Post-Discharge Ambient Sulfur Dioxide Exposure and Stroke Recurrence After Acute Ischemic Stroke.
22 affiliations
- 1Department of Neurology, Korea University College of Medicine, Korea University Guro Hospital, Seoul, Korea. [email protected].
- 2Department of Medical IT Engineering, College of Software Convergence, Soonchunhyang University, Asan, Korea.
- 3Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.
- 4Department of Neurology, Chonnam National University Hospital, Gwangju, Korea.
- 5Department of Neurology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea.
- 6Department of Neurology, Dong-A University Hospital, Busan, Korea.
- 7Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Korea.
- 8Department of Neurology, Uijeongbu Eulji Hospital, Eulji University School of Medicine, Uijeongbu, Korea.
- 9Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea.
- 10Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Korea.
- 11Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea.
- 12Department of Neurology, Inje University Ilsan Paik Hospital, Goyang, Korea.
- 13Department of Neurology, Jeju National University Hospital, Jeju, Korea.
- 14Department of Neurology, Seoul Medical Center, Seoul, Korea.
- 15Department of Neurology, Ulsan University Hospital, Ulsan, Korea.
- 16Department of Neurology, Yeungnam University Medical Center, Daegu, Korea.
- 17Department of Neurology, Soonchunhyang University Seoul Hospital, Seoul, Korea.
- 18Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, Korea.
- 19Department of Neurology, Chung-Ang University Hospital, Seoul, Korea.
- 20Department of Neurology, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon, Korea.
- 21Department of Biostatistics, Korea University, Seoul, Korea.
- 22Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea. [email protected].
Abstract
Background and purpose
Ambient air pollution is an established risk factor for incident stroke, but whether post-discharge pollutant exposure influences stroke recurrence remains unclear. We investigated the association between post-discharge exposure to six ambient air pollutants and stroke recurrence after acute ischemic stroke.Methods
We analyzed 27,340 patients in the Clinical Research Collaboration for Stroke in Korea-National Institutes of Health nationwide multicenter registry (2014-2021). The 3-month post-discharge district-level mean concentrations of particulate matter ≤10 μm (PM10), ≤2.5 μm (PM2.5), nitrogen dioxide, sulfur dioxide (SO2), carbon monoxide, and ozone were estimated by inverse-distance-weighted interpolation. The primary outcome was stroke recurrence from 3 to 15 months post-discharge. Cause-specific Cox models with cluster-robust standard errors were used, treating death as a competing risk; non-linear dose-response was assessed by restricted cubic splines.Results
During follow-up (median 364.8 days), 764 patients had recurrence and 542 died. Only SO2 showed a significant association with recurrence (P for overall association in the spline model= 0.024), with a graded dose-response; the non-linear (J-shaped) pattern did not reach significance (P for non-linearity=0.095), and quartile contrasts were individually non-significant (Q4 vs. Q1: hazard ratio 1.19, 95% confidence interval 0.94-1.50). The association was numerically stronger among older adults (≥75 years; P for interaction=0.051) and women (P for interaction=0.062). The highest SO2 concentrations were observed in harbor cities (Incheon, Ulsan, Busan). No significant associations were observed for the other five pollutants.Conclusions
Elevated post-discharge SO2 exposure was associated with increased stroke recurrence, with a graded dose-response, supporting consideration of ambient air quality in secondary stroke prevention.
Related
- The association between short-term nitrogen dioxide (NO2) exposure and ischemic stroke or transient ischemic attacks (TIA): a national study in Israel
- Long-Term Exposure to Ambient Air Pollution and Cervical Cancer Outcomes in Chinese Women: A Prospective Study on Recurrence and Mortality Risks.
