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Epidemiology. 2014 May;25(3):368-78. doi: 10.1097/EDE.0000000000000076.

Long-term exposure to air pollution and cardiovascular mortality: an analysis of 22 European cohorts.

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From the aInstitute for Risk Assessment Sciences, Utrecht University, Utrecht, The Netherlands; bDepartment of Epidemiology, Lazio Regional Health Service, Rome, Italy; cDanish Cancer Society Research Center, Copenhagen, Denmark; dCenter for Epidemiology and Screening, Department of Public Health, University of Copenhagen, CSS, København K, Denmark; eMRC-HPA Centre for Environment and Health, Department of Epidemiology and Biostatistics, Imperial College London, St Mary's Campus, London, United Kingdom; fUniversity College London, CeLSIUS, London, United Kingdom; gDepartment of Hygiene, Epidemiology, and Medical Statistics, Medical School, University of Athens, Athens, Greece; hJulius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands; iInstitute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany; jIUF-Leibniz Research Institute for Environmental Medicine, Düsseldorf, Germany, and Medical Faculty, University of Düsseldorf, Düsseldorf, Germany; kInstitute of Epidemiology II, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany; lNational Institute for Public Health and the Environment, Bilthoven, The Netherlands; mCentre for Research in Environmental Epidemiology (CREAL), Barcelona, and Parc de Recerca Biomèdica de Barcelona-PRBB (office 183.05) C. Doctor Aiguader, Barcelona, Spain; nConsortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública-CIBERESP), Melchor Fernández Almagro 3-5, Madrid, Spain; oDivision of Occupational and Environmental Medicine, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden; pNational Institute for Health and Welfare, Kuopio, Finland; qNorwegian Institute of Public Health, Oslo, Norway; rInstitute of Health and Society, University of Oslo, Oslo, Norway; sInstitute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; tDepartm



Air pollution has been associated with cardiovascular mortality, but it remains unclear as to whether specific pollutants are related to specific cardiovascular causes of death. Within the multicenter European Study of Cohorts for Air Pollution Effects (ESCAPE), we investigated the associations of long-term exposure to several air pollutants with all cardiovascular disease (CVD) mortality, as well as with specific cardiovascular causes of death.


Data from 22 European cohort studies were used. Using a standardized protocol, study area-specific air pollution exposure at the residential address was characterized as annual average concentrations of the following: nitrogen oxides (NO2 and NOx); particles with diameters of less than 2.5 μm (PM2.5), less than 10 μm (PM10), and 10 μm to 2.5 μm (PMcoarse); PM2.5 absorbance estimated by land-use regression models; and traffic indicators. We applied cohort-specific Cox proportional hazards models using a standardized protocol. Random-effects meta-analysis was used to obtain pooled effect estimates.


The total study population consisted of 367,383 participants, with 9994 deaths from CVD (including 4,992 from ischemic heart disease, 2264 from myocardial infarction, and 2484 from cerebrovascular disease). All hazard ratios were approximately 1.0, except for particle mass and cerebrovascular disease mortality; for PM2.5, the hazard ratio was 1.21 (95% confidence interval = 0.87-1.69) per 5 μg/m and for PM10, 1.22 (0.91-1.63) per 10 μg/m.


In a joint analysis of data from 22 European cohorts, most hazard ratios for the association of air pollutants with mortality from overall CVD and with specific CVDs were approximately 1.0, with the exception of particulate mass and cerebrovascular disease mortality for which there was suggestive evidence for an association.

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