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Introduction

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

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Comments (1)
"Re:""Expert position paper on air pollution and cardiovascular disease""Newby, et al., 36 (2): 83-93 doi:10.1093/eurheartj/ehu458"
21 January 2015
Tomoyuki Kawada, Professor
Nippon Medical School
I read “Expert position paper” on air pollution and cardiovascular disease (CVD) with interest (1). I want to add some recent information on this research field.
Heinrich et al. (2) reported a positive cause-effect relationship between air pollution (PM10 and NO2) and mortality (all-cause and cardiopulmonary) with special reference to women aged 55 years old. Newby et al. quoted a meta-analysis on the effect of long-term exposure to air pollution on natural-cause mortality by Beelen et al. (3), concluding that there was a significant association even selecting studies under the present European annual mean limit value for PM 2.5. In contrast, Beelen et al. (4) reported another meta-analysis for the effect of long-term exposure to air pollution on cardiovascular mortality (overall and cause-specific), and concluded that there was no significant association. Even the recent meta-analyses, there is a dissociation in their study outcome. Heinrich et al. mentioned that each study of meta-analysis showed different number of samples and sex distribution, which contributed to the study outcomes. In addition, each study of meta-analysis showed different follow-up period and ethnic difference. These factors should be checked for the meta-analysis.
As additional information, Yamamoto et al. (5) reported the association between air pollution and cardiovascular disease in South Asia. The authors gathered nine articles for their systematic review, and the authors could not elucidate air pollution as a significant risk factor for CVD.
CVD is composed of specific causes such as cerebrovascular disease, ischemic heart disease and myocardial infarction, and sub-analysis are recommended to simplify the causality, although the enough number of samples is needed for the study. Taking together, a systematic review should be conducted by setting the type of air pollution and CVD outcome. For the present time, much more information is needed to conduct a systematic review on the association between air pollution and CVD.
References
1. Newby DE, Mannucci PM, Tell GS, Baccarelli AA, Brook RD, Donaldson K, Forastiere F, Franchini M, Franco OH, Graham I, Hoek G, Hoffmann B, Hoylaerts MF, Kunzli N, Mills N, Pekkanen J, Peters A, Piepoli MF, Rajagopalan S, Storey RF; on behalf of ESC Working Group on Thrombosis, European Association for Cardiovascular Prevention and Rehabilitation and ESC Heart Failure Association. Expert position paper on air pollution and cardiovascular disease. Eur Heart J 2015;36:83-93.
2. Heinrich J, Thiering E, Rzehak P, Kramer U, Hochadel M, Rauchfuss KM, Gehring U, Wichmann HE. Long-term exposure to NO2 and PM10 and all-cause and cause-specific mortality in a prospective cohort of women. Occup Environ Med 2013;70:179-186.
3. Beelen R, Raaschou-Nielsen O, Stafoggia M, Andersen ZJ, Weinmayr G, Hoffmann B, Wolf K, Samoli E, Fischer P, Nieuwenhuijsen M, Vineis P, Xun WW, Katsouyanni K, Dimakopoulou K, Oudin A, Forsberg B, Modig L, Havulinna AS, Lanki T, Turunen A, Oftedal B, Nystad W, Nafstad P, De Faire U, Pedersen NL, Ostenson CG, Fratiglioni L, Penell J, Korek M, Pershagen G, Eriksen KT, Overvad K, Ellermann T, Eeftens M, Peeters PH, Meliefste K, Wang M, Bueno-de-Mesquita B, Sugiri D, Kramer U, Heinrich J, de Hoogh K, Key T, Peters A, Hampel R, Concin H, Nagel G, Ineichen A, Schaffner E, Probst-Hensch N, Kunzli N, Schindler C, Schikowski T, Adam M, Phuleria H, Vilier A, Clavel-Chapelon F, Declercq C, Grioni S, Krogh V, Tsai MY, Ricceri F, Sacerdote C, Galassi C, Migliore E, Ranzi A, Cesaroni G, Badaloni C, Forastiere F, Tamayo I, Amiano P, Dorronsoro M, Katsoulis M, Trichopoulou A, Brunekreef B, Hoek G. Effects of long-term exposure to air pollution on natural-cause mortality: an analysis of 22 European cohorts within the multicentre ESCAPE project. Lancet 2014;383:785-795.
4. Beelen R, Stafoggia M, Raaschou-Nielsen O, Andersen ZJ, Xun WW, Katsouyanni K, Dimakopoulou K, Brunekreef B, Weinmayr G, Hoffmann B, Wolf K, Samoli E, Houthuijs D, Nieuwenhuijsen M, Oudin A, Forsberg B, Olsson D, Salomaa V, Lanki T, Yli-Tuomi T, Oftedal B, Aamodt G, Nafstad P, De Faire U, Pedersen NL, Östenson CG, Fratiglioni L, Penell J, Korek M, Pyko A, Eriksen KT, Tjønneland A, Becker T, Eeftens M, Bots M, Meliefste K, Wang M, Bueno-de-Mesquita B, Sugiri D, Krämer U, Heinrich J, de Hoogh K, Key T, Peters A, Cyrys J, Concin H, Nagel G, Ineichen A, Schaffner E, Probst-Hensch N, Dratva J, Ducret-Stich R, Vilier A, Clavel-Chapelon F, Stempfelet M, Grioni S, Krogh V, Tsai MY, Marcon A, Ricceri F, Sacerdote C, Galassi C, Migliore E, Ranzi A, Cesaroni G, Badaloni C, Forastiere F, Tamayo I, Amiano P, Dorronsoro M, Katsoulis M, Trichopoulou A, Vineis P, Hoek G. Long-term exposure to air pollution and cardiovascular mortality: an analysis of 22 European cohorts. Epidemiology 2014;25:368-378.
5. Yamamoto SS, Phalkey R, Malik AA. A systematic review of air pollution as a risk factor for cardiovascular disease in South Asia: limited evidence from India and Pakistan. Int J Hyg Environ Health 2014;217:133-144.
Submitted on 21/01/2015 7:00 PM GMT