Comment

Air pollution and cardiovascular disease onset: hours, days,

particles and component pollutants, such as particulate operationally, questions remain on how policy makers
matter (PM) or total suspended particles, investigators should prioritise public health efforts and which
relied on counting the number of excess deaths before sensitive groups should be targeted for intervention
and after episodes of smog to draw inferences. The most efforts. In The Lancet Public Health, Andrew Fu Wah
well known historical event is the great smog of London Ho and colleagues9 report their findings on air quality
in 1952, during which a combination of cold weather, and the risk of out-of-hospital cardiac arrest (OHCA)
low-quality household coal, and factory emissions in Singapore using a time series analysis. Ho and
resulted in thousands of excess deaths attributable to colleagues analysed 18 131 OHCA cases (from hospital
severe air pollution. This event was widely considered a and ambulance service records between 2010 and 2018)
catalyst for the field of environmental epidemiology and with a median age of 65 years (IQR 56–80), of which
led to several time series analyses on air pollution-related 6484 (35·8%) were in females and 11 647 (64·2%)
morbidity and mortality,1 but a large prospective study were in males. They used multivariable fractional
was still needed to infer causality.2 In 1994, the Six Cities modelling of OHCA excess risk associated with exposure
Studies published data from a longitudinal study with to PM2·5, PM with a diameter of less than 10 μm (PM10),
more than a decade of follow-up showing that residents ozone (O3), carbon monoxide (CO), nitrogen dioxide
living in cities with more pollution had higher mortality (NO2), and sulphur dioxide (SO2). Ho and colleagues
rates than did residents living in cities with less pollution.3 found that increases in PM2·5 concentrations were
Increasing evidence led WHO to adopt a landmark associated with an acute increase in OHCAs in the
resolution in 2015 on air quality and health, recognising 2 days after exposure, with a decrease in risk over
air pollution as a risk factor for premature mortality, the subsequent 3 days, which the authors hypothesised
ischaemic heart disease, stroke, chronic obstructive to be due to a harvesting effect.9
pulmonary disease, asthma, and cancer. In 2021, WHO Singapore is an advanced economy with a high
updated the Air Quality Guidelines to lower the exposure human development index. Air pollution concen­
recommendation for PM with a diameter of less than tration, while heterogenous in the study, is generally
2·5 μm (PM2·5) from 10 μg/m³ to 5 μg/m³ for annual low compared with other populous places. This study
exposure, and to advise that 24-h exposure should not contributed several key pieces of evidence. First, even
exceed 15 μg/m³ on more than 3–4 days in a year.4 at low levels of air pollution exposure, increases in
Exposure to air pollution increases the risk of PM concentrations are still associated with increased
myocardial infarction, stroke, heart failure, arrhythmia, risk of OHCA. In hypothetical modelling, Ho and
and sudden death onset by approximately 1–2% per colleagues estimated that a 1 μg/m³ reduction in
10 μg/m³ increase in concentration of PM2·5, and long- PM2·5 concentrations would reduce the number of OHCA
term exposure is associated with a 5–10% increased events by 8%, and a reduction of 3 μg/m³ would reduce
risk.5,6 Because the cardiopulmonary organs are the first the number of OHCA events by 30%, indicating large
line of contact with air pollutants, particle inhalation can relative effects in the control of PM2·5 concentrations on
elicit immediate oxidative stress, followed by chronic benefits to cardiovascular health. Second, this research
inflammatory responses that reach the circulatory provided real-world evidence on the different types and
system and its vasculatures and can affect all organ locations of cardiac arrest events. PM2·5 concentrations
systems. The American Heart Association, European affected non-shockable OHCA events, and had less
Society of Cardiology, Chinese Center for Disease Control of an effect on shockable OHCA events, the cause of
and Prevention, and national academies from many which is still to be explored. Finally, the investigators
countries have recognised air pollution as a major risk found the effects of increasing PM2·5 concentrations
factor for cardiopulmonary disease.7,8 were the largest in the immediate 2 days after exposure,

www.thelancet.com/public-health Vol 7 November 2022 e890

indicating an acute manifestation of OHCA due to air Future clinical guidelines should include air pollution
pollution. screening and ways to alert patients and providers
Both exposure windows of PM2·5, before cardiovascular ahead of a pollution event, thereby preventing medical
disease onset and time to onset after exposure, are emergencies.
informative to clinicians and patients. A recent study10 I declare no competing interests.
found that air pollution could trigger acute coronary Copyright © 2022 The Author(s). Published by Elsevier Ltd. This is an Open
Access article under the CC BY 4.0 license.
syndrome within 1 h of exposure, resulting in a heart
attack or unstable angina. John S Ji
johnji@tsinghua.edu.cn
Unanswered questions still remain. First, most air
Vanke School of Public Health, Tsinghua University, Beijing 100084, China
pollution is reported as daily or annual averages, which
1 Bell ML, Davis DL. Reassessment of the lethal London fog of 1952: novel
can mask information on amplitudes of exposure level. indicators of acute and chronic consequences of acute exposure to air
pollution. Environ Health Perspect 2001; 109 (suppl 3): 389–94.
Is the peak exposure or the cumulative average exposure
2 Dab W, Ségala C, Dor F, et al. Air pollution and health: correlation or
most predictive of health outcomes? Particularly in causality? The case of the relationship between exposure to particles and
cardiopulmonary mortality. J Air Waste Manag Assoc 2001; 51: 220–35.
the case of cardiovascular events, is the strongest risk 3 Dockery DW, Pope CA 3rd, Xu X, et al. An association between air pollution
within the first hour of exposure, over the course of and mortality in six U.S. cities. N Engl J Med 1993; 329: 1753–59.
4 WHO. WHO global air quality guidelines: particulate matter (PM2·5 and PM10),
the day, or within a few days? Second, how do single ozone, nitrogen dioxide, sulfur dioxide and carbon monoxide. World Health
pollutants or mixtures of pollutants affect outcomes? Organization, 2021. https://apps.who.int/iris/handle/10665/345329
(assessed Sept 23, 2022).
Air pollutant mixtures vary a great deal globally due to 5 Bourdel T, Bind M-A, Béjot Y, Morel O, Argacha J-F. Cardiovascular effects of
different emission sources, and particulate pollutants air pollution. Arch Cardiovasc Dis 2017; 110: 634–42.
6 Brook RD, Franklin B, Cascio W, et al. Air pollution and cardiovascular
co-occur with gaseous pollutants, which might explain disease: a statement for healthcare professionals from the Expert Panel on
Population and Prevention Science of the American Heart Association.
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temporal variability in different microenvironments American Heart Association, and the European Society of Cardiology.
Circulation 2021; 143: e800–04.
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benefit from environmental surveillance data on 9 Ho AFW, Ho JSY, Tan BY-Q, et al. Air quality and the risk of out-of-hospital
cardiac arrest in Singapore (PAROS): a time series analysis.
duration of exposure, severity of exposure, timing of Lancet Public Health 2022; 7: e932–41.
exposure, coexposures, and location of exposure to 10 Chen R, Jiang Y, Hu J, et al. Hourly air pollutants and acute coronary
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e891 www.thelancet.com/public-health Vol 7 November 2022