Air pollution is well recognized as a major risk factor for chronic non-communicable diseases and has been estimated to contribute more to global morbidity and mortality than all other known environmental risk factors combined. Although air pollution contains a heterogeneous mixture of gases, the most robust evidence for detrimental effects on health is for fine particulate matter (particles ≤2.5 µm in diameter (PM2.5)) and ozone gas and, therefore, these species have been the main focus of environmental health research and regulatory standards. The evidence to date supports a strong link between the risk of cardiovascular events and all-cause mortality with PM2.5 across a range of exposure levels, including to levels below current regulatory standards, with no ‘safe’ lower exposure levels at the population level. In this comprehensive Review, the empirical evidence supporting the effects of air pollution on cardiovascular health are examined, potential mechanisms that lead to increased cardiovascular risk are described, and measures to reduce this risk and identify key gaps in our knowledge that could help address the increasing cardiovascular morbidity and mortality associated with air pollution are discussed.
Air pollution is the most important environmental cardiovascular risk factor, with fine particulate matter (PM2.5) and ozone gas being the most-studied air pollutants.
The health effects of air pollution might depend on chronic exposure, pre-existing medical conditions and sources or composition of the pollutants.
Multiple primary initiating and secondary effector mechanisms are responsible for the cardiovascular effects of air pollution.
Numerous animal and human studies have shown that inhalation of PM2.5 pollution can contribute to cardiovascular disease and mortality.
The most widely studied personalized approaches to reducing the cardiovascular risk of air pollution include the use of face masks and in-home air purifiers.
Subscribe to Journal
Get full journal access for 1 year
only $4.92 per issue
All prices are NET prices.
VAT will be added later in the checkout.
Tax calculation will be finalised during checkout.
Rent or Buy article
Get time limited or full article access on ReadCube.
All prices are NET prices.
GBD 2015 Risk Factors Collaborators. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 388, 1659–1724 (2016).
Landrigan, P. J. et al. The Lancet Commission on pollution and health. Lancet 391, 462–512 (2018).
Brook, R. D. et al. Particulate matter air pollution and cardiovascular disease. An update to the scientific statement from the American Heart Association. Circulation 121, 2331–2378 (2010).
World Health Organization & Occupational and Environmental Health Team. WHO Air quality guidelines for particulate matter, ozone, nitrogen dioxide and sulfur dioxide : global update 2005 : summary of risk assessment (WHO, 2006).
Newby, D. E. et al. Expert position paper on air pollution and cardiovascular disease. Eur. Heart J. 36, 83–93b (2015).
US Environmental Protection Agency. Fact sheets and additional information regarding the 2012 particulate matter (PM) National Ambient Air Quality Standards (NAAQS). EPA https://www.epa.gov/pm-pollution/fact-sheets-and-additional-information-regarding-2012-particulate-matter-pm-national (2012).
Krzyzanowski, M. & Cohen, A. Update of WHO air quality guidelines. Air Qual. Atmos. Health 1, 7–13 (2008).
Tucker, W. G. An overview of PM2.5 sources and control strategies. Fuel Process. Technol. 65, 379–392 (2000).
Miller, M. R. et al. Inhaled nanoparticles accumulate at sites of vascular disease. ACS Nano 11, 4542–4552 (2017).
Downward, G. S. et al. Long-term exposure to ultrafine particles and incidence of cardiovascular and cerebrovascular disease in a prospective study of a Dutch cohort. Environ. Health Perspect. 126, 127007 (2018).
Lippmann, M., Chen, L.-C., Gordon, T., Ito, K. & Thurston, G. D. National Particle Component Toxicity (NPACT) Initiative: integrated epidemiologic and toxicologic studies of the health effects of particulate matter components. Res. Rep. Health Eff. Inst. 177, 5–13 (2013).
Smith, K. R. et al. Public health benefits of strategies to reduce greenhouse-gas emissions: health implications of short-lived greenhouse pollutants. Lancet 374, 2091–2103 (2009).
Jerrett, M. et al. Long-term ozone exposure and mortality. N. Engl. J. Med. 360, 1085–1095 (2009).
Rajagopalan, S., Al-Kindi, S. G. & Brook, R. D. Air pollution and cardiovascular disease: JACC state-of-the-art review. J. Am. Coll. Cardiol. 72, 2054–2070 (2018).
de Souza, A., Guo, Y., Pav, H. G. & Fernandes, W. A. Effects of air pollution on disease respiratory: structures lag. Health 6, 1333–1339 (2014).
Silverman, R. A. & Ito, K. Age-related association of fine particles and ozone with severe acute asthma in New York City. J. Allergy Clin. Immunol. 125, 367–373.e5 (2010).
Mitchell, R. & Popham, F. Effect of exposure to natural environment on health inequalities: an observational population study. Lancet 372, 1655–1660 (2008).
Münzel, T. et al. Environmental stressors and cardio-metabolic disease: part I–epidemiologic evidence supporting a role for noise and air pollution and effects of mitigation strategies. Eur. Heart J. 38, 550–556 (2017).
Münzel, T. et al. Environmental stressors and cardio-metabolic disease: part II–mechanistic insights. Eur. Heart J. 38, 557–564 (2017).
Kumar, P. et al. Ultrafine particles in cities. Environ. Int. 66, 1–10 (2014).
