Air pollution has wide-ranging and deleterious effects on human health and is a major issue for the global community. The Global Burden of Disease study has described the worldwide impact of air pollution with as many as 3.1 million of 52.8 million all-cause and all-age deaths being attributable to ambient air pollution in the year 2010.1 Moreover, ambient air pollution ranked ninth among the modifiable disease risk factors, being listed above other commonly recognized factors, such as low physical activity, a high-sodium diet, high cholesterol, and drug use. Finally, air pollution accounts for 3.1% of global disability-adjusted life years, an index that measures the time spent in states of reduced health.1
Although it is intuitive that air pollution is an important stimulus for the development and exacerbation of respiratory diseases, such as asthma, chronic obstructive pulmonary disease, and lung cancer, there is generally less public awareness of its substantial impact on cardiovascular disease. Historically, the 1952 Great Smog of London led to an increase in cardiovascular death as well as deaths due to respiratory disease. Subsequent studies in the 1990s, such as the Harvard Six Cities2 and American Cancer Society cohort studies,2,3 established an enduring positive association between long-term exposure to air pollution and total and cardiovascular mortality, mainly due to coronary artery disease.4 In Europe, the first study that supported this association between long-term exposure and mortality was the Netherlands Cohort Study on Diet and Cancer.5 Associations with cardiovascular morbidity and mortality are also seen with short-term (e.g. day-to-day fluctuations) pollutant exposures of residents in large urban areas worldwide, including the United States of America6 and Europe.7,8 Among multiple 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.9
Here, we present an expert consensus document on behalf of the European Society of Cardiology that explores the mechanisms and relationships between ambient air pollution and cardiovascular disease. The purpose of this document is to highlight and raise awareness of the importance and wide-ranging impact of air pollution on cardiovascular disease. It will also provide guidance to society, patients, and healthcare professionals on the potential health impacts of air pollution, and make recommendations for future public health and research priorities to manage and mitigate this avoidable cause of death and disease.