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Underrecognized Impact of Pollution on Cardiovascular Disease: NEJM Review



Many cardiovascular disease prevention strategies and guidelines focus on modifying traditional risk factors, such as tobacco use, dyslipidemia, diabetes, and hypertension. However, a recent review from the New England Journal of Medicine details the underrecognized effects of environmental pollution on the burden of cardiovascular disease. Pollution was estimated to be responsible for 9 million deaths worldwide in 2019, 31.7% of which were related to ischemic heart disease and 27.7% of which were related to stroke.2, 3

Several causes and mitigation strategies of pollution are identified in this review, along with a summary of evidence linking cardiovascular disease to the primary forms of pollution: air pollution, climate change, toxic metals, and manufactured chemicals. Mechanisms for linking cardiovascular disease to pollution are categorized as 1) initiating mechanisms such as oxidative stress and inflammation, 2) effector pathways such as autonomic dysfunction and endocrine disruption, and 3) risk factor development such as type 2 diabetes and hypertension (Figure 3).

Pollution should be considered a major—and potentially preventable—risk factor for cardiovascular disease. Pollution-related cardiovascular disease has been linked with social determinants of health, including tree canopy coverage, food deserts, and nearby industrial facilities.4 Pollution exposure history and anticipatory guidance can be discussed during clinical encounters, including recommendations to avoid hazardous workplace exposures, avoid routes with heavy traffic, and check air quality before outdoor activities (Figure 4).


  1. Rajagopalan S, Landrigan PJ. Pollution and the heart. N Engl J Med. 2021;385(20):1881-1892. doi:10.1056/NEJMra2030281.

  2. GBD 2019 Risk Factors Collaborators. Global burden of 87 risk factors in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396(10258):1223-1249. doi:10.1016/S0140-6736(20)30752-2.

  3. Newman JD, Bhatt DL, Rajagopalan S, et al. Cardiopulmonary impact of particulate air pollution in high-risk populations: JACC state-of-the-art review. J Am Coll Cardiol. 2020;76(24):2878-2894. doi:10.1016/j.jacc.2020.10.020. 

  4. Hajat A, Hsia C, O’Neill, MS. Socioeconomic Disparities and Air Pollution Exposure: a Global Review. Curr Envir Health Rpt. 2105 Dec;2(4):440-50.



© 2020 Cardi-OH