Strosnider, H., Kennedy, C., Monti, M. & Yip, F. Rural and urban differences in air quality, 2008–2012, and community drinking water quality, 2010–2015—United States. MMWR Surveill. Summaries 66, 1–10 (2017).
Reid, C. E. et al. Critical review of health impacts of wildfire smoke exposure. Environ. Health Perspect. 124, 1334–1343 (2016).
Wettstein, Z. S. et al. Cardiovascular and cerebrovascular emergency department visits associated with wildfire smoke exposure in California in 2015. J. Am. Heart Assoc. 7, e007492 (2018).
DeFlorio-Barker, S., Crooks, J., Reyes, J. & Rappold, A. G. Cardiopulmonary effects of fine particulate matter exposure among older adults, during wildfire and non-wildfire periods, in the United States 2008–2010. Env. Health Perspect. 127, 37006 (2019).
Committee on the Medical Effects of Air Pollutants. Statement on the evidence for differential health effects of particulate matter according to source or components (COMEAP, 2015).
Ostro, B. et al. Long-term exposure to constituents of fine particulate air pollution and mortality: results from the California Teachers Study. Environ. Health Perspect. 118, 363–369 (2010).
Ostro, B. et al. Associations of mortality with long-term exposures to fine and ultrafine particles, species and sources: results from the California teachers study cohort. Environ. Health Perspect. 123, 549–556 (2015).
Atkinson, R. W., Mills, I. C., Walton, H. A. & Anderson, H. R. Fine particle components and health — a systematic review and meta-analysis of epidemiological time series studies of daily mortality and hospital admissions. J. Expo. Sci. Environ. Epidemiol. 25, 208 (2015).
Thurston, G. D. et al. Ischemic heart disease mortality and long-term exposure to source-related components of US fine particle air pollution. Environ. Health Perspect. 124, 785–794 (2015).
Fisk, W. J. & Chan, W. R. Effectiveness and cost of reducing particle-related mortality with particle filtration. Indoor Air 27, 909–920 (2017).
Rajagopalan, S. & Brook, R. D. The indoor-outdoor air-pollution continuum and the burden of cardiovascular disease: an opportunity for improving global health. Glob. Heart 7, 207–213 (2012).
Yu, K. et al. Association of solid fuel use with risk of cardiovascular and all-cause mortality in rural China. JAMA 319, 1351–1361 (2018).
Van Donkelaar, A. et al. Global estimates of ambient fine particulate matter concentrations from satellite-based aerosol optical depth: development and application. Environ. Health Perspect. 118, 847–855 (2010).
Di, Q. et al. Assessing PM2.5 exposures with high spatiotemporal resolution across the continental United States. Environ. Sci. Technol. 50, 4712–4721 (2016).
Feng, X. et al. Artificial neural networks forecasting of PM2.5 pollution using air mass trajectory based geographic model and wavelet transformation. Atmos. Environ. 107, 118–128 (2015).
Zhou, Q., Jiang, H., Wang, J. & Zhou, J. A hybrid model for PM2.5 forecasting based on ensemble empirical mode decomposition and a general regression neural network. Sci. Total Environ. 496, 264–274 (2014).
Bell, M. L. The use of ambient air quality modeling to estimate individual and population exposure for human health research: a case study of ozone in the northern Georgia region of the United States. Environ. Int. 32, 586–593 (2006).
Holliday, K. M. et al. Estimating personal exposures from ambient air pollution measures: using meta-analysis to assess measurement error. Epidemiology 25, 35–43 (2014).
McKercher, G. R., Salmond, J. A. & Vanos, J. K. Characteristics and applications of small, portable gaseous air pollution monitors. Environ. Pollut. 223, 102–110 (2017).
World Health Organization. Ambient air pollution: a global assessment of exposure and burden of disease (WHO, 2016).
Cohen, A. J. et al. Estimates and 25-year trends of the global burden of disease attributable to ambient air pollution: an analysis of data from the Global Burden of Diseases Study 2015. Lancet 389, 1907–1918 (2017).
Lelieveld, J. et al. Effects of fossil fuel and total anthropogenic emission removal on public health and climate. Proc. Natl Acad. Sci. USA 116, 7192–7197 (2019).
Burnett, R. T. et al. An integrated risk function for estimating the global burden of disease attributable to ambient fine particulate matter exposure. Environ. Health Perspect. 122, 397–403 (2014).
Brauer, M. et al. Ambient air pollution exposure estimation for the global burden of disease 2013. Environ. Sci. Technol. 50, 79–88 (2016).
Pope 3rd, C. A., Cohen, A. J. & Burnett, R. T. Cardiovascular disease and fine particulate matter: lessons and limitations of an integrated exposure-response approach. Circ. Res. 122, 1645–1647 (2018).
Burnett, R. et al. Global estimates of mortality associated with long-term exposure to outdoor fine particulate matter. Proc. Natl Acad. Sci. USA 115, 9592–9597 (2018).
Brook, R. D. & Rajagopalan, S. Particulate matter air pollution and atherosclerosis. Curr. Atheroscler. Rep. 12, 291–300 (2010).
Sun, Q. et al. Long-term air pollution exposure and acceleration of atherosclerosis and vascular inflammation in an animal model. JAMA 294, 3003–3010 (2005).
