February 12, 2026
7 min read
Key takeaways:
- Four cardiology societies come together with call-to-action to address environmental risk factors for CVD.
- One author spoke with Healio about how pollutants adversely impact heart health.
Evidence of environmental risk factors’ negative impact on heart health has greatly increased, leading to several cardiology societies to issue a joint statement encouraging regulations to reduce risk for noncommunicable diseases.
Environmental stressors on the heart can include climate change, chemical pollution, soil pollution, water pollution, noise and light pollution, and especially air pollution, researchers reported.
Addressing pollution sources as well as aging infrastructure may not only provide CV benefits by lowering risk for disease, but also decrease the economic burden by lowering health care expenditures and increase years of productivity across the population, according to Sanjay Rajagopalan, MD, MBA, FACC, FAHA, chief of cardiovascular medicine and chief academic and scientific officer at University Hospitals, Harrington Heart & Vascular Institute and director of the Case Cardiovascular Research Institute.
“This statement was released during the World Economic Forum, which has often been at the center of discussions around climate change, geopolitical forces shaping the industry of clean technology and emissions,” Rajagopalan told Healio. “The discussion this year was very interesting, and it was serendipitous and opportune that these societies released the document when they did to bring the focus back on the health consequences of environmental degradation.”
The statement was a joint effort by the American Heart Association, American College of Cardiology, European Society of Cardiology and World Heart Federation. The document was published in Circulation, the Journal of the American College of Cardiology, the European Heart Journal and Global Heart.
Healio spoke with Rajagopalan, who is also the Herman K. Hellerstein MD, Professor of Cardiovascular Medicine and professor in the department of internal medicine and biomedical engineering at Case Western Reserve University, about the document, how environmental factors could impact CV health and what should be done mitigate risk from exposure to various pollutants.
Healio: It’s not often we see the European Society of Cardiology, American Heart Association, American College of Cardiology and World Heart Federation come together to release joint statements. What precipitated this level of collaboration?
Rajagopalan: There’s been a shift in awareness of environmental factors and their importance for global health. Awareness has increased exponentially over the last 10 years, when we started seeing an increased incidence of environmental-related calamities in the U.S., synchronously with that occurring in Europe and globally. People are sensitized when they see things happening in their own backyards, such as the torrential floods and hurricanes in North Carolina. Currently you’re seeing unprecedented snowstorms in parts of the country such as Houston and flash floods in North Carolina related to climate change and increasing reports of environmental toxins with health impact. This has changed people’s view on the importance of having a healthy external environment. Professional bodies such as the American Heart Association, ACC and ESC are now starting to see health from a wider-angle lens, where the external environment and climate play a larger than expected role in determining cardiovascular and metabolic outcomes.
In America, things are a little bit more politicized because there’s a lot of support of industries that are at the forefront of emissions and climate, and the political sentiment around fossil fuel emissions, climate and the environment is unfortunate. But we all agree, the health impact is there and it’s real.
Healio: Is it possible to quantify the impact of environmental risk factors and their contribution to CVD and CV mortality?
Rajagopalan: Yes. Pollution alone causes around 12.6 million deaths yearly, according to the Global Burden of Disease report, perhaps the best source.
For air pollution alone, it is between 6 million or 7 million deaths yearly, and the rest is related to other environmental risk factors. This is almost certainly an underestimation, as there tends to be an attribution gap.
The problem is, how do you say somebody died of an environmental exposure? It is hard to do when environmental exposures are pervasive and do not have a fingerprint to assign causality. Most risk factors oftentimes have a long latency period of decades before manifesting with disease, also causing lack of causal recognition.
Finally, environmental exposures also cause risk factors. For instance, air pollution causes high BP and diabetes. Thus, when you look at the totality of the burden of environmental risk factors, it’s massive.
Healio: Who is the most severely affected by environmental CVD risk factors, and are there inequities in exposure?
Rajagopalan: Looking at air pollution in particular, people exposed to higher levels are probably incurring most of the adverse effects. People who are disproportionately affected are from lower socioeconomic groups, in particular, people living in Black and Hispanic communities; individuals living close to highways; and people living close to power plants, etc.
In the U.S., we’ve made tremendous progress since the Clean Air Act was put into effect in 1972. Most areas in the U.S. now have air with PM2.5 levels of less than 10 µg/m3, which is quite an accomplishment. Comparatively, even European levels tend to be higher, while Canadian levels tend to be lower than the U.S.
Even at levels less than 10 µg/m3, you continue to see air pollution-related effects in the U.S.
There are also rural communities exposed to certain types of environmental risk factors. For instance, if you live in the Southwest and get your water from a well, there’s higher risk for arsenic exposure.
Lead exposures continue in most industrial cities. For example, Detroit, Cleveland and Chicago all have lead exposure due to aging infrastructure and lead paint.
