Global association of air pollution and heart failure: a systematic review and meta-analysis

Lancet. 2013 Sep 21;382(9897):1039-48. doi: 10.1016/S0140-6736(13)60898-3. Epub 2013 Jul 10.


Background: Acute exposure to air pollution has been linked to myocardial infarction, but its effect on heart failure is uncertain. We did a systematic review and meta-analysis to assess the association between air pollution and acute decompensated heart failure including hospitalisation and heart failure mortality.

Methods: Five databases were searched for studies investigating the association between daily increases in gaseous (carbon monoxide, sulphur dioxide, nitrogen dioxide, ozone) and particulate (diameter <2·5 μm [PM2·5] or <10 μm [PM10]) air pollutants, and heart failure hospitalisations or heart failure mortality. We used a random-effects model to derive overall risk estimates per pollutant.

Findings: Of 1146 identified articles, 195 were reviewed in-depth with 35 satisfying inclusion criteria. Heart failure hospitalisation or death was associated with increases in carbon monoxide (3·52% per 1 part per million; 95% CI 2·52-4·54), sulphur dioxide (2·36% per 10 parts per billion; 1·35-3·38), and nitrogen dioxide (1·70% per 10 parts per billion; 1·25-2·16), but not ozone (0·46% per 10 parts per billion; -0·10 to 1·02) concentrations. Increases in particulate matter concentration were associated with heart failure hospitalisation or death (PM2·5 2·12% per 10 μg/m(3), 95% CI 1·42-2·82; PM10 1·63% per 10 μg/m(3), 95% CI 1·20-2·07). Strongest associations were seen on the day of exposure, with more persistent effects for PM2·5. In the USA, we estimate that a mean reduction in PM2·5 of 3·9 μg/m(3) would prevent 7978 heart failure hospitalisations and save a third of a billion US dollars a year.

Interpretation: Air pollution has a close temporal association with heart failure hospitalisation and heart failure mortality. Although more studies from developing nations are required, air pollution is a pervasive public health issue with major cardiovascular and health economic consequences, and it should remain a key target for global health policy.

Funding: British Heart Foundation.

Publication types

  • Meta-Analysis
  • Research Support, Non-U.S. Gov't
  • Review
  • Systematic Review

MeSH terms

  • Air Pollutants / toxicity*
  • Air Pollution / adverse effects*
  • Carbon Monoxide / analysis
  • Carbon Monoxide / toxicity
  • Epidemiologic Methods
  • Global Health
  • Heart Failure / chemically induced*
  • Heart Failure / mortality
  • Humans
  • Nitrogen Dioxide / analysis
  • Nitrogen Dioxide / toxicity
  • Ozone / analysis
  • Ozone / toxicity
  • Particulate Matter
  • Sulfur Dioxide / analysis
  • Sulfur Dioxide / toxicity


  • Air Pollutants
  • Particulate Matter
  • Sulfur Dioxide
  • Ozone
  • Carbon Monoxide
  • Nitrogen Dioxide