European Heart Journal (2021) 42, 773–775 EDITORIAL

doi:10.1093/eurheartj/ehaa1020

Air pollution triggers inflammation and

cardiovascular events: now is the time to act
Baris Gencer and Franc¸ois Mach*
Cardiology Division, Geneva University Hospitals, Switzerland

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.
This editorial refers to ‘A leucopoietic–arterial axis according to summary socio-economic scores) has the same risk of
under- lying the link between ambient air pollution and
.. coronary heart disease as the poorest person living in the most
.
cardiovas- cular disease in humans’†, by S. Abohashem et advantaged neighbourhood.3 The model of social determinants of
.. health helps to illustrate the influence of multidimensional determi-
al., on page 761. .
nants of socio-economic status and environment on the practice of
.. preventive and clinical CV medicine. In Figure 1, the first circle includ-
In this issue of the European Heart Journal, Shady Abohashem and col- .
leagues elegantly demonstrate for the first time in humans how air ing small individual factors is embedded within many other mutual
pollution increases leucopoiesis and atherosclerotic inflammation, and is .. circles affecting individual outcomes directly or indirectly. Doctors
directly and independently associated with major adverse cardiovascular .. should, however, be more attentive to interpersonal influences (se-
events (MACE).1 In their study, 503 individuals with- out previous
. cond circle), such as social connections and networks. In this regard,
cardiovascular (CV) disease underwent [18F]flurodeox- uglucose positron .. exercising with a friend can increase motivation. The third circle eng-
.
emission tomography/computed tomography to quantify leucopoietic lobes local neighbourhood and community environment. Living close
tissue activity and arterial inflammation, where- by their exposure to air .. to green parks can be beneficial to the development of children and
.
pollution was defined based on the annual exposure of particulate early integration of physical activity in daily life. On the other hand,
matter with a diameter <2.5 mm (PM2.5) in the zone of residence (and not
.. areas where noise or air pollution are prominent, such as buildings
.
at the individual level). Significant asso- ciations were found between higher close to airports, but also in the case of daily commutes to work in
.. polluted zones, impact negatively on our health.2 The disparity in
levels of PM2.5 and increased in- flammatory leucopoietic (P = 0.004) and .
atherosclerotic (P = 0.036) activity, even after adjustment for traditional available services is also observable according to neighbourhood
CV risk factors. In add- ition to baseline association, 40 patients presented .. wealth and racial segregation.4 Residents in low-income and minority
MACE over a me- dian follow-up period of 4.1 years. Here too, higher .. neighbourhoods tend to have worse access to healthy food options,
levels of PM2.5 predicted the incident case of MACE [adjusted
. with a higher prevalence of obesity and other CV risk factors.5
standardized hazard ratio (HR) 1.40, 95% confidence interval (CI) 1.14– .. Fourth, we must critically reconsider stakeholders (e.g. media, educa-
.
1.74, P = 0.002, per 1 SD increase in PM 2.5] even after further adjustment tion system, and employment) that can affect our health. Finally, we
for socio- determinant factors. Finally, a mediation analysis estimated that .. are reminded of the importance of macrosocial values, since the pol-
.
leu- copoiesis and atherosclerotic inflammation explained 30% of the itical and policy streams can have a very strong impact on health sys-
increased risk of MACE due to air pollution after adjustment for age and .. tem performance and other issues related to the environment,
.
sex. climate, and public health.2
As treating physicians, we recommend adopting new lifestyle hab- .. One of the key technical aspects of environmental research is the
.
its to decrease CV disease, such as physical activity and healthy eating, but extent of granularity in the data and how these can be collected.
we must acknowledge that macro-level determinants also need to be .. There are two types of data: derived data, issued directly from indi-
considered, such as neighbourhood and air pollution.2 As shown in the .. vidual measurements often collected via self-report; and integral
Atherosclerosis Risk in Communities (ARIC) study, the richest person . data, collected from geographic information systems or governmen-
living in the most disadvantaged area (defined .. tal agencies. An important methodological challenge is to clarify
.
whether the observed associations are causal, in other words

The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.
†
doi:10.1093/eurheartj/ehaa982.
* Corresponding author. Cardiology Division, Department of Specialties in Medicine, Geneva University Hospitals, Rue Gabrielle-Perret Gentil 4, 1211 Geneva 14, Switzerland. Tel: 41 22
372 72
þ 34, Fax: 41 22 372 72 þ 45, Email: [email protected]
Published on behalf of the European Society of Cardiology. All rights reserved. VC The Author(s) 2021 For permissions, please email: [email protected].
774 Editorial

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Figure 1 A social–ecological model for the social and environmental determinants of health.

. government restriction and mandates; (ii) media and education; (iii)

attributable to contextual effects (e.g. air pollution), or whether they are
confounded by compositional effects due to individual differences (e.g. .. labelling and information; (iv) economic incentives; (v) schools; (vi)
.
income and physical inactivity). A potential source of bias in this type of workplaces; and (vii) community setting.12 Most of the recommenda-
assumption is ecological inference fallacy.6 Indeed, an obser- vation made .. tions are based on expert consensus rather than randomized con-
.
for an individual in, for example, a polluted area cannot be assumed to be trolled trials, as generally observed for individual-level interventions.
true for all the individuals of that area. Multilevel modelling enables the .. Multiple challenging factors need still to be considered. How can we
analysis of the exposure at more than two lev- els to disentangle .. integrate household mobility or neighbourhood transience over
environmental from individual factors.7 The poten- tial pathways .
time? What is the definition of neighbourhood area? What is the la-
explaining how neighbourhood can affect health are the physical (e.g. .. tency of a given effect on health outcomes? Could overall weak
playground, green space for walkability, traffic, and air pollution), service
.
effects mask strong effects for some subgroups?
(grocery or supermarket selling healthy foods vs. fast-food or restaurant .. In conclusion, where we live and the characteristics of that place
.
offering junk foods) and social environment (community, safety, and influence health and health behaviours beyond traditional individual-
crime) factors.2 In the moving to opportunity (MTO) social experiment .. level risk factors. The article by Shady Abohashem and colleagues
programme that randomly assigned a housing voucher to 4248 families .. underscores the detrimental impact of air pollution on our health
with youths in high-poverty areas of five US cities that could be used to .
and the urgent need for global-level strategies to reduce and prevent
move to lower poverty neigh- bourhoods, moving reduced the rate of .. associated CV disease.2
obesity (42.2% vs. 46.8%, P = 0.04).8 A methodological point to consider .
is the concept of endoge- neity, as individual choice of a neighbourhood .
.
is also attributable to willingness or not to have a healthy lifestyle, and . Acknowledgements
therefore the associ- ation might be threatened due to intrinsic .. B.G. acknowledges the theoretical support provided by the course of
preferences or reverse causation.9 Providing access to healthier habits .
Social, Behavioral, and Structural Determinants of Health offered at
does not necessarily change the preferences of subjects, especially if habits .. the Harvard School of Public Health (Professor Monica Wang).
are related to socio-economic status. One of the solutions can be to plan
.. Special gratitude is expressed to Aliki Buhayer (Prism Scientific Sa`rl)
in-store marketing interventions based on the principles of the ‘four Ps’, .
for medical writing support.
..
price,
promotion, product,10and placement, to influence the purchase of References
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