Then there is a newer type of exposure, wildfires, that can even affect many communities in the American West.
Healio: Air pollution seems to be the major leading environmental contributor to CVD. Is that where most attention needs to be paid with regard to policymaking?
Rajagopalan: Yes, for several reasons.
Air pollution is a priority as it is actionable and because climate change and air pollution go hand-in-hand. They are from the same sources. A shift towards clean technology, decarbonization and non-fossil fuel-based approaches are a solution for air pollution and also can massively drive CO2 emissions, with the caveat that there’s also a lot we don’t know about some of the cleaner technologies. For example, what are the implications of rare-metal earth mining to extract resources that fuel batteries for clean technologies?
The whole world is decarbonizing, whether the U.S. likes it or not. The U.S. has gone backward in its commitments. From a health perspective, it’s not a good thing. You can save thousands of lives in the U.S. today by reducing air pollution levels further, particularly in disadvantaged communities, which unfortunately costs the health system a lot of money.
For air pollution, we have had policy and regulation levers that have successfully lowered levels, saved millions of lives and contributed to longevity in this country.
The science of air pollution exposure and epidemiology has shaped policy. Unfortunately, we do not understand the health effects of many chemicals for us to enact policy. What is the dose-response relationship on diabetes or CV events for most environmental exposures? The answer is we don’t know for most chemical exposures. For example, we do not have detailed data on newer-generation bisphenols or phthalates, and newer per- and poly-fluoroalkyl substances (PFAS) chemicals. It’s difficult to regulate if you don’t clearly understand the health effects.
Politicians, government and health care systems must all work together to clean up the environment and physicians need to be an advocate for cleaner environments.
Healio: Should discussion of these environmental risk factors be routine in clinical practice?
Rajagopalan: I think so but in practice I would say it depends. Physicians are facing an increasing amount of information they need to share. The most important thing you can do is focus on risk factors that we know are causal and that you know how to modify. Traditional risk factors should therefore remain the focus. Because there is a lot of implementation science to translate things that are already known.
Do the environmental factors require a conversation? Yes, in those patients where you think you’ve done everything and there is there is still ongoing risk. The conversation might be had particularly if you live in an area with high exposure to air pollution, like Los Angeles; areas where there’s high forest fire exposure; or in communities seeing high arsenic levels or metal pollution.
It requires a pragmatic approach. Treat traditional risk factors first. If the patient does seem to have disproportionate exposure to certain types of environmental factors, a further conversation can be had.
Healio: What are the first steps to improving the impact of environmental pollution on CV health?
Rajagopalan: First, we need to sensitize physicians, nurse practitioners and other clinicians to understand the strong link between environmental exposures and CV health. Most environmental exposures mediate their effects on adverse health outcomes through CV pathways. Many physicians still don’t know that air pollution kills through CV events, not through lung cancer.
Second is incorporation of environmental exposures as part of clinical guidelines. This document from the American Heart Association/ACC/ESC and WHF is a step in the right direction, where societies have come together to recognize the importance of environmental exposures. The impact of environmental exposures should be formally part of most prevention guidelines, to recognize the large impact that these exposures have on cardiometabolic health. We physicians have narrowly focused on traditional risk factors when they examine patients, but now we need to zoom out to see the impact that socioeconomic circumstances and other environmental exposures have on health.
Most physicians know that your ZIP code is often a very good predictor of CV events because of environmental exposures, and due to social-environmental exposures often going together.
The American Heart Association hypertension guideline, for the first time, recognizes air pollution as an important risk factor. The European prevention guidelines recognize environmental factors.
Third is for physicians to be advocates for action in their communities. The climate argument has become too political. The way out of this is to put health in the center of the argument.
Fourth is what’s good for your CV health is good for the planet. Get your exercise, if possible. Try to walk or take a bike to work, if you can, and reduce your automobile usage.
Consume less. It’s good because it reduces your weight, and it reduces your risk for diabetes.
Eat more plants and less meat. Plant-based diets are good not only for your heart, but also for the planet.
Finally, anything in a plastic container is probably not good for you, because it’s ultraprocessed food. Here, I’m consistent with the USDA guidelines to say, don’t eat ultraprocessed food, eat fresh food as much as possible. You’re reducing plastic usage, and by doing that, you’re dissociating yourself from fossil fuel pollution, because petroleum is what it takes to make plastics.
These are some simple recipes for leading a heart-healthy life, but also helpful from an environmental exposure and planetary health perspective.
For more information:
Sanjay Rajagopalan, MD, MBA, FACC, FAHA, can be reached at sxr647@case.edu.
Sources/Disclosures
Source:
Healio Interviews
References:
Disclosures:
Rajagopalan reports consulting for Novo Nordisk. Please see the document for all other authors’ relevant financial disclosures.
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