Rao, X. et al. CD36-dependent 7-ketocholesterol accumulation in macrophages mediates progression of atherosclerosis in response to chronic air pollution exposure. Circ. Res. 115, 770–780 (2014).
Yang, S. et al. PM2.5 concentration in the ambient air is a risk factor for the development of high-risk coronary plaques. Eur. Heart J. Cardiovasc. Imaging 20, 1355–1364 (2019).
Schwartz, J. Harvesting and long term exposure effects in the relation between air pollution and mortality. Am. J. Epidemiol. 151, 440–448 (2000).
Araujo, J. A. & Nel, A. E. Particulate matter and atherosclerosis: role of particle size, composition and oxidative stress. Part. Fibre Toxicol. 6, 24 (2009).
Li, N., Xia, T. & Nel, A. E. The role of oxidative stress in ambient particulate matter-induced lung diseases and its implications in the toxicity of engineered nanoparticles. Free Radic. Biol. Med. 44, 1689–1699 (2008).
Rao, X., Zhong, J., Brook, R. D. & Rajagopalan, S. Effect of pa rticulate matter air pollution on cardiovascular oxidative stress pathways. Antioxid. Redox Signal. 28, 797–818 (2018).
Calderon-Garciduenas, L. et al. Air pollution and children: neural and tight junction antibodies and combustion metals, the role of barrier breakdown and brain immunity in neurodegeneration. J. Alzheimers Dis. 43, 1039–1058 (2015).
Roy, A. et al. The cardiopulmonary effects of ambient air pollution and mechanistic pathways: a comparative hierarchical pathway analysis. PLoS One 9, e114913 (2014).
O’Neil, L. A. J. How frustration leads to inflammation. Science 320, 2–3 (2008).
Shoenfelt, J. et al. Involvement of TLR2 and TLR4 in inflammatory immune responses induced by fine and coarse ambient air particulate matter. J. Leukoc. Biol. 86, 303–312 (2009).
Becker, S., Fenton, M. J. & Soukup, J. M. Involvement of microbial components and toll-like receptors 2 and 4 in cytokine responses to air pollution particles. Am. J. Respir. Cell Mol. Biol. 27, 611–618 (2002).
Inoue, K. et al. The role of toll-like receptor 4 in airway inflammation induced by diesel exhaust particles. Arch. Toxicol. 80, 275–279 (2006).
Xu, X. et al. Effect of early particulate air pollution exposure on obesity in mice: role of p47phox. Arterioscler. Thromb. Vasc. Biol. 30, 2518–2527 (2010).
Kampfrath, T. et al. Chronic fine particulate matter exposure induces systemic vascular dysfunction via NADPH oxidase and TLR4 pathways. Circ. Res. 108, 716–726 (2011).
Robertson, S. et al. Pulmonary diesel particulate increases susceptibility to myocardial ischemia/reperfusion injury via activation of sensory TRPV1 and β1 adrenoreceptors. Part. Fibre Toxicol. 11, 12 (2014).
Lakey, P. S. et al. Chemical exposure-response relationship between air pollutants and reactive oxygen species in the human respiratory tract. Sci. Rep. 6, 32916 (2016).
Pope 3rd, C. A. et al. Ambient particulate air pollution, heart rate variability, and blood markers of inflammation in a panel of elderly subjects. Environ. Health Perspect. 112, 339–345 (2004).
Ruckerl, R. et al. Air pollution and markers of inflammation and coagulation in patients with coronary heart disease. Am. J. Respir. Crit. Care Med. 173, 432–441 (2006).
Eze, I. C. et al. Association between ambient air pollution and diabetes mellitus in Europe and North America: systematic review and meta-analysis. Environ. Health Perspect. 123, 381–389 (2015).
Zeka, A., Sullivan, J. R., Vokonas, P. S., Sparrow, D. & Schwartz, J. Inflammatory markers and particulate air pollution: characterizing the pathway to disease. Int. J. Epidemiol. 35, 1347–1354 (2006).
Liu, C. et al. Air pollution-mediated susceptibility to inflammation and insulin resistance: influence of CCR2 pathways in mice. Environ. Health Perspect. 122, 17–26 (2014).
Deiuliis, J. A. et al. Pulmonary T cell activation in response to chronic particulate air pollution. Am. J. Physiol. Lung Cell Mol. Physiol. 302, L399–L409 (2012).
Maher, B. A. et al. Magnetite pollution nanoparticles in the human brain. Proc. Natl Acad. Sci. USA 113, 10797–10801 (2016).
Ganguly, K. et al. Early pulmonary response is critical for extra-pulmonary carbon nanoparticle mediated effects: comparison of inhalation versus intra-arterial infusion exposures in mice. Part. Fibre Toxicol. 14, 19 (2017).
Simovic, S., Song, Y., Nann, T. & Desai, T. A. Intestinal absorption of fluorescently labeled nanoparticles. Nanomedicine: Nanotechnol. Biol. Med. 11, 1169–1178 (2015).
Elder, A. et al. Translocation of inhaled ultrafine manganese oxide particles to the central nervous system. Environ. Health Perspect. 114, 1172–1178 (2006).
