Associations of outdoor fine particulate air pollution and cardiovascular disease in 157 436 individuals from 21 high-income, middle-income, and low-income countries (PURE): a prospective cohort study

Background Most studies of long-term exposure to outdoor fine particulate matter (PM 2·5 ) and cardiovascular disease are from high-income countries with relatively low PM 2·5 concentrations. It is unclear whether risks are similar in low-income and middle-income countries (LMICs) and how outdoor PM 2·5 contributes to the global burden of cardiovascular disease. In our analysis of the Prospective Urban and Rural Epidemiology (PURE) study, we aimed to investigate the association between long-term exposure to PM 2·5 concentrations and cardiovascular disease in a large cohort of adults from 21 high-income, middle-income, and low-income countries. Methods In this multinational, prospective cohort study, we studied 157 436 adults aged 35–70 years who were enrolled in the PURE study in countries with ambient PM 2·5 estimates, for whom follow-up data were available. Cox proportional hazard frailty models were used to estimate the associations between long-term mean community outdoor PM 2·5 concentrations and cardiovascular disease events (fatal and non-fatal), cardiovascular disease mortality, and other non-accidental mortality. Findings Between Jan 1, 2003, and July 14, 2018, 157 436 adults from 747 communities in 21 high-income, middle-income, and low-income countries were enrolled and followed up, of whom 140 020 participants resided in LMICs. During a median follow-up period of 9·3 years (IQR 7·8–10·8; corresponding to 1·4 million person-years), we documented 9996 non-accidental deaths, of which 3219 were attributed to cardiovascular disease. 9152 (5·8%) of 157 436 participants had cardiovascular disease events (fatal and non-fatal incident cardiovascular disease), including 4083 myocardial infarctions and 4139 strokes. Mean 3-year PM 2·5 at cohort baseline was 47·5 μg/m 3 (range 6–140). In models adjusted for individual, household, and geographical factors, a 10 μg/m 3 increase in PM 2·5 was associated with increased risk for cardiovascular disease events (hazard ratio 1·05 [95% CI 1·03–1·07]), myocardial infarction (1·03 [1·00–1·05]), stroke (1·07 [1·04–1·10]), and cardiovascular disease mortality (1·03 [1·00–1·05]). Results were similar for LMICs and communities with high PM 2·5 concentrations (>35 μg/m 3 ). The population attributable fraction for PM 2·5 in the PURE cohort was 13·9% (95% CI 8·8–18·6) for cardiovascular disease events, 8·4% (0·0–15·4) for myocardial infarction, 19·6% (13·0–25·8) for stroke, and 8·3% (0·0–15·2) for cardiovascular disease mortality. We identified no consistent associations between PM 2·5 and risk for non-cardiovascular disease deaths. