Expert Position Paper on Air Pollution and Cardiovascular Disease | Ten Points to Remember

Newby DE, Mannucci PM, Tell GS, et al.
Eur Heart J 2014;Dec 9:[Epub ahead of print].
The following are 10 points to remember from this Expert Position Paper on air pollution and cardiovascular disease:

1. Air pollution has wide-ranging and deleterious effects on human health, with worldwide impact of air pollution attributed to as many as 6% of all-cause and all-age deaths. Ambient air pollution ranks 9th among the modifiable disease risk factors, and is higher than cholesterol and inadequate physical activity.

2. In addition to air pollution’s effect on development and exacerbation of respiratory diseases, there is a strong positive association between long-term exposure to air pollution and total and cardiovascular mortality, mainly due to coronary artery disease.

3. From a health perspective, important components of the pollutant mixture include airborne particulate matter (PM) and the gaseous pollutants' ozone, nitrogen dioxide (NO2), volatile organic compounds (including benzene), carbon monoxide (CO), and sulphur dioxide (SO2).

4. Primary pollutants, such as soot particles, and oxides of nitrogen and sulphur, are emitted directly into the air by soil and road dust by wind or moving vehicles; combustion of fossil fuels from power plants; road traffic; and heating oil, coal, and wood. Major sources of NO2 are motorized road traffic, power generation, industrial sources, and residential heating.

5. Pollutant particles are represented by the mass concentration of particles smaller than 2.5 µm (PM2.5) and 10 µm (PM10). The former can travel very long distances (>100 km). Large urban-rural differences are found for soot (average 38% higher), NO2 (63% higher), and ultrafine particle numbers.

6. The toxic effects of the pollutants include increasing the systemic inflammatory response through the immunologic response by the lung and direct entry into the circulation. Among the pathways linking air pollution to cardiovascular morbidity and mortality, the most relevant are the induction of oxidative stress, systemic inflammation, endothelial dysfunction, atherothrombosis, and arrhythmogenesis.

7. The effect of PM on mortality is primarily with long-term exposure. There is about a 6% increase for all-cause and 11% for cardiovascular mortality for a 10 µm/m3 PM2.5 increase.

8. Air pollution associated with particulate mass and number of particles as well as gaseous pollutants is associated with an increase in incident and prevalent preclinical coronary and carotid disease, clinical coronary artery disease, heart failure, peripheral vascular disease, and strokes. The evidence for an effect of short- and long-term exposure for venous thromboembolism and arrhythmia and sudden death is suspected, but less convincing.

9. Air pollutants may acutely exacerbate and instigate the development of several traditional risk factors. This includes acutely raising blood pressure and promoting the development of chronic hypertension, and impairing insulin sensitivity, leading to overt diabetes.

10. Reduction in exposure to airborne pollutants can be achieved through simple measures such as: travel by walking, cycling, and public transportation; and avoid walking and cycling in streets with high traffic intensity and limit time spent outdoors during highly polluted periods. The latter advice is especially for infants, elderly, and those with or at high risk for cardiovascular disease and respiratory disorders.

Clinical Topics: Arrhythmias and Clinical EP, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Exercise, Hypertension, Stress

Keywords: Air Pollutants, Air Pollution, Arrhythmias, Cardiac, Benzene, Blood Pressure, Carbon Monoxide, Wood, Coal, Coronary Artery Disease, Death, Diabetes Mellitus, Dust, Fossil Fuels, Heart Failure, Hypertension, Inflammation, Insulin Resistance, Nitrogen Dioxide, Oxidative Stress, Oxides, Ozone, Particulate Matter, Peripheral Vascular Diseases, Risk Factors, Soot, Stroke, Sulfur, Sulfur Dioxide, Transportation, Venous Thromboembolism, Walking, Nitrogen, Power Plants

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