Cardiovascular disease burden from ambient air pollution in Europe reassessed using novel hazard ratio functions

Jos Lelieveld, Klaus Klingmüller, Andrea Pozzer, Ulrich Pöschl, Mohammed Fnais, Andreas Daiber, Thomas Münzel, Jos Lelieveld, Klaus Klingmüller, Andrea Pozzer, Ulrich Pöschl, Mohammed Fnais, Andreas Daiber, Thomas Münzel

Abstract

Aims: Ambient air pollution is a major health risk, leading to respiratory and cardiovascular mortality. A recent Global Exposure Mortality Model, based on an unmatched number of cohort studies in many countries, provides new hazard ratio functions, calling for re-evaluation of the disease burden. Accordingly, we estimated excess cardiovascular mortality attributed to air pollution in Europe.

Methods and results: The new hazard ratio functions have been combined with ambient air pollution exposure data to estimate the impacts in Europe and the 28 countries of the European Union (EU-28). The annual excess mortality rate from ambient air pollution in Europe is 790 000 [95% confidence interval (95% CI) 645 000-934 000], and 659 000 (95% CI 537 000-775 000) in the EU-28. Between 40% and 80% are due to cardiovascular events, which dominate health outcomes. The upper limit includes events attributed to other non-communicable diseases, which are currently not specified. These estimates exceed recent analyses, such as the Global Burden of Disease for 2015, by more than a factor of two. We estimate that air pollution reduces the mean life expectancy in Europe by about 2.2 years with an annual, attributable per capita mortality rate in Europe of 133/100 000 per year.

Conclusion: We provide new data based on novel hazard ratio functions suggesting that the health impacts attributable to ambient air pollution in Europe are substantially higher than previously assumed, though subject to considerable uncertainty. Our results imply that replacing fossil fuels by clean, renewable energy sources could substantially reduce the loss of life expectancy from air pollution.

Keywords: Air pollution; Cardiovascular risk; Excess mortality rate; Fine particulate matter; Health promotion intervention; Loss of life expectancy.

© The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology.

Figures

Figure 1
Figure 1
Hazard ratios as a function of annual mean PM2.5, referring to cerebrovascular disease (A) and ischaemic heart disease (B) (after ref.13). Solid lines show the range for which epidemiological data are available, and the dashed ones extrapolate to higher concentrations. For Global Burden of Disease 2015, the extrapolation was based on smoking studies. Shaded areas show 95% confidence intervals. CEV, cerebrovascular disease; GBD, Global Burden of Disease; GEMM, Global Exposure Mortality Model; IHD, ischaemic heart disease; PM2.5, fine particulate matter with a diameter below 2.5 µm.
Figure 2
Figure 2
Regional distribution of estimated annual excess mortality rates from cardiovascular diseases (CVD = IHD + CEV) attributed to air pollution. These rates are lower limits as other non-communicable diseases are not included.
Figure 3
Figure 3
Estimated annual excess mortality rates attributed to air pollution in the EU-28 for lower respiratory tract infections, chronic obstructive pulmonary disease, lung cancer, cerebrovascular disease, ischaemic heart disease, and other non-communicable diseases. Bars compare results from the Global Burden of Disease (2015) and the new GEMM. CEV, cerebrovascular disease; COPD, chronic obstructive pulmonary disease; EU-28, 28 countries of the European Union; GBD, Global Burden of Disease; GEMM, Global Exposure Mortality Model; IHD, ischaemic heart disease; LC, lung cancer; LRI, lower respiratory tract infections; NCD, non-communicable diseases.
Figure 4
Figure 4
Estimated excess mortality attributed to air pollution in Europe, and the contributing disease categories. At least 48% are due to cardiovascular disease (ischaemic heart disease and stroke). A fraction of other non-communicable diseases should also be counted to cardiovascular diseases related mortality, with an upper limit of 32%. COPD, chronic obstructive pulmonary disease.
Figure 5
Figure 5
Ratio between attributable excess mortalities related to cardiovascular diseases and to respiratory diseases (including lung cancer) for different countries. The calculated ratios are lower limits as other non-communicable diseases are not included. CVD, cardiovascular diseases; RD, respiratory diseases.

