Ambient Cold and Mortality in Pan-Arterial Diseases: A Nationwide Ecological Analysis of CDC WONDER Data

Heng Wang,1,2 Keyi Fan,3 Yaling Li,4 Ziyan Wang,5 Shule Wang,6 Guoping Zheng1,2 1Centre for Transplant and Renal Research, Westmead Institute for Medical Research, The University of Sydney, Sydney, NSW, Australia; 2Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; 3Department of Vascular Surgery, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, People’s Republic of China; 4Department of Vascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, People’s Republic of China; 5Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, People’s Republic of China; 6Neuroscience Institute, JFK University Medical Center, Edison, NJ, USACorrespondence: Guoping Zheng, Centre for Transplant and Renal Research, Westmead Institute for Medical Research, The University of Sydney, Sydney, NSW, Australia, Email [email protected]: Pan-arterial diseases, including atherosclerosis (AS), aortic aneurysm and dissection (AAD), and peripheral arterial disease (PAD), impose a substantial global health burden. Although ambient temperature has been implicated in individual arterial conditions, its association with mortality across the pan-arterial spectrum remains incompletely understood.Objective: To evaluate the association between ambient temperature and mortality from pan-arterial diseases across the United States.Methods: We analysed mortality data for adults aged ≥ 25 years with AS, AAD, or PAD in the United States CDC WONDER database from 1999 to 2023. Age-adjusted mortality rates (AAMR) and average annual percent change (AAPC) were estimated. Monthly air-temperature metrics (1999– 2023) were linked at the United States Census region level. Seasonal variation was assessed using analysis of variance. Associations between temperature and mortality were examined using Spearman correlation, Poisson regression with lag structures, and distributed lag non-linear models (DLNM), with results expressed as relative risks (RR) per 10°F increase in temperature.Results: Between 1999 and 2023, AAMRs declined for AS, AAD, and PAD, yet mortality burden remained substantial. Mortality from all three conditions was consistently higher in winter than in summer across Census regions. Monthly mean temperature was inversely correlated with crude mortality for pan-arterial diseases (P < 0.05). In the Northeast, cumulative RR per +10°F across lags 0– 3 months was 0.919 for AS, 0.945 for AAD, and 0.953 for PAD, with similar patterns observed in other regions. DLNM analyses demonstrated a predominantly cold-related excess risk, with acute effects and regional heterogeneity at higher temperatures.Conclusion: Lower ambient temperatures are associated with increased mortality from pan-arterial diseases in the United States. These findings highlight shared vulnerability to cold exposure across arterial diseases and support winter-focused preventive and healthcare preparedness strategies.Keywords: pan-arterial diseases, atherosclerosis, aortic aneurysm and dissection, peripheral arterial disease, ambient temperature, mortality