Yin, F. et al. Diesel exhaust induces systemic lipid peroxidation and development of dysfunctional pro-oxidant and pro-inflammatory high-density lipoprotein. Arterioscler. Thromb. Vasc. Biol. 33, 1153–1161 (2013).
Kurhanewicz, N. et al. TRPA1 mediates changes in heart rate variability and cardiac mechanical function in mice exposed to acrolein. Toxicol. Appl. Pharmacol. 324, 51–60 (2017).
Fariss, M. W., Gilmour, M. I., Reilly, C. A., Liedtke, W. & Ghio, A. J. Emerging mechanistic targets in lung injury induced by combustion-generated particles. Toxicol. Sci. 132, 253–267 (2013).
Brook, R. D. et al. Hemodynamic, autonomic, and vascular effects of exposure to coarse particulate matter air pollution from a rural location. Environ. Health Perspect. 122, 624–630 (2014).
Fakhri, A. A. et al. Autonomic effects of controlled fine particulate exposure in young healthy adults: effect modification by ozone. Environ. Health Perspect. 117, 1287–1292 (2009).
Bartoli, C. R. et al. Concentrated ambient particles alter myocardial blood flow during acute ischemia in conscious canines. Environ. Health Perspect. 117, 333–337 (2009).
Ying, Z. et al. Long-term exposure to concentrated ambient PM2.5 increases mouse blood pressure through abnormal activation of the sympathetic nervous system: a role for hypothalamic inflammation. Environ. health Perspect. 122, 79–86 (2014).
Calderon-Garcidueñas, L. et al. Long-term air pollution exposure is associated with neuroinflammation, an altered innate immune response, disruption of the blood-brain barrier, ultrafine particulate deposition, and accumulation of amyloid β-42 and α-synuclein in children and young adults. Toxicol. Pathol. 36, 289–310 (2008).
Block, M. L. et al. The Outdoor Air Pollution and Brain Health Workshop. Neurotoxicology 33, 972–984 (2012).
Aragon, M. J. et al. Serum-borne bioactivity caused by pulmonary multiwalled carbon nanotubes induces neuroinflammation via blood-brain barrier impairment. Proc. Natl Acad. Sci. USA 114, E1968–E1976 (2017).
Mumaw, C. L. et al. Microglial priming through the lung-brain axis: the role of air pollution-induced circulating factors. FASEB J. 30, 1880–1891 (2016).
Hajat, A. et al. The association between long-term air pollution and urinary catecholamines: evidence from the multi-ethnic study of atherosclerosis. Environ. Health Perspect. 127, 57007 (2019).
Münzel, T. et al. Effects of gaseous and solid constituents of air pollution on endothelial function. Eur. Heart J. 39, 3543–3550 (2018).
Mills, N. L. et al. Diesel exhaust inhalation causes vascular dysfunction and impaired endogenous fibrinolysis. Circulation 112, 3930–3936 (2005).
Miller, M. R. et al. Direct impairment of vascular function by diesel exhaust particulate through reduced bioavailability of endothelium-derived nitric oxide induced by superoxide free radicals. Environ. Health Perspect. 117, 611–616 (2009).
Brook, R. D. et al. Insights into the mechanisms and mediators of the effects of air pollution exposure on blood pressure and vascular function in healthy humans. Hypertension 54, 659–667 (2009).
Mills, N. L. et al. Ischemic and thrombotic effects of dilute diesel-exhaust inhalation in men with coronary heart disease. N. Engl. J. Med. 357, 1075–1082 (2007).
Langrish, J. P. et al. Altered nitric oxide bioavailability contributes to diesel exhaust inhalation-induced cardiovascular dysfunction in man. J. Am. Heart Assoc. 2, e004309 (2013).
Sun, Q. et al. Air pollution exposure potentiates hypertension through reactive oxygen species-mediated activation of Rho/ROCK. Arterioscler. Thromb. Vasc. Biol. 28, 1760–1766 (2008).
Cherng, T. W. et al. Mechanisms of diesel-induced endothelial nitric oxide synthase dysfunction in coronary arterioles. Environ. Health Perspect. 119, 98–103 (2010).
Sun, Q. et al. Ambient air pollution exaggerates adipose inflammation and insulin resistance in a mouse model of diet-induced obesity. Circulation 119, 538–546 (2009).
O’Toole, T. E. et al. Episodic exposure to fine particulate air pollution decreases circulating levels of endothelial progenitor cells. Circ. Res. 107, 200–203 (2010).
Haberzettl, P. et al. Exposure to ambient air fine particulate matter prevents VEGF-induced mobilization of endothelial progenitor cells from the bone marrow. Environ. Health Perspect. 120, 848–856 (2012).
Cosselman, K. E. et al. Blood pressure response to controlled diesel exhaust exposure in human subjects. Hypertension 59, 943–948 (2012).
Byrd, J. B. et al. Acute increase in blood pressure during inhalation of coarse particulate matter air pollution from an urban location. J. Am. Soc. Hypertens. 10, 133–139.e4 (2016).
Wold, L. E. et al. Cardiovascular remodeling in response to long-term exposure to fine particulate matter air pollution. Circ. Heart Fail. 5, 452–461 (2012).
Mirowsky, J. E. et al. Ozone exposure is associated with acute changes in inflammation, fibrinolysis, and endothelial cell function in coronary artery disease patients. Environ. Health 16, 126 (2017).
