Perry Hystad1, Andrew Larkin2, Sumathy Rangarajan3, Khalid F AlHabib4, Álvaro Avezum5, Kevser Burcu Tumerdem Calik6, Jephat Chifamba7, Antonio Dans8, Rafael Diaz9, Johan L du Plessis10, Rajeev Gupta11, Romaina Iqbal12, Rasha Khatib13, Roya Kelishadi14, Fernando Lanas15, Zhiguang Liu16, Patricio Lopez-Jaramillo17, Sanjeev Nair18, Paul Poirier19, Omar Rahman20, Annika Rosengren21, Hany Swidan22, Lap Ah Tse16, Li Wei23, Andreas Wielgosz24, Karen Yeates25, Khalid Yusoff26, Tomasz Zatoński27, Rick Burnett28, Salim Yusuf3, Michael Brauer29. 1. College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, USA; Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada. Electronic address: perry.hystad@oregonstate.edu. 2. College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, USA. 3. Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada. 4. Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia. 5. Department of Medicine, Universidade de Santo Amaro, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil. 6. Department of Health Management, Faculty of Health Sciences, Marmara University, Istanbul, Turkey. 7. Department of Physiology, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe. 8. Department of Cardiac Sciences, University of Philippines, Manila, Philippines. 9. Estudios Clínicos Latinoamérica (ECLA), Rosario, Santa Fe, Argentina. 10. Occupational Hygiene and Health Research Initiative, North-West University, Potchefstroom, South Africa. 11. Eternal Heart Care Centre and Research Institute, Jaipur, India. 12. Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan. 13. Institute for Community and Public Health, Birzeit University, Birzeit, Palestine; Advocate Health Care, Chicago, IL, USA. 14. Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran. 15. Department of Medicine, Universidad de La Frontera, Temuco, Chile. 16. Jockey Club School of Public Health and Primary Care, the Chinese University of Hong Kong, Prince of Wales Hospital, Sha Tin, Hong Kong. 17. Fundación Oftalmológica de Santander Clínica Carlos Ardila Lulle (FOSCAL), Bucaramanga, Colombia; Escuela de Medicina, Universidad de Santander, Bucaramanga, Colombia. 18. Health Action by People, Thiruvananthapuram, India. 19. Faculty of Pharmacy, University Institute of Cardiology and Respirology of Quebec, Laval University, Québec, QC, Canada. 20. Independent University, Dhaka, Bangladesh. 21. Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden. 22. Dubai Health Authority, Dubai, United Arab Emirates. 23. National Centre for Cardiovascular Diseases, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China. 24. Department of Medicine, University of Ottawa, Ottawa, ON, Canada. 25. Department of Medicine, Queen's University, Kingston, ON, Canada. 26. Faculty of Medicine, Universiti Teknologi MARA, Selangor, Malaysia; UCSI University, Cheras, Kuala Lumpur, Malaysia. 27. Department of Otolaryngology Head and Neck Surgery, Wrocław Medical University, Wrocław, Poland. 28. Environmental Health Science and Research Bureau, Health Canada, Ottawa, ON, Canada. 29. School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.
