key: cord-0923408-xfxbqfp7 authors: Brauer, Michael; Casadei, Barbara; Harrington, Robert A.; Kovacs, Richard; Sliwa, Karen title: Taking a Stand Against Air Pollution—The Impact on Cardiovascular Disease: A Joint Opinion from the World Heart Federation, American College of Cardiology, American Heart Association, and the European Society of Cardiology date: 2021-01-28 journal: J Am Coll Cardiol DOI: 10.1016/j.jacc.2020.12.003 sha: bd9f6c94f0720b63cc6145b36499ac83dac41f87 doc_id: 923408 cord_uid: xfxbqfp7 Although the attention of the world and the global health community specifically is deservedly focused on the COVID-19 pandemic, other determinants of health continue to have large impacts and may also interact with COVID-19. Air pollution is one crucial example. Established evidence from other respiratory viruses and emerging evidence for COVID-19 specifically indicates that air pollution alters respiratory defense mechanisms leading to worsened infection severity. Air pollution also contributes to co-morbidities that are known to worsen outcomes amongst those infected with COVID-19, and air pollution may also enhance infection transmission due to its impact on more frequent coughing. Yet despite the massive disruption of the COVID-19 pandemic, there are reasons for optimism: broad societal lockdowns have shown us a glimpse of what a future with strong air pollution measures could yield. Thus, the urgency to combat air pollution is not diminished, but instead heightened in the context of the pandemic. 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. . 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 (8) . Time series studies conducted in hundreds of urban areas globally indicate a consistent association between shortterm variability in PM and cardiovascular disease deaths (9) , while large cohort studies from both high and lower income settings demonstrate increased cardiovascular disease incidence and mortality in association with PM levels (10) . Further, PM air pollution has been associated with progression of atherosclerosis (11) . 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 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 pre- (19) . 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 (20) , exposure reduction, and ef- Particulate matter air pollution and cardiovascular disease: An update to the scientific statement from the American Heart Association Expert position paper on air pollution and cardiovascular disease Air Pollution and Cardiovascular Disease: JACC State-of-the-Art Review Short term exposure to air pollution and stroke: Systematic review and meta-analysis Air Pollution and Noncommunicable Diseases: A Review by the Forum of International Respiratory Societies' Environmental Committee, Part 2: Air Pollution and Organ Systems Ambient Particulate Air Pollution and Daily Mortality in 652 Cities Modifiable risk factors, cardiovascular disease, and mortality in 155 722 individuals from 21 high-income, middleincome, and low-income countries (PURE): A prospective cohort study Association between air pollution and coronary artery calcification within six metropolitan areas in the USA (the Multi-Ethnic Study of Atherosclerosis and Air Pollution): A longitudinal cohort study Effects of gaseous and solid constituents of air pollution on endothelial function Examining the Shape of the Association between Low Levels of Fine Particulate Matter and Mortality across Three Cycles of the Canadian Census Health and Environment Cohort Critical review of health impacts of wildfire smoke exposure Particulate matter air pollution and national and county life expectancy loss in the USA: A spatiotemporal analysis Fine-particulate air pollution and life expectancy in the United States Using sales data to assess cooking gas adoption and the impact of India's Ujjwala programme in rural Karnataka. Nat Energy Cardiopulmonary benefits of reducing indoor particles of outdoor origin: A randomized, double-blind crossover trial of air purifiers The air quality index: A tool for managing patients with cardiopulmonary disease Factors influencing health care and service providers' and their respective 'at risk' populations' adoption of the Air Quality Health Index (AQHI): A qualitative study Developing a clinical approach to air pollution and cardiovascular health KEY WORDS air pollution, cardiovascular disease, CVD, environmental health impacts, climate