Taking a Stand Against Air PollutionThe Impact on Cardiovascular Disease

Although the attention of the world and the global health community specifically is deservedly focused on the COVID-19
Further, we aim to generate awareness about the impact of air pollution on cardiovascular disease as a means towards reaching the World Heart Federation Goal of a 25% reduction in premature cardiovascular mortality by 2025.
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## Air pollution and cvd evidence
Air pollution is a complex and dynamic mixture of numerous compounds in gaseous and particle form, originating from diverse sources, subject to atmospheric transformation and varying over space and time. Three common air pollutants, particulate matter (PM), ozone and nitrogen dioxide (NO 2 ), are the focus of most monitoring programs, communication efforts (3), health impact assessments, and regulatory efforts.
Evidence for impacts on cardiovascular disease is most consistent for PM, which is responsible for the vast majority of the disease burden via its impacts on ischemic heart disease (4-6), and stroke (7), as well as lung cancer, COPD, lower respiratory infections, Type 2 diabetes, pregnancy outcomes and related infant mortality [bib_ref] Air Pollution and Noncommunicable Diseases: A Review by the Forum of International..., Schraufnagel [/bib_ref].
Time series studies conducted in hundreds of urban areas globally indicate a consistent association between shortterm variability in PM and cardiovascular disease deaths [bib_ref] Ambient Particulate Air Pollution and Daily Mortality in 652 Cities, Liu [/bib_ref] , while large cohort studies from both high and lower income settings demonstrate increased cardiovascular disease incidence and mortality in association with PM levels [bib_ref] Modifiable risk factors, cardiovascular disease, and mortality in 155 722 individuals from..., Yusuf [/bib_ref]. Further, PM air pollution has been associated with progression of atherosclerosis [bib_ref] Association between air pollution and coronary artery calcification within six metropolitan areas..., Kaufman [/bib_ref]. Ozone is mainly associated with exacerbation of respiratory disease, with COPD incidence and mortality and with metabolic effects.
NO 2 is often used as an indicator of traffic-related air pollution. Chronic exposure to NO 2 is associated with incident childhood asthma while short-term variability is associated with exacerbation of asthma and increased daily mortality counts.
A Scientific Statement from the American Heart Association provides a detailed description of the pathophysiologic mechanisms through which PM triggers The WHF, ACC, AHA, and ESC are united in our commitment to research, advocacy, and education to reduce the impacts of air pollution on cardiovascular health. Specifically, we will advocate for further research on cardiovascular disease and air quality, disseminating findings to our memberships and via other activities, such as World Heart Day. We will also work to educate and raise awareness among health care providers on the importance of reducing air pollution and the cardiovascular benefits of air pollution mitigation. We will work with senior decision-makers in national, regional and global governmental institutions to make air pollution related heart disease a priority and to identify interventions to reduce air pollution and its impact on NCDs. Finally, we will work with our members to increase the development and use of clinical guidelines on air pollution and cardiovascular disease to ensure clinicians are educated on the topic. In addition, we will strive to provide presentations on the links between air pollution and cardio- [bib_ref] The air quality index: A tool for managing patients with cardiopulmonary disease, Riles [/bib_ref]. Detailed air pollution maps that provide information on long-term exposures and their impacts at neighborhood scales can also be used to target CVD treatment [bib_ref] Factors influencing health care and service providers' and their respective 'at risk'..., Radisic [/bib_ref] , exposure reduction, and ef-
[fig] FIGURE 1: Ranking of Air Pollution Relative to Other Leading Risk Factors for Global Mortality Mortality Risk Factors, Both sexes, all ages, 2019. Institute for Health Metrics and Evaluation. (Adapted from Institute for Health Metrics and Evaluation [/fig]
[fig] Figure 2: summarizes the likely dominant pathways including activation of oxidative stress/inflammation and autonomic imbalance, as well as translocation of components of the PM mixture (ultrafine particles or specific constituents) into the systemic circulation (4). In turn, these alterations promote both subclinical cardiovascular disease (myocardial remodeling, atherosclerosis progression, systemic and pulmonary hypertension, enhanced vasoconstriction and coagulation) and thrombotic and non-thrombotic acute cardiovascular events (acute coronary syndromes, decompensated heart failure, stroke, life-threatening arrhythmias) (4,5,12). The AHA statement suggests the existing evidence is consistent with a causal relationship between PM exposure and cardiovascular morbidity and mortality. More recently, the European Society of Cardiology expert position paper updated the observational and mechanistic evidence and identified air pollution as one of several major modifiable risk factors relevant to the prevention and management of cardiovascular disease (5). The ESC paper identified a need for additional research regarding the role of air pollution in relation to hypertension and incident heart failure. This position paper also highlighted the role of health professionals, including cardiologists, in counselling their patients on the risks of air pollution while also supporting [/fig]