.5 for men and women were the same (1.14; 95% CI: 1.09, 1.22) indicating no statistically different risks. Men and women did not have statistically different risks of daily CVD mortality, hospitalizations from all CVD, ischemic heart disease, cardiac arrest, acute myocardial infarction, and heart failure from short-term PM _2.5 exposure (difference in % change in risk per 10 µ g m ^−3 PM _2.5 : 0.04 (95% CI, −0.42–0.51); −0.05 (−0.47–0.38); 0.17 (−0.90, 1.24); 1.42 (−1.06, 3.97); 1.33 (−0.05, 2.73); and −0.48 (−1.94, 1.01), respectively). Analysis using GRADE found low or very low quality of evidence for sex differences for PM _2.5 -CVD risks. In conclusion, this meta-analysis and quality of evidence assessment of current observational studies found very limited evidence of the effect modification by sex for effects of PM _2.5 on CVD outcomes in adults, which can inform clinical approaches and policies.