Long-term exposure to low-level ambient air pollution and incidence of stroke and coronary heart disease: a pooled analysis of six European cohorts within the ELAPSE project

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  • Kathrin Wolf, Institute of Epidemiology, Helmholtz Zentrum München-German Research Centre for Environmental Health, D-85764 Neuherberg, Germany., Tyskland
  • Barbara Hoffmann, Institute for Occupational, Social, and Environmental Medicine, Centre for Health and Society, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Tyskland
  • Zorana J Andersen, Section of Environmental Health, Department of Public Health, University of Copenhagen, Denmark, Danmark
  • Richard W Atkinson, Population Health Research Institute, St George's, University of London, Storbritannien
  • Mariska Bauwelinck, Interface Demography – Department of Sociology, Vrije Universiteit Brussel, Pleinlaan 2, 1050 Brussels, Belgium, Belgien
  • Tom Bellander, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Center for Occupational and Environmental Medicine, Region Stockholm, Sverige
  • Jørgen Brandt
  • Bert Brunekreef, Institute for Risk Assessment Sciences, Utrecht University, Utrecht, Netherlands., Holland
  • Giulia Cesaroni, Epidemiology Department, Lazio Regional Health Service, Rome, Italien
  • Jie Chen, Institute for Risk Assessment Sciences, Utrecht University, Utrecht, Netherlands., Holland
  • Ulf de Faire, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sverige
  • Kees de Hoogh, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland., Schweiz
  • Daniela Fecht, School of Public Health, Faculty of Medicine, Imperial College London, London, W6 8RP, UK., Storbritannien
  • Francesco Forastiere, Department of Epidemiology-Lazio Regional Health Service, ASL Roma 1, Rome, School of Public Health, Faculty of Medicine, Imperial College London, London, W6 8RP, UK., Italien
  • John Gulliver, School of Public Health, Faculty of Medicine, Imperial College London, London, W6 8RP, UK., Centre for Environmental Health and Sustainability & School of Geography, Geology and the Environment, University of Leicester, Storbritannien
  • Ole Hertel
  • Ulla Arthur Hvidtfeldt, Danish Cancer Society Research Center, Danish Cancer Society, Copenhagen, Denmark., Danmark
  • Nicole A H Janssen, National Institute for Public Health and the Environment (RIVM), Bilthoven, Holland
  • Jeanette T Jørgensen, Section of Environmental Health, Department of Public Health, University of Copenhagen, Denmark, Danmark
  • Klea Katsouyanni, National and Kapodistrian University of Athens, School of Public Health, Faculty of Medicine, Imperial College London, London, W6 8RP, UK., Grækenland
  • Matthias Ketzel
  • Jochem O Klompmaker, National Institute for Public Health and the Environment (RIVM), Bilthoven, Harvard T.H. Chan School of Public Health, Boston, MA, Holland
  • Anton Lager, Department of Global Public Health, Karolinska Institutet, Stockholm, Sverige
  • Shuo Liu, Section of Environmental Health, Department of Public Health, University of Copenhagen, Denmark, Danmark
  • Conor J MacDonald, Inserm, Centre de Recherche en Epidémiologie et Santé des Populations (CESP, U1018), Université Paris-Saclay, Université Paris-Sud, UVSQ, Institut Gustave Roussy, Villejuif, France., Frankrig
  • Patrik K E Magnusson, Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden., Sverige
  • Amar J Mehta, Section of Epidemiology, Department of Public Health, The University of Copenhagen, Copenhagen, Denmark, Danmark
  • Gabriele Nagel, Ulm Univ, Ulm University, Tyskland
  • Bente Oftedal, Norwegian Institute of Public Health, Norge
  • Nancy L Pedersen, Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden., Sverige
  • Göran Pershagen, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Center for Occupational and Environmental Medicine, Region Stockholm, Sverige
  • Ole Raaschou-Nielsen
  • Matteo Renzi, Epidemiology Department, Lazio Regional Health Service, Rome, Italien
  • Debora Rizzuto, Aging Research Center, Department of Neurobiology, Care Sciences, and Society, Karolinska Institutet and Stockholm University, The Stockholm Gerontology Research Center, Sverige
  • Sophia Rodopoulou, National and Kapodistrian University of Athens, Grækenland
  • Evangelia Samoli, National and Kapodistrian University of Athens, Grækenland
  • Yvonne T van der Schouw, Julius Center for Health Sciences and Primary Care, Cardiovascular Epidemiology, University Medical Center Utrecht, Utrecht, Netherlands., Holland
  • Sara Schramm, Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, University of Duisburg-Essen, 45147, Essen, Germany., Tyskland
  • Per Schwarze, Norwegian Institute of Public Health, Norge
  • Torben Sigsgaard
  • Mette Sørensen, Danish Cancer Society Research Center, Danish Cancer Society, Copenhagen, Denmark., Roskilde University, Danmark
  • Massimo Stafoggia, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Department of Epidemiology-Lazio Regional Health Service, ASL Roma 1, Rome, Sverige
  • Maciek Strak, Institute for Risk Assessment Sciences, Utrecht University, Utrecht, Netherlands., National Institute for Public Health and the Environment, Bilthoven, Netherlands., Holland
  • Anne Tjønneland, Danish Cancer Society Research Center, Danish Cancer Society, Copenhagen, Denmark., Danmark
  • W M Monique Verschuren, National Institute for Public Health and the Environment, Bilthoven, Netherlands., Julius Center for Health Sciences and Primary Care, Cardiovascular Epidemiology, University Medical Center Utrecht, Utrecht, Netherlands., Holland
  • Danielle Vienneau, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland., Schweiz
  • Gudrun Weinmayr, Ulm Univ, Ulm University, Tyskland
  • Gerard Hoek, Institute for Risk Assessment Sciences, Utrecht University, Utrecht, Netherlands., Holland
  • Annette Peters, Institute of Epidemiology I, Helmholtz Zentrum München, German Research Centre of Environmental Health, Neuherberg, Germany., Ludwig-Maximilians-Universität München, Tyskland
  • Petter L S Ljungman, Department of Cardiology, Danderyd University Hospital, Stockholm, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sverige