- Long-term ambient benzene exposure increases incident NAFLD risk through accelerated biological aging
- Health risks and lag effects of ambient PM2.5 exposure on respiratory and cardiovascular mortality and morbidity in Ratchaburi, Thailand
- Comparative effectiveness of amlodipine versus nifedipine prescribed at discharge in patients with ischemic stroke or transient ischemic attack: A nationwide 5-year follow-up registry study
BibTeX
@article{lee2026postdischarge,
title = {{Post-Discharge Ambient Sulfur Dioxide Exposure and Stroke Recurrence After Acute Ischemic Stroke.}},
author = {Keon-Joo Lee and Jeongeun Hwang and Seong-Eun Kim and Beom Joon Kim and Moon-Ku Han and Hyunsoo Kim and Joon-Tae Kim and Kang-Ho Choi and Kyu Sun Yum and Dong-Ick Shin and Jae-Kwan Cha and Dae-Hyun Kim and Dong-Seok Gwak and Dong-Eog Kim and Jong-Moo Park and Kyusik Kang and Soo Joo Lee and Jae Guk Kim and Minwoo Lee and Mi-Sun Oh and Kyung-Ho Yu and Hong-Kyun Park and Keun-Sik Hong and Yong-Jin Cho and Joong-Goo Kim and Jay Chol Choi and Tai Hwan Park and Sang-Soon Park and Jee-Hyun Kwon and Wook-Joo Kim and Doo Hyuk Kwon and Jun Lee and Kyungbok Lee and Jeong-Yoon Lee and Sung Il Sohn and Jeong-Ho Hong and Kwang-Yeol Park and Hae-Bong Jeong and Chulho Kim and Sang-Hwa Lee and Juneyoung Lee and Hee-Joon Bae and CRCS-K-NIH Investigators},
journal = {Journal of stroke},
year = {2026},
month = aug,
doi = {10.5853/jos.2026.03265},
url = {https://europepmc.org/article/MED/42894454},
note = {CC BY-NC},
}
RIS
TY - JOUR
TI - Post-Discharge Ambient Sulfur Dioxide Exposure and Stroke Recurrence After Acute Ischemic Stroke.
AU - Keon-Joo Lee
AU - Jeongeun Hwang
AU - Seong-Eun Kim
AU - Beom Joon Kim
AU - Moon-Ku Han
AU - Hyunsoo Kim
AU - Joon-Tae Kim
AU - Kang-Ho Choi
AU - Kyu Sun Yum
AU - Dong-Ick Shin
AU - Jae-Kwan Cha
AU - Dae-Hyun Kim
AU - Dong-Seok Gwak
AU - Dong-Eog Kim
AU - Jong-Moo Park
AU - Kyusik Kang
AU - Soo Joo Lee
AU - Jae Guk Kim
AU - Minwoo Lee
AU - Mi-Sun Oh
AU - Kyung-Ho Yu
AU - Hong-Kyun Park
AU - Keun-Sik Hong
AU - Yong-Jin Cho
AU - Joong-Goo Kim
AU - Jay Chol Choi
AU - Tai Hwan Park
AU - Sang-Soon Park
AU - Jee-Hyun Kwon
AU - Wook-Joo Kim
AU - Doo Hyuk Kwon
AU - Jun Lee
AU - Kyungbok Lee
AU - Jeong-Yoon Lee
AU - Sung Il Sohn
AU - Jeong-Ho Hong
AU - Kwang-Yeol Park
AU - Hae-Bong Jeong
AU - Chulho Kim
AU - Sang-Hwa Lee
AU - Juneyoung Lee
AU - Hee-Joon Bae
AU - CRCS-K-NIH Investigators
PY - 2026
DA - 2026/08/30
JO - Journal of stroke
DO - 10.5853/jos.2026.03265
UR - https://europepmc.org/article/MED/42894454
AB - Background and purpose Ambient air pollution is an established risk factor for incident stroke, but whether post-discharge pollutant exposure influences stroke recurrence remains unclear. We investigated the association between post-discharge exposure to six ambient air pollutants and stroke recurrence after acute ischemic stroke.Methods We analyzed 27,340 patients in the Clinical Research Collaboration for Stroke in Korea-National Institutes of Health nationwide multicenter registry (2014-2021). The 3-month post-discharge district-level mean concentrations of particulate matter ≤10 μm (PM10), ≤2.5 μm (PM2.5), nitrogen dioxide, sulfur dioxide (SO2), carbon monoxide, and ozone were estimated by inverse-distance-weighted interpolation. The primary outcome was stroke recurrence from 3 to 15 months post-discharge. Cause-specific Cox models with cluster-robust standard errors were used, treating death as a competing risk; non-linear dose-response was assessed by restricted cubic splines.Results During follow-up (median 364.8 days), 764 patients had recurrence and 542 died. Only SO2 showed a significant association with recurrence (P for overall association in the spline model= 0.024), with a graded dose-response; the non-linear (J-shaped) pattern did not reach significance (P for non-linearity=0.095), and quartile contrasts were individually non-significant (Q4 vs. Q1: hazard ratio 1.19, 95% confidence interval 0.94-1.50). The association was numerically stronger among older adults (≥75 years; P for interaction=0.051) and women (P for interaction=0.062). The highest SO2 concentrations were observed in harbor cities (Incheon, Ulsan, Busan). No significant associations were observed for the other five pollutants.Conclusions Elevated post-discharge SO2 exposure was associated with increased stroke recurrence, with a graded dose-response, supporting consideration of ambient air quality in secondary stroke prevention.
SN - 2287-6391
SN - 2287-6405
ER -