Lund, A. K. et al. Vehicular emissions induce vascular MMP-9 expression and activity associated with endothelin-1-mediated pathways. Arterioscler. Thromb. Vasc. Biol. 29, 511–517 (2009).
Campen, M. J. et al. A comparison of vascular effects from complex and individual air pollutants indicates a role for monoxide gases and volatile hydrocarbons. Environ. Health Perspect. 118, 921–927 (2010).
Hunter, A. L. et al. Effect of wood smoke exposure on vascular function and thrombus formation in healthy fire fighters. Part. Fibre Toxicol. 11, 62 (2014).
Nemmar, A., Hoylaerts, M. F., Hoet, P. H. & Nemery, B. Possible mechanisms of the cardiovascular effects of inhaled particles: systemic translocation and prothrombotic effects. Toxicol. Lett. 149, 243–253 (2004).
Rückerl, R. et al. Ultrafine particles and platelet activation in patients with coronary heart disease–results from a prospective panel study. Part. Fibre Toxicol. 4, 1 (2007).
Mutlu, G. M. et al. Ambient particulate matter accelerates coagulation via an IL-6-dependent pathway. J. Clin. Invest. 117, 2952–2961 (2007).
Chiarella, S. E. et al. β2-Adrenergic agonists augment air pollution-induced IL-6 release and thrombosis. J. Clin. Invest. 124, 2935–2946 (2014).
Budinger, G. S. et al. Particulate matter-induced lung inflammation increases systemic levels of PAI-1 and activates coagulation through distinct mechanisms. PLoS One 6, e18525 (2011).
Tang, L. et al. Air pollution and venous thrombosis: a meta-analysis. Sci. Rep. 6, 32794–32794 (2016).
Xu, H. et al. Extreme levels of air pollution associated with changes in biomarkers of atherosclerotic plaque vulnerability and thrombogenicity in healthy adults. Circ. Res. 124, e30–e43 (2019).
Rich, D. Q. et al. Association between changes in air pollution levels during the beijing olympics and biomarkers of inflammation and thrombosis in healthy young adults. JAMA 307, 2068–2078 (2012).
Lucking, A. J. et al. Diesel exhaust inhalation increases thrombus formation in man. Eur. Heart J. 29, 3043–3051 (2008).
Rao, X., Montresor-Lopez, J., Puett, R., Rajagopalan, S. & Brook, R. D. Ambient air pollution: an emerging risk factor for diabetes mellitus. Curr. Diab. Rep. 15, 603 (2015).
Rao, X., Patel, P., Puett, R. & Rajagopalan, S. Air pollution as a risk factor for type 2 diabetes. Toxicol. Sci. 143, 231–241 (2015).
Liu, C. et al. Central IKKβ inhibition prevents air pollution mediated peripheral inflammation and exaggeration of type II diabetes. Part. Fibre Toxicol. 11, 53 (2014).
Miller, D. B. et al. Ozone exposure increases circulating stress hormones and lipid metabolites in humans. Am. J. Respir. Crit. Care Med. 193, 1382–1391 (2016).
Gruzieva, O. et al. Epigenome-wide meta-analysis of methylation in children related to prenatal NO2 air pollution exposure. Environ. Health Perspect. 125, 104–110 (2016).
Breton, C. V. et al. Small-magnitude effect sizes in epigenetic end points are important in children’s environmental health studies: the Children’s Environmental Health and Disease Prevention Research Center’s Epigenetics Working Group. Environ. Health Perspect. 125, 511–526 (2017).
Bind, M.-A. et al. Air pollution and gene-specific methylation in the Normative Aging Study: association, effect modification, and mediation analysis. Epigenetics 9, 448–458 (2014).
Wang, T. et al. The NIEHS TaRGET II Consortium and environmental epigenomics. Nat. Biotechnol. 36, 225–458 (2018).
Gondalia, R. et al. Methylome-wide association study provides evidence of particulate matter air pollution-associated DNA methylation. Environ. Int. 132, 104723 (2019).
Sayols-Baixeras, S. et al. Association between long-term air pollution exposure and DNA methylation: the REGICOR study. Environ. Res. 176, 108550 (2019).
Pope 3rd, C. A. & Dockery, D. W. Health effects of fine particulate air pollution: lines that connect. J. Air Waste Manag. Assoc. 56, 709–742 (2006).
Lu, F. et al. Systematic review and meta-analysis of the adverse health effects of ambient PM2.5 and PM10 pollution in the Chinese population. Environ. Res. 136, 196–204 (2015).
Krewski, D. et al. Extended follow-up and spatial analysis of the American Cancer Society study linking particulate air pollution and mortality (Health Effects Institute, 2009).
Crouse, D. L. et al. Risk of nonaccidental and cardiovascular mortality in relation to long-term exposure to low concentrations of fine particulate matter: a Canadian national-level cohort study. Environ. Health Perspect. 120, 708–714 (2012).
Malik, A. O. et al. Association of long-term exposure to particulate matter and ozone with health status and mortality in patients after myocardial infarction. Circ. Cardiovasc. Qual. Outcomes 12, e005598 (2019).
Lim, C. C. et al. Long-term exposure to ozone and cause-specific mortality risk in the US. Am. J. Respir. Crit. Care Med. 200, 1022–1031 (2019).
