Background: Temperature-related circulatory mortality has gained consistent public health importance worldwide due to changes in inter-annual average temperatures and the increased frequency of extreme events over time. This study investigates the association between temper-ature and circulatory deaths in one of the highest population densities in the world (Malta) with a Mediterranean climate. Methods: Daily deaths relating to circulatory mortality (32,847 deaths) were obtained from January 1992 to December 2017. A distributed lag non-linear model (DLNM) with a Poisson distribution was utilized to estimate effects of ambient temperatures and heatwaves or cold spells (2-4 consecutive days). Effects were also explored for the specific cause of death, different age groups, gender and time periods. Results: The study observed a U-shaped cumulative exposure-response curve with a greater mortality risk due to cooler temperatures (8-15 degrees C) after adjusting for harvesting effects (0-27 days). Colder temperatures (<8.9<degrees>C) were strongly related to both ischemic heart disease (IHD) (RR, 1.85, 95% CI, 1.24-2.77) and cerebrovascular disease (RR, 3.80,95% CI, 1.57-9.17). While heat effects were short-term (0-5 lag days), the cold effects were long-term (0-27 days) and consistent across different lag days. Cooler temperatures (8.99-12.6 degrees C) were also related to IHD mortality in males (RR, 1.94, 95% CI, 1.05-3.59) and females (RR, 1.95, 95% CI, 1.2-3.59) and cerebrovascular mortality in females (RR, 8.32, 95% CI, 2.58-26.80). Elderly females (over 65 years) had a higher risk of death relating to IHD (RR, 1.33, 95% CI, 1.19-3.18) and cerebro-vascular diseases (RR, 8.84, 95% CI, 2.64-29.61). Interestingly, colder temperatures (<8.9<degrees>C) were highly related to cerebrovascular deaths in the earliest time period (1992-2000) and IHD deaths in the most recent time period (2000-2017). While the effect of heatwaves was unclear across the time periods, there was some visible cold-spell effects for cerebrovascular mortality (RR, 1.03, 95% CI, 1.01-1.06). Conclusion: This study used a long time series of mortality data from a high population density area to explore the impact of ambient temperature and extreme events on circulatory deaths. The results of the study will help to improve preventive and adaptive strategies to mitigate climatic health impacts.