Environmental factors in cardiovascular disease

Key Points

  • Environmental exposure, over which the individual has little control, can have an important role in the development and severity of cardiovascular disease (CVD)

  • The WHO has identified air pollution as the world's largest single environmental-health risk, and 80% of deaths related to outdoor air pollution result from ischaemic heart disease and stroke

  • Metals such as lead, cadmium, and arsenic—listed among the WHO's top 10 environmental chemicals of concern—also mediate the development and progression of CVD

  • Exposure to fine particulate matter, a major component in urban air pollution, is associated with mortality and cardiovascular risk, even at concentrations below current US and EU regulatory standards

  • Effects occur via pathways known to affect cardiovascular risk, including changes in blood pressure, lipids, vascular function, and atherosclerosis

  • With the widespread prevalence of exposure, policy interventions that reduce environmental pollution can have substantial beneficial effects on cardiovascular health for populations around the world


Environmental exposure is an important but underappreciated risk factor contributing to the development and severity of cardiovascular disease (CVD). The heart and vascular system are highly vulnerable to a number of environmental agents—ambient air pollution and the metals arsenic, cadmium, and lead are widespread and the most-extensively studied. Like traditional risk factors, such as smoking and diabetes mellitus, these exposures advance disease and mortality via augmentation or initiation of pathophysiological processes associated with CVD, including blood-pressure control, carbohydrate and lipid metabolism, vascular function, and atherogenesis. Although residence in highly polluted areas is associated with high levels of cardiovascular risk, adverse effects on cardiovascular health also occur at exposure levels below current regulatory standards. Considering the widespread prevalence of exposure, even modest contributions to CVD risk can have a substantial effect on population health. Evidence-based clinical and public-health strategies aimed at reducing environmental exposures from current levels could substantially lower the burden of CVD-related death and disability worldwide.

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Figure 1: A framework for the characterization of the effects of environmental factors in cardiovascular disease.
Figure 2: Size categorization of airborne pollutants.
Figure 3: Cardiovascular effects and proposed mechanisms of chronic exposure to traffic-related air pollution.
Figure 4: Cardiovascular effects and proposed mechanisms of acute exposure to traffic-related air pollution.
Figure 5: Possible mechanisms for the cardiovascular effects of exposure to arsenic.


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Cosselman, K., Navas-Acien, A. & Kaufman, J. Environmental factors in cardiovascular disease. Nat Rev Cardiol 12, 627–642 (2015). https://doi.org/10.1038/nrcardio.2015.152

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