Kaufman, J. D. et al. Association between air pollution and coronary artery calcification within six metropolitan areas in the USA (the Multi-Ethnic Study of Atherosclerosis and Air Pollution): a longitudinal cohort study. Lancet 388, P696–P704 (2016).
Provost, E. B., Madhloum, N., Int Panis, L., De Boever, P. & Nawrot, T. S. Carotid intima-media thickness, a marker of subclinical atherosclerosis, and particulate air pollution exposure: the meta-analytical evidence. PLoS One 10, e0127014 (2015).
Liang, R. et al. Effect of exposure to PM2.5 on blood pressure: a systematic review and meta-analysis. J. Hypertens. 32, 2130–2140 (2014).
Giorgini, P. et al. Air pollution exposure and blood pressure: an updated review of the literature. Curr. Pharm. Des. 22, 28–51 (2016).
Cai, Y. et al. Associations of short-term and long-term exposure to ambient air pollutants with hypertension: a systematic review and meta-analysis. Hypertension 68, 62–70 (2016).
Yang, B. Y. et al. Global association between ambient air pollution and blood pressure: a systematic review and meta-analysis. Environ. Pollut. 235, 576–588 (2018).
Pedersen, M. et al. Ambient air pollution and pregnancy-induced hypertensive disorders: a systematic review and meta-analysis. Hypertension 64, 494–500 (2014).
Zhao, X. et al. Personal black carbon exposure influences ambulatory blood pressure: air pollution and cardiometabolic disease (AIRCMD-China) study. Hypertension 63, 871–877 (2014).
Langrish, J. P. et al. Reducing personal exposure to particulate air pollution improves cardiovascular health in patients with coronary heart disease. Environ. Health Perspect. 120, 367–372 (2012).
Shi, J. et al. Cardiovascular benefits of wearing particulate-filtering respirators: a randomized crossover trial. Environ. Health Perspect. 125, 175–180 (2016).
Morishita, M. et al. Effect of portable air filtration systems on personal exposure to fine particulate matter and blood pressure among residents in a low-income senior facility: a randomized clinical trial. JAMA Intern. Med. 178, 1350–1357 (2018).
Pope 3rd, C. A. et al. Ischemic heart disease events triggered by short-term exposure to fine particulate air pollution. Circulation 114, 2443–2448 (2006).
Mustafić, H. et al. Main air pollutants and myocardial infarction: a systematic review and meta-analysis. JAMA 307, 713–721 (2012).
Weaver, A. M. et al. Neighborhood sociodemographic effects on the associations between long-term PM2.5 exposure and cardiovascular outcomes and diabetes. Environ. Epidemiol. 3, e038 (2019).
Rich, D. Q. et al. Association of ventricular arrhythmias detected by implantable cardioverter defibrillator and ambient air pollutants in the St Louis, Missouri metropolitan area. Occup. Env. Med. 63, 591–596 (2006).
Folino, F. et al. Association between air pollution and ventricular arrhythmias in high-risk patients (ARIA study): a multicentre longitudinal study. Lancet Planet. Health 1, e58–e64 (2017).
Shao, Q. et al. Association between air pollution and development of atrial fibrillation: a meta-analysis of observational studies. Heart Lung 45, 557–562 (2016).
Shah, A. S. et al. Global association of air pollution and heart failure: a systematic review and meta-analysis. Lancet 382, 1039–1048 (2013).
Kim, H. et al. Cardiovascular effects of long-term exposure to air pollution: a population-based study with 900 845 person-years of follow-up. J. Am. Heart Assoc. 6, e007170 (2017).
Kloog, I. Fine particulate matter (PM2.5) association with peripheral artery disease admissions in northeastern United States. Int. J. Environ. Health Res. 26, 572–577 (2016).
Zhang, S. et al. Long-term effects of air pollution on ankle-brachial index. Environ. Int. 118, 17–25 (2018).
Kloog, I. et al. Effects of airborne fine particles (PM2.5) on deep vein thrombosis admissions in the northeastern United States. J. Thromb. Haemost. 13, 768–774 (2015).
Rajagopalan, S. & Brook, R. D. Air pollution and type 2 diabetes: mechanistic insights. Diabetes 61, 3037–3045 (2012).
Wang, B. et al. Effect of long-term exposure to air pollution on type 2 diabetes mellitus risk: a systemic review and meta-analysis of cohort studies. Eur. J. Endocrinol. 171, R173–R182 (2014).
Brook, R. D. et al. Long-term fine particulate matter exposure and mortality from diabetes in Canada. Diabetes Care 36, 3313–3320 (2013).
Bowe, B. et al. The 2016 global and national burden of diabetes mellitus attributable to PM2.5 air pollution. Lancet Planet. Health 2, e301–e312 (2018).
Haberzettl, P., O’Toole, T. E., Bhatnagar, A. & Conklin, D. J. Exposure to fine particulate air pollution causes vascular insulin resistance by inducing pulmonary oxidative stress. Environ. Health Perspect. 124, 1830–1839 (2016).
Fu, P., Guo, X., Cheung, F. M. H. & Yung, K. K. L. The association between PM2.5 exposure and neurological disorders: a systematic review and meta-analysis. Sci. Total Environ. 655, 1240–1248 (2019).
