Nationwide association between ambient ozone and sudden cardiac arrests in South Korea

Several studies reported the association between ambient ozone and out-of-hospital cardiac arrest (OHCA). However, due to the limited geographical scope of monitoring, existing research has not fully evaluated the nationwide risk or identified high-risk populations. We conducted a nationwide time-stratified case-crossover study to examine the association between short-term outdoor ozone exposure during the warm season (April-September) and OHCA in South Korea (2015-2019), with a machine learning ensemble model for ozone (R² > 0.92). Among the total population (51,912 cases), ozone exposure was associated with OHCA (odds ratio [OR] per 10 ppb increase in ozone: 1.022, 95% CI: 1.009 to 1.034). Individuals aged 0-59 years (OR: 1.026, 95% CI: 1.005 to 1.047) and 60-74 years (OR: 1.024, 95% CI: 1.002 to 1.048) exhibited associations with ozone exposure, and the risk estimates were not statistically different from the risk of those aged 75 years or older. Males had a higher risk (OR: 1.030, 95% CI: 1.014 to 1.045) than females, based on the point estimates. Stratification analysis revealed that males aged 60-74 years with medical histories faced the highest point risk estimates of ozone. This study provides crucial evidence to support targeted interventions for high-risk populations.