References

    1. World Health Organization. Global Health Observatory (18 October 2018).
    1. European Heart Network. European Cardiovascular Disease Statistics 2017. Brussels, Belgium: EHN; 2017.
    1. Landrigan PJ, Fuller R, Acosta NJR, Adeyi O, Arnold R, Basu N, Baldé AB, Bertollini R, Bose-O’Reilly S, Boufford JI, Breysse PN, Chiles T, Mahidol C, Coll-Seck AM, Cropper ML, Fobil J, Fuster V, Greenstone M, Haines A, Hanrahan D, Hunter D, Khare M, Krupnick A, Lanphear B, Lohani B, Martin K, Mathiasen KV, McTeer MA, Murray CJL, Ndahimananjara JD, Perera F, Potočnik J, Preker AS, Ramesh J, Rockström J, Salinas C, Samson LD, Sandilya K, Sly PD, Smith KR, Steiner A, Stewart RB, Suk WA, van Schayck OCP, Yadama GN, Yumkella K, Zhong M.. The Lancet Commission on pollution and health. Lancet 2018;391:464–512.
    1. Brook RD, Rajagopalan S, Pope CA III, Brook JR, Bhatnagar A, Diez-Roux AV, Holguin F, Hong Y, Luepker RV, Mittleman MA, Peters A, Siscovick D, Smith SC Jr, Whitsel L, Kaufman JD; American Heart Association Council on Epidemiology and Prevention, Council on the Kidney in Cardiovascular Disease, and Council on Nutrition, Physical Activity and Metabolism. Particulate matter air pollution and cardiovascular disease: an update to the scientific statement from the American Heart Association. Circulation 2010;121:2331–2378.
    1. Münzel T, Sørensen M, Gori T, Schmidt FP, Rao X, Brook FR, Chen LC, Brook RD, Rajagopalan S.. Environmental stressors and cardio-metabolic disease: part II-mechanistic insights. Eur Heart J 2017;38:557–564.
    1. Lelieveld J, Evans JS, Fnais M, Giannadaki D, Pozzer A.. The contribution of outdoor air pollution sources to premature mortality on a global scale. Nature 2015;525:367–371.
    1. Lelieveld J, Haines A, Pozzer A.. Age-dependent health risk from ambient air pollution: a modelling and data analysis of childhood mortality in middle-income and low-income countries. Lancet Planet Health 2018;2:e292–e300.
    1. Cohen AJ, Brauer M, Burnett R, Anderson HR, Frostad J, Estep K, Balakrishnan K, Brunekreef B, Dandona L, Dandona R, Feigin V, Freedman G, Hubbell B, Jobling A, Kan H, Knibbs L, Liu Y, Martin R, Morawska L, Pope CA 3rd, Shin H, Straif K, Shaddick G, Thomas M, van Dingenen R, van Donkelaar A, Vos T, Murray CJL, Forouzanfar MH.. Estimates and 25-year trends of the global burden of disease attributable to ambient air pollution: an analysis of data from the Global Burden of Diseases Study 2015. Lancet 2017;389:1907–1918.
    1. Pope CA 3rd, Burnett RT, Turner MC, Cohen A, Krewski D, Jerrett M, Gapstur SM, Thun MJ.. Lung cancer and cardiovascular disease mortality associated with ambient air pollution and cigarette smoke: shape of the exposure–response relationships. Environ Health Perspect 2011;119:1616–1621.
    1. Hoek G, Krishnan RM, Beelen R, Peters A, Ostro B, Brunekreef B, Kaufman JD.. Long-term air pollution exposure and cardio-respiratory mortality: a review. Environ Health 2013;12:1–15.
    1. Münzel T, Gori T, Al-Kindi S, Deanfield J, Lelieveld J, Daiber A, Rajagopalan S.. Effects of gaseous and solid constituents of air pollution on endothelial function. Eur Heart J 2018;39:3543–3550.
    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, Künzli N, Mills N, Pekkanen J, Peters A, Piepoli MF, Rajagopalan S, Storey RF; 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.
    1. Burnett R, Chen H, Szyszkowicz M, Fann N, Hubbell B, Pope CA, Apte JS, Brauer M, Cohen A, Weichenthal S, Coggins J, Di Q, Brunekreef B, Frostad J, Lim SS, Kan H, Walker KD, Thurston GD, Hayes RB, Lim CC, Turner MC, Jerrett M, Krewski D, Gapstur SM, Diver WR, Ostro B, Goldberg D, Crouse DL, Martin RV, Peters P, Pinault L, Tjepkema M, van Donkelaar A, Villeneuve PJ, Miller AB, Yin P, Zhou M, Wang L, Janssen NAH, Marra M, Atkinson RW, Tsang H, Quoc Thach T, Cannon JB, Allen RT, Hart JE, Laden F, Cesaroni G, Forastiere F, Weinmayr G, Jaensch A, Nagel G, Concin H, Spadaro JV.. Global estimates of mortality associated with long-term exposure to outdoor fine particulate matter. Proc Natl Acad Sci USA 2018;115:9592–9597.
    1. GBD 2015 Risk Factors Collaborators. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016;388:1659–1724.