[No authors listed] Short term exposure to air pollution and stroke: systematic review and meta-analysis. BMJ 354, i4851 (2016).
Miller, K. A. et al. Long-term exposure to air pollution and incidence of cardiovascular events in women. N. Engl. J. Med. 356, 447–458 (2007).
Pope 3rd, C. A., Ezzati, M. & Dockery, D. W. Fine-particulate air pollution and life expectancy in the United States. N. Engl. J. Med. 360, 376–386 (2009).
Currie, J., Ray, S. H. & Neidell, M. Quasi-experimental studies suggest that lowering air pollution levels benefits infants’ and children’s health. Health Aff. 30, 2391–2399 (2011).
James, P., Banay, R. F., Hart, J. E. & Laden, F. A review of the health benefits of greenness. Curr. Epidemiol. Rep. 2, 131–142 (2015).
James, P. et al. Interrelationships between walkability, air pollution, greenness, and body mass index. Epidemiology 28, 780–788 (2017).
Yitshak-Sade, M. et al. Neighborhood greenness attenuates the adverse effect of PM2.5 on cardiovascular mortality in neighborhoods of lower socioeconomic status. Int. J. Environ. Res. Public. Health 16, 814 (2019).
Nowak, D. J., Hirabayashi, S., Bodine, A. & Greenfield, E. Tree and forest effects on air quality and human health in the United States. Environ. Pollut. 193, 119–129 (2014).
McDonald, R., Kroeger, T., Boucher, T., Wang, L. & Salem, R. Planting healthy air: a global analysis of the role of urban trees in addressing particulate matter pollution and extreme heat (The Nature Conservancy, 2016).
Kroeger, T. et al. Reforestation as a novel abatement and compliance measure for ground-level ozone. Proc. Natl Acad. Sci. USA 111, E4204–E4213 (2014).
Hadley, M. B., Baumgartner, J. & Vedanthan, R. Developing a clinical approach to air pollution and cardiovascular health. Circulation 137, 725–742 (2018).
Brook, R. D., Newby, D. E. & Rajagopalan, S. Air pollution and cardiometabolic disease: an update and call for clinical trials. Am. J. Hypertens. 31, 1–10 (2017).
Shakya, K. M., Noyes, A., Kallin, R. & Peltier, R. E. Evaluating the efficacy of cloth facemasks in reducing particulate matter exposure. J. Expo. Sci. Environ. Epidemiol. 27, 352–357 (2017).
Guan, T. et al. The effects of facemasks on airway inflammation and endothelial dysfunction in healthy young adults: a double-blind, randomized, controlled crossover study. Part. Fibre Toxicol. 15, 30 (2018).
Langrish, J. P. et al. Beneficial cardiovascular effects of reducing exposure to particulate air pollution with a simple facemask. Part. Fibre Toxicol. 6, 8 (2009).
Laumbach, R. J. et al. A controlled trial of acute effects of human exposure to traffic particles on pulmonary oxidative stress and heart rate variability. Part. Fibre Toxicol. 11, 45 (2014).
Allen, R. W. et al. An air filter intervention study of endothelial function among healthy adults in a woodsmoke-impacted community. Am. J. Respir. Crit. Care Med. 183, 1222–1230 (2011).
Weichenthal, S. et al. A randomized double-blind crossover study of indoor air filtration and acute changes in cardiorespiratory health in a First Nations community. Indoor Air 23, 175–184 (2013).
Chen, R. et al. Cardiopulmonary benefits of reducing indoor particles of outdoor origin: a randomized, double-blind crossover trial of air purifiers. J. Am. Coll. Cardiol. 65, 2279–2287 (2015).
van der Zee, S. C., Fischer, P. H. & Hoek, G. Air pollution in perspective: health risks of air pollution expressed in equivalent numbers of passively smoked cigarettes. Environ. Res. 148, 475–483 (2016).
Vieira, R. P. et al. Anti-inflammatory effects of aerobic exercise in mice exposed to air pollution. Med. Sci. Sports Exerc. 44, 1227–1234 (2012).
Fashi, M., Agha Alinejad, H. & Asilian Mahabadi, H. The effect of aerobic exercise in ambient particulate matter on lung tissue inflammation and lung cancer. Iran. J. Cancer Prev. 8, e2333 (2015).
Tainio, M. et al. Can air pollution negate the health benefits of cycling and walking? Prev. Med. 87, 233–236 (2016).
Sinharay, R. et al. Respiratory and cardiovascular responses to walking down a traffic-polluted road compared with walking in a traffic-free area in participants aged 60 years and older with chronic lung or heart disease and age-matched healthy controls: a randomised, crossover study. Lancet 391, 339–349 (2018).
Qin, F. et al. Exercise and air pollutants exposure: a systematic review and meta-analysis. Life Sci. 218, 153–164 (2019).
Tong, H. Dietary and pharmacological intervention to mitigate the cardiopulmonary effects of air pollution toxicity. Biochim. Biophys. Acta 1860, 2891–2898 (2016).
Mancebo, S. E. & Wang, S. Q. Recognizing the impact of ambient air pollution on skin health. J. Eur. Acad. Dermatol. Venereol. 29, 2326–2332 (2015).