Abstract
BACKGROUND: Most studies of long-term exposure to outdoor fine particulate matter (PM2·5) and cardiovascular disease are from high-income countries with relatively low PM2·5 concentrations. It is unclear whether risks are similar in low-income and middle-income countries (LMICs) and how outdoor PM2·5 contributes to the global burden of cardiovascular disease. In our analysis of the Prospective Urban and Rural Epidemiology (PURE) study, we aimed to investigate the association between long-term exposure to PM2·5 concentrations and cardiovascular disease in a large cohort of adults from 21 high-income, middle-income, and low-income countries. METHODS: In this multinational, prospective cohort study, we studied 157 436 adults aged 35-70 years who were enrolled in the PURE study in countries with ambient PM2·5 estimates, for whom follow-up data were available. Cox proportional hazard frailty models were used to estimate the associations between long-term mean community outdoor PM2·5 concentrations and cardiovascular disease events (fatal and non-fatal), cardiovascular disease mortality, and other non-accidental mortality. FINDINGS: Between Jan 1, 2003, and July 14, 2018, 157 436 adults from 747 communities in 21 high-income, middle-income, and low-income countries were enrolled and followed up, of whom 140 020 participants resided in LMICs. During a median follow-up period of 9·3 years (IQR 7·8-10·8; corresponding to 1·4 million person-years), we documented 9996 non-accidental deaths, of which 3219 were attributed to cardiovascular disease. 9152 (5·8%) of 157 436 participants had cardiovascular disease events (fatal and non-fatal incident cardiovascular disease), including 4083 myocardial infarctions and 4139 strokes. Mean 3-year PM2·5 at cohort baseline was 47·5 μg/m3 (range 6-140). In models adjusted for individual, household, and geographical factors, a 10 μg/m3 increase in PM2·5 was associated with increased risk for cardiovascular disease events (hazard ratio 1·05 [95% CI 1·03-1·07]), myocardial infarction (1·03 [1·00-1·05]), stroke (1·07 [1·04-1·10]), and cardiovascular disease mortality (1·03 [1·00-1·05]). Results were similar for LMICs and communities with high PM2·5 concentrations (>35 μg/m3). The population attributable fraction for PM2·5 in the PURE cohort was 13·9% (95% CI 8·8-18·6) for cardiovascular disease events, 8·4% (0·0-15·4) for myocardial infarction, 19·6% (13·0-25·8) for stroke, and 8·3% (0·0-15·2) for cardiovascular disease mortality. We identified no consistent associations between PM2·5 and risk for non-cardiovascular disease deaths. INTERPRETATION: Long-term outdoor PM2·5 concentrations were associated with increased risks of cardiovascular disease in adults aged 35-70 years. Air pollution is an important global risk factor for cardiovascular disease and a need exists to reduce air pollution concentrations, especially in LMICs, where air pollution levels are highest. FUNDING: Full funding sources are listed at the end of the paper (see Acknowledgments).
BACKGROUND: Most studies of long-term exposure to outdoor fine particulate matter (PM2·5) and cardiovascular disease are from high-income countries with relatively low PM2·5 concentrations. It is unclear whether risks are similar in low-income and middle-income countries (LMICs) and how outdoor PM2·5 contributes to the global burden of cardiovascular disease. In our analysis of the Prospective Urban and Rural Epidemiology (PURE) study, we aimed to investigate the association between long-term exposure to PM2·5 concentrations and cardiovascular disease in a large cohort of adults from 21 high-income, middle-income, and low-income countries. METHODS: In this multinational, prospective cohort study, we studied 157 436 adults aged 35-70 years who were enrolled in the PURE study in countries with ambient PM2·5 estimates, for whom follow-up data were available. Cox proportional hazard frailty models were used to estimate the associations between long-term mean community outdoor PM2·5 concentrations and cardiovascular disease events (fatal and non-fatal), cardiovascular diseasemortality, and other non-accidental mortality. FINDINGS: Between Jan 1, 2003, and July 14, 2018, 157 436 adults from 747 communities in 21 high-income, middle-income, and low-income countries were enrolled and followed up, of whom 140 020 participants resided in LMICs. During a median follow-up period of 9·3 years (IQR 7·8-10·8; corresponding to 1·4 million person-years), we documented 9996 non-accidental deaths, of which 3219 were attributed to cardiovascular disease. 9152 (5·8%) of 157 436 participants had cardiovascular disease events (fatal and non-fatal incident cardiovascular disease), including 4083 myocardial infarctions and 4139 strokes. Mean 3-year PM2·5 at cohort baseline was 47·5 μg/m3 (range 6-140). In models adjusted for individual, household, and geographical factors, a 10 μg/m3 increase in PM2·5 was associated with increased risk for cardiovascular disease events (hazard ratio 1·05 [95% CI 1·03-1·07]), myocardial infarction (1·03 [1·00-1·05]), stroke (1·07 [1·04-1·10]), and cardiovascular diseasemortality (1·03 [1·00-1·05]). Results were similar for LMICs and communities with high PM2·5 concentrations (>35 μg/m3). The population attributable fraction for PM2·5 in the PURE cohort was 13·9% (95% CI 8·8-18·6) for cardiovascular disease events, 8·4% (0·0-15·4) for myocardial infarction, 19·6% (13·0-25·8) for stroke, and 8·3% (0·0-15·2) for cardiovascular diseasemortality. We identified no consistent associations between PM2·5 and risk for non-cardiovascular disease deaths. INTERPRETATION: Long-term outdoor PM2·5 concentrations were associated with increased risks of cardiovascular disease in adults aged 35-70 years. Air pollution is an important global risk factor for cardiovascular disease and a need exists to reduce air pollution concentrations, especially in LMICs, where air pollution levels are highest. FUNDING: Full funding sources are listed at the end of the paper (see Acknowledgments).