BACKGROUND: Long-term exposure to outdoor air pollution increases the risk of cardiovascular disease, but evidence is unclear on the health effects of exposure to pollutant concentrations lower than current EU and US standards and WHO guideline limits. Within the multicentre study Effects of Low-Level Air Pollution: A Study in Europe (ELAPSE), we investigated the associations of long-term exposures to fine particulate matter (PM2·5), nitrogen dioxide (NO2), black carbon, and warm-season ozone (O3) with the incidence of stroke and acute coronary heart disease.

METHODS: We did a pooled analysis of individual data from six population-based cohort studies within ELAPSE, from Sweden, Denmark, the Netherlands, and Germany (recruited 1992-2004), and harmonised individual and area-level variables between cohorts. Participants (all adults) were followed up until migration from the study area, death, or incident stroke or coronary heart disease, or end of follow-up (2011-15). Mean 2010 air pollution concentrations from centrally developed European-wide land use regression models were assigned to participants' baseline residential addresses. We used Cox proportional hazards models with increasing levels of covariate adjustment to investigate the association of air pollution exposure with incidence of stroke and coronary heart disease. We assessed the shape of the concentration-response function and did subset analyses of participants living at pollutant concentrations lower than predefined values.

FINDINGS: From the pooled ELAPSE cohorts, data on 137 148 participants were analysed in our fully adjusted model. During a median follow-up of 17·2 years (IQR 13·8-19·5), we observed 6950 incident events of stroke and 10 071 incident events of coronary heart disease. Incidence of stroke was associated with PM2·5 (hazard ratio 1·10 [95% CI 1·01-1·21] per 5 μg/m3 increase), NO2 (1·08 [1·04-1·12] per 10 μg/m3 increase), and black carbon (1·06 [1·02-1·10] per 0·5 10-5/m increase), whereas coronary heart disease incidence was only associated with NO2 (1·04 [1·01-1·07]). Warm-season O3 was not associated with an increase in either outcome. Concentration-response curves indicated no evidence of a threshold below which air pollutant concentrations are not harmful for cardiovascular health. Effect estimates for PM2·5 and NO2 remained elevated even when restricting analyses to participants exposed to pollutant concentrations lower than the EU limit values of 25 μg/m3 for PM2·5 and 40 μg/m3 for NO2.

INTERPRETATION: Long-term air pollution exposure was associated with incidence of stroke and coronary heart disease, even at pollutant concentrations lower than current limit values.

FUNDING: Health Effects Institute.

OriginalsprogEngelsk
TidsskriftThe Lancet. Planetary Health
Vol/bind5
Nummer9
Sider (fra-til)e620-e632
Antal sider13
ISSN2542-5196
DOI
StatusUdgivet - sep. 2021

Bibliografisk note

Copyright © 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.

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