Long-term exposure to low-level ambient air pollution and incidence of stroke and coronary heart disease: a pooled analysis of six European cohorts within the ELAPSE project

Kathrin Wolf, Barbara Hoffmann, Zorana J Andersen, Richard W Atkinson, Mariska Bauwelinck, Tom Bellander, Jørgen Brandt, Bert Brunekreef, Giulia Cesaroni, Jie Chen, Ulf de Faire, Kees de Hoogh, Daniela Fecht, Francesco Forastiere, John Gulliver, Ole Hertel, Ulla Arthur Hvidtfeldt, Nicole A H Janssen, Jeanette T Jørgensen, Klea KatsouyanniMatthias Ketzel, Jochem O Klompmaker, Anton Lager, Shuo Liu, Conor J MacDonald, Patrik K E Magnusson, Amar J Mehta, Gabriele Nagel, Bente Oftedal, Nancy L Pedersen, Göran Pershagen, Ole Raaschou-Nielsen, Matteo Renzi, Debora Rizzuto, Sophia Rodopoulou, Evangelia Samoli, Yvonne T van der Schouw, Sara Schramm, Per Schwarze, Torben Sigsgaard, Mette Sørensen, Massimo Stafoggia, Maciek Strak, Anne Tjønneland, W M Monique Verschuren, Danielle Vienneau, Gudrun Weinmayr, Gerard Hoek, Annette Peters, Petter L S Ljungman

Research output: Contribution to journalArticlepeer-review

81 Citations (Scopus)


BACKGROUND: Long-term exposure to outdoor air pollution increases the risk of cardiovascular disease, but evidence is unclear on the health effects of exposure to pollutant concentrations lower than current EU and US standards and WHO guideline limits. Within the multicentre study Effects of Low-Level Air Pollution: A Study in Europe (ELAPSE), we investigated the associations of long-term exposures to fine particulate matter (PM2·5), nitrogen dioxide (NO2), black carbon, and warm-season ozone (O3) with the incidence of stroke and acute coronary heart disease.

METHODS: We did a pooled analysis of individual data from six population-based cohort studies within ELAPSE, from Sweden, Denmark, the Netherlands, and Germany (recruited 1992-2004), and harmonised individual and area-level variables between cohorts. Participants (all adults) were followed up until migration from the study area, death, or incident stroke or coronary heart disease, or end of follow-up (2011-15). Mean 2010 air pollution concentrations from centrally developed European-wide land use regression models were assigned to participants' baseline residential addresses. We used Cox proportional hazards models with increasing levels of covariate adjustment to investigate the association of air pollution exposure with incidence of stroke and coronary heart disease. We assessed the shape of the concentration-response function and did subset analyses of participants living at pollutant concentrations lower than predefined values.

FINDINGS: From the pooled ELAPSE cohorts, data on 137 148 participants were analysed in our fully adjusted model. During a median follow-up of 17·2 years (IQR 13·8-19·5), we observed 6950 incident events of stroke and 10 071 incident events of coronary heart disease. Incidence of stroke was associated with PM2·5 (hazard ratio 1·10 [95% CI 1·01-1·21] per 5 μg/m3 increase), NO2 (1·08 [1·04-1·12] per 10 μg/m3 increase), and black carbon (1·06 [1·02-1·10] per 0·5 10-5/m increase), whereas coronary heart disease incidence was only associated with NO2 (1·04 [1·01-1·07]). Warm-season O3 was not associated with an increase in either outcome. Concentration-response curves indicated no evidence of a threshold below which air pollutant concentrations are not harmful for cardiovascular health. Effect estimates for PM2·5 and NO2 remained elevated even when restricting analyses to participants exposed to pollutant concentrations lower than the EU limit values of 25 μg/m3 for PM2·5 and 40 μg/m3 for NO2.

INTERPRETATION: Long-term air pollution exposure was associated with incidence of stroke and coronary heart disease, even at pollutant concentrations lower than current limit values.

FUNDING: Health Effects Institute.

Original languageEnglish
Pages (from-to)e620-e632
Number of pages13
JournalThe Lancet. Planetary health
Issue number9
Publication statusPublished - Sep 2021

Bibliographical note

Copyright © 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.


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