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Associations of Outdoor Fine Particulate Air Pollution and Cardiovascular Disease in 157 436 Individuals From 21 High-Income, Middle-Income, and Low-Income Countries (Pure): A Prospective Cohort Study Publisher Pubmed



Hystad P1, 2 ; Larkin A1 ; Rangarajan S2 ; Alhabib KF3 ; Avezum A4 ; Calik KBT5 ; Chifamba J6 ; Dans A7 ; Diaz R8 ; Du Plessis JL9 ; Gupta R10 ; Iqbal R11 ; Khatib R12, 13 ; Kelishadi R14 Show All Authors
Authors
  1. Hystad P1, 2
  2. Larkin A1
  3. Rangarajan S2
  4. Alhabib KF3
  5. Avezum A4
  6. Calik KBT5
  7. Chifamba J6
  8. Dans A7
  9. Diaz R8
  10. Du Plessis JL9
  11. Gupta R10
  12. Iqbal R11
  13. Khatib R12, 13
  14. Kelishadi R14
  15. Lanas F15
  16. Liu Z16
  17. Lopezjaramillo P17, 18
  18. Nair S19
  19. Poirier P20
  20. Rahman O21
  21. Rosengren A22
  22. Swidan H23
  23. Tse LA16
  24. Wei L24
  25. Wielgosz A25
  26. Yeates K26
  27. Yusoff K27, 28
  28. Zatonski T29
  29. Burnett R30
  30. Yusuf S2
  31. Brauer M31
Show Affiliations
Authors Affiliations
  1. 1. College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, United States
  2. 2. Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
  3. 3. Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
  4. 4. Department of Medicine, Universidade de Santo Amaro, Hospital Alemao Oswaldo Cruz, Sao Paulo, Brazil
  5. 5. Department of Health Management, Faculty of Health Sciences, Marmara University, Istanbul, Turkey
  6. 6. Department of Physiology, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
  7. 7. Department of Cardiac Sciences, University of Philippines, Manila, Philippines
  8. 8. Estudios Clinicos Latinoamerica (ECLA), Rosario, Santa Fe, Argentina
  9. 9. Occupational Hygiene and Health Research Initiative, North-West University, Potchefstroom, South Africa
  10. 10. Eternal Heart Care Centre and Research Institute, Jaipur, India
  11. 11. Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
  12. 12. Institute for Community and Public Health, Birzeit University, Birzeit, Palestine
  13. 13. Advocate Health Care, Chicago, IL, United States
  14. 14. Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
  15. 15. Department of Medicine, Universidad de La Frontera, Temuco, Chile
  16. 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. 17. Fundacion Oftalmologica de Santander Clinica Carlos Ardila Lulle (FOSCAL), Bucaramanga, Colombia
  18. 18. Escuela de Medicina, Universidad de Santander, Bucaramanga, Colombia
  19. 19. Health Action by People, Thiruvananthapuram, India
  20. 20. Faculty of Pharmacy, University Institute of Cardiology and Respirology of Quebec, Laval University, Quebec, QC, Canada
  21. 21. Independent University, Dhaka, Bangladesh
  22. 22. Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
  23. 23. Dubai Health Authority, Dubai, United Arab Emirates
  24. 24. National Centre for Cardiovascular Diseases, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
  25. 25. Department of Medicine, University of Ottawa, Ottawa, ON, Canada
  26. 26. Department of Medicine, Queen's University, Kingston, ON, Canada
  27. 27. Faculty of Medicine, Universiti Teknologi MARA, Selangor, Malaysia
  28. 28. UCSI University, Cheras, Kuala Lumpur, Malaysia
  29. 29. Department of Otolaryngology Head and Neck Surgery, Wroclaw Medical University, Wroclaw, Poland
  30. 30. Environmental Health Science and Research Bureau, Health Canada, Ottawa, ON, Canada
  31. 31. School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada

Source: The Lancet Planetary Health Published:2020


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). © 2020 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND 4.0 license
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