    1. Pozzer A, de Meij A, Pringle KJ, Tost H, Doering UM, van Aardenne J, Lelieveld J.. Distributions and regional budgets of aerosols and their precursors simulated with the EMAC chemistry-climate model. Atmos Chem Phys 2012;12:961–987.
    1. Jöckel P, Tost H, Pozzer A, Kunze M, Kirner O, Brenninkmeijer CAM, Brinkop S, Cai DS, Dyroff C, Eckstein J, Frank F, Garny H, Gottschaldt K-D, Graf P, Grewe V, Kerkweg A, Kern B, Matthes S, Mertens M, Meul S, Neumaier M, Nützel M, Oberländer-Hayn S, Ruhnke R, Runde T, Sander R, Scharffe D, Zahn A.. Earth System Chemistry integrated Modelling (ESCiMo) with the Modular Earth Submodel System (MESSy) version 2.51. Geosci Model Dev 2016;9:1153–1200.
    1. World Health Organization. Report on the Global Tobacco Epidemic, 2017. Geneva, Switzerland: WHO; 2017.
    1. European Environment Agency. Air Quality in Europe 2017. Copenhagen, Denmark: EEA; 2017.
    1. European Court of Auditors 2018. (27 October 2018).
    1. Pope CA, Muhlestein JB, Anderson JL, Cannon JB, Hales NM, Meredith KG, Le V, Horne BD.. Short-term exposure to fine particulate matter air pollution is preferentially associated with the risk of ST-segment elevation acute coronary events. J Am Heart Assoc 2015;4:e002506.
    1. Rajagopalan S, Al-Kindi SG, Brook RD.. Air pollution and cardiovascular disease: JACC state-of-the-art review. J Am Coll Cardiol 2018;72:2054–2070.
    1. Di Q, Wang Y, Zanobetti A, Wang Y, Koutrakis P, Choirat C, Dominici F, Schwartz JD.. Air pollution and mortality in the medicare population. N Engl J Med 2017;376:2513–2522.
    1. Wang B, Xu D, Jing Z, Liu D, Yan S, Wang Y.. Effect of long-term exposure to air pollution on type 2 diabetes mellitus risk: a systemic review and meta-analysis of cohort studies. Eur J Endocrinol 2014;171:R173–R182.
    1. Cesaroni G, Forastiere F, Stafoggia M, Andersen ZJ, Badaloni C, Beelen R, Caracciolo B, de Faire U, Erbel R, Eriksen KT, Fratiglioni L, Galassi C, Hampel R, Heier M, Hennig F, Hilding A, Hoffmann B, Houthuijs D, Jockel KH, Korek M, Lanki T, Leander K, Magnusson PK, Migliore E, Ostenson CG, Overvad K, Pedersen NL, J JP, Penell J, Pershagen G, Pyko A, Raaschou-Nielsen O, Ranzi A, Ricceri F, Sacerdote C, Salomaa V, Swart W, Turunen AW, Vineis P, Weinmayr G, Wolf K, de Hoogh K, Hoek G, Brunekreef B, Peters A.. Long term exposure to ambient air pollution and incidence of acute coronary events: prospective cohort study and meta-analysis in 11 European cohorts from the ESCAPE Project. BMJ 2014;348:f7412..
    1. Eze IC, Hemkens LG, Bucher HC, Hoffmann B, Schindler C, Kunzli N, Schikowski T, Probst-Hensch NM.. Association between ambient air pollution and diabetes mellitus in Europe and North America: systematic review and meta-analysis. Environ Health Perspect 2015;123:381–389.
    1. Liang R, Zhang B, Zhao X, Ruan Y, Lian H, Fan Z.. Effect of exposure to PM2.5 on blood pressure: a systematic review and meta-analysis. J Hypertens 2014;32:2130–2141.
    1. Chen H, Burnett RT, Kwong JC, Villeneuve PJ, Goldberg MS, Brook RD, van Donkelaar A, Jerrett M, Martin RV, Kopp A, Brook JR, Copes R.. Spatial association between ambient fine particulate matter and incident hypertension. Circulation 2014;129:562–569.
    1. Hink U, Li H, Mollnau H, Oelze M, Matheis E, Hartmann M, Skatchkov M, Thaiss F, Stahl RA, Warnholtz A, Meinertz T, Griendling K, Harrison DG, Forstermann U, Munzel T.. Mechanisms underlying endothelial dysfunction in diabetes mellitus. Circ Res 2001;88:E14–E22.
    1. Mollnau H, Wendt M, Szocs K, Lassegue B, Schulz E, Oelze M, Li H, Bodenschatz M, August M, Kleschyov AL, Tsilimingas N, Walter U, Forstermann U, Meinertz T, Griendling K, Munzel T.. Effects of angiotensin II infusion on the expression and function of NAD(P)H oxidase and components of nitric oxide/cGMP signaling. Circ Res 2002;90:E58–E65.
    1. Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, Cooney MT, Corra U, Cosyns B, Deaton C, Graham I, Hall MS, Hobbs FDR, Lochen ML, Lollgen H, Marques-Vidal P, Perk J, Prescott E, Redon J, Richter DJ, Sattar N, Smulders Y, Tiberi M, van der Worp HB, van Dis I, Verschuren WMM, Binno S; ESC Scientific Document Group. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: the Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts)Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J 2016;37:2315–2381.

Source: PubMed

Sponsorer og samarbeidspartnere

Medisinsk tilstand

Legemiddelintervensjoner

3
Abonnere