Canova, C. et al. PM10-induced hospital admissions for asthma and chronic obstructive pulmonary disease: the modifying effect of individual characteristics. Epidemiology 23, 607–615 (2012).
Romieu, I. et al. Antioxidant supplementation and respiratory functions among workers exposed to high levels of ozone. Am. J. Respir. Crit. Care Med. 158, 226–232 (1998).
Mohsenin, V. Effect of vitamin C on NO2-induced airway hyperresponsiveness in normal subjects. A randomized double-blind experiment. Am. Rev. Respir. Dis. 136, 1408–1411 (1987).
Possamai, F. P. et al. Antioxidant intervention compensates oxidative stress in blood of subjects exposed to emissions from a coal electric-power plant in South Brazil. Environ. Toxicol. Pharmacol. 30, 175–180 (2010).
Sack, C. S. et al. Pretreatment with antioxidants augments the acute arterial vasoconstriction caused by diesel exhaust inhalation. Am. J. Respir. Crit. Care Med. 193, 1000–1007 (2016).
Lim, C. C. et al. Mediterranean diet and the association between air pollution and cardiovascular disease mortality risk. Circulation 139, 1766–1775 (2019).
Lin, Z. et al. Cardiovascular benefits of fish-oil supplementation against fine particulate air pollution in China. J. Am. Coll. Cardiol. 73, 2076–2085 (2019).
Mirabelli, M. C. et al. Air quality awareness among US adults with respiratory and heart disease. Am. J. Prev. Med. 54, 679–687 (2018).
Crimmins, A. et al. (eds) The impacts of climate change on human health in the United States: a scientific assessment (US Global Change Research Program, 2016).
Bloomer, B. J., Stehr, J. W., Piety, C. A., Salawitch, R. J. & Dickerson, R. R. Observed relationships of ozone air pollution with temperature and emissions. Geophys. Res. Lett. 36, L09803 (2009).
Camalier, L., Cox, W. & Dolwick, P. The effects of meteorology on ozone in urban areas and their use in assessing ozone trends. Atmos. Environ. 41, 7127–7137 (2007).
Gao, J. et al. Public health co-benefits of greenhouse gas emissions reduction: a systematic review. Sci. Total Environ. 627, 388–402 (2018).
Guttikunda, S. Primer on pollution source apportionment. Urban Emissions http://www.urbanemissions.info/publications/primer-on-pollution-source-apportionment/ (2020).
The authors were funded by the NIH grants 5R01ES019616 (S.R. and R.D.B.), 1R01ES026291 (S.R.) and U01ES026721 (S.B. and S.R.).
The authors declare no competing interests.
Peer review information
Nature Reviews Cardiology thanks P. Mannucci and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
- Ozone gas
An inorganic molecule composed of three atoms of oxygen, which mainly exists in the Earth’s stratosphere (ozone layer) and troposphere (low-level ozone).
- Primary particulates
Particulates that are directly released into the atmosphere by the source (such as combustion).
- Secondary particulates
Particulates that form in the atmosphere from primary gases (such as oxidation of nitrogen into nitric acid).
- Primary combustion
The release of unburned combustible gases from wood burning with heat, as opposed to secondary combustion, which involves gases that react secondarily (oxidize) to form other pollutants.
- Atmospheric stability
The measure of atmospheric resistance to vertical motion, which determines the movement of air and storm formation.
- Integrated Exposure–Response
(IER). A meta-analytical approach integrating data from studies of ambient air pollution, second-hand smoking, household pollution and active smoking to estimate the shape of the association between air pollution and mortality.
- Disability-adjusted life years
(DALYs). Number of years alive, adjusted for disability, which estimates the burden of life years lost to the disease.
- Anthropogenic emissions
Emissions originating from human activity, such as burning of fossil fuels for cooking, mining and manufacturing.
- Global Exposure Mortality Model
(GEMM). An integrated approach including only ambient air pollution studies to define the shape of the association between air pollution and mortality.
- Harvesting effect
(Also known as mortality displacement). The hypothesis that excess deaths that occur after an environmental trigger (such as air pollution) would have occurred in the short term, regardless of the presence of the trigger.
- Frustrated phagocytosis
Occurs when phagocytic cells do not internalize the target, resulting in its release into the environment.
- Intratracheal instillation
Direct inoculation of a substance into the trachea.
- Ankle–brachial index
A non-invasive marker of the presence of peripheral arterial disease, estimated using the ratio of lower-extremity to upper-extremity blood pressure.
About this article
Cite this article
Al-Kindi, S.G., Brook, R.D., Biswal, S. et al. Environmental determinants of cardiovascular disease: lessons learned from air pollution. Nat Rev Cardiol 17, 656–672 (2020). https://doi.org/10.1038/s41569-020-0371-2
Indian Heart Journal (2021)
Toxicology and Applied Pharmacology (2021)
Particulate matter air pollution and reduced heart rate variability: How the associations vary by particle size in Shanghai, China
Ecotoxicology and Environmental Safety (2021)
The effects of lockdown-induced air quality changes on the results of cardiac functional stress testing in coronary artery disease and heart failure patients
Environmental Science and Pollution Research (2021)
Nanoscale observation of PM2.5 incorporated into mammalian cells using scanning electron-assisted dielectric microscope
Scientific Reports (2021)