Authors: Cora L Craig; Alison L Marshall; Michael Sjöström; Adrian E Bauman; Michael L Booth; Barbara E Ainsworth; Michael Pratt; Ulf Ekelund; Agneta Yngve; James F Sallis; Pekka Oja Journal: Med Sci Sports Exerc Date: 2003-08 Impact factor: 5.411
Authors: Michael Brauer; Greg Freedman; Joseph Frostad; Aaron van Donkelaar; Randall V Martin; Frank Dentener; Rita van Dingenen; Kara Estep; Heresh Amini; Joshua S Apte; Kalpana Balakrishnan; Lars Barregard; David Broday; Valery Feigin; Santu Ghosh; Philip K Hopke; Luke D Knibbs; Yoshihiro Kokubo; Yang Liu; Stefan Ma; Lidia Morawska; José Luis Texcalac Sangrador; Gavin Shaddick; H Ross Anderson; Theo Vos; Mohammad H Forouzanfar; Richard T Burnett; Aaron Cohen Journal: Environ Sci Technol Date: 2015-12-04 Impact factor: 9.028
Authors: Yang Yang; Robert Tang; Hong Qiu; Poh-Chin Lai; Paulina Wong; Thuan-Quoc Thach; Ryan Allen; Michael Brauer; Linwei Tian; Benjamin Barratt Journal: Environ Int Date: 2018-05-03 Impact factor: 9.621
Authors: Raphael E Arku; Aaron Birch; Matthew Shupler; Salim Yusuf; Perry Hystad; Michael Brauer Journal: Environ Int Date: 2018-03-19 Impact factor: 9.621
Authors: Cong Liu; Renjie Chen; Francesco Sera; Ana M Vicedo-Cabrera; Yuming Guo; Shilu Tong; Micheline S Z S Coelho; Paulo H N Saldiva; Eric Lavigne; Patricia Matus; Nicolas Valdes Ortega; Samuel Osorio Garcia; Mathilde Pascal; Massimo Stafoggia; Matteo Scortichini; Masahiro Hashizume; Yasushi Honda; Magali Hurtado-Díaz; Julio Cruz; Baltazar Nunes; João P Teixeira; Ho Kim; Aurelio Tobias; Carmen Íñiguez; Bertil Forsberg; Christofer Åström; Martina S Ragettli; Yue-Leon Guo; Bing-Yu Chen; Michelle L Bell; Caradee Y Wright; Noah Scovronick; Rebecca M Garland; Ai Milojevic; Jan Kyselý; Aleš Urban; Hans Orru; Ene Indermitte; Jouni J K Jaakkola; Niilo R I Ryti; Klea Katsouyanni; Antonis Analitis; Antonella Zanobetti; Joel Schwartz; Jianmin Chen; Tangchun Wu; Aaron Cohen; Antonio Gasparrini; Haidong Kan Journal: N Engl J Med Date: 2019-08-22 Impact factor: 91.245
Authors: Gavin Shaddick; Matthew L Thomas; Heresh Amini; David Broday; Aaron Cohen; Joseph Frostad; Amelia Green; Sophie Gumy; Yang Liu; Randall V Martin; Annette Pruss-Ustun; Daniel Simpson; Aaron van Donkelaar; Michael Brauer Journal: Environ Sci Technol Date: 2018-07-30 Impact factor: 9.028
Authors: Seulkee Heo; Ji-Young Son; Chris C Lim; Kelvin C Fong; Hayon Michelle Choi; Raul U Hernandez-Ramirez; Kate Nyhan; Preet K Dhillon; Suhela Kapoor; Dorairaj Prabhakaran; Donna Spiegelman; Michelle L Bell Journal: Environ Res Lett Date: 2022-05-16 Impact factor: 6.947
Authors: Herman Bagula; Toyib Olaniyan; Kees de Hoogh; Apolline Saucy; Bhawoodien Parker; Joy Leaner; Martin Röösli; Mohamed Aqiel Dalvie Journal: Int J Environ Res Public Health Date: 2021-12-17 Impact factor: 3.390