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Chapter Summary

This chapter discusses the effects of air pollution on cardiovascular risk factors and outcomes. The vast majority (>90%) of the world’s population is exposed to ambient fine particulate matter air pollution that exceeds World Health Organization guidelines. Almost 5 million deaths (8.7% of global mortality) were attributed to air pollution in 2017, and >50% of air pollution deaths are due to cardiovascular disease. Indeed, at least one in nine cardiovascular deaths are attributed to air pollution. Fine particulate matter is the component of air pollution most linked to adverse cardiovascular effects; the particles have diameter <2.5 μm and are largely derived from fossil-fuel combustion from power generation, industrial emissions, motorized vehicles, and household burning of solid fuel. Inhaled fine particulate matter triggers multiple interdependent initiating mechanisms (see Fuster and Hurst’s Central Illustration), with subsequent effector pathways leading to development and exacerbation of cardiovascular risk factors such as elevated blood pressure, elevated blood glucose, atherosclerosis, and myocardial remodeling. A large body of evidence links air pollution exposure with cardiovascular mortality, acute coronary syndrome, stroke, heart failure, and arrhythmias. Cardiovascular risk from air pollution is modifiable at the individual and population levels. Various strategies for mitigating the harmful effects of air pollution are discussed.

eFig 9-01 Chapter 9: Air Pollution and Cardiovascular Disease


Air pollution is responsible for one in nine cardiovascular deaths globally, with attributable mortality expected to double by 2050.1–4 The American Heart Association and other medical societies now list air pollution as a key modifiable risk factor for cardiovascular morbidity and mortality.5–7 Importantly, reductions in air pollution exposures are estimated to avert cardiovascular (CV) events, increase population life expectancy, and reduce health care expenses.6–9 Health care providers and policymakers therefore have an opportunity and a responsibility to mitigate pollution exposures and improve CV health.10 In this chapter, we discuss the burden of air pollution-attributable cardiovascular disease (CVD), the complex pathophysiology of air pollution CV effects, and strategies to assess and intervene on air pollution exposure mediated CV events.


Air pollution is the leading environmental cause of reversible premature morbidity and mortality worldwide.1,11 In 2017 alone, 4.9 million deaths were attributed to air pollution (8.7% of global mortality).1 Air pollution is responsible for more deaths than obesity, renal disease, alcohol use, malnutrition, physical inactivity, or HIV/AIDS, malaria, and tuberculosis combined1 (Fig. 9–1). The large global impact of air pollution exposure is on account of its ubiquitous exposure. Over 90% of the global population is exposed to levels of ambient fine particulate matter air pollution exceeding World Health Organization (WHO) guidelines (<10 μg/m3 annually and <25 μg/m3 daily).12 In densely populated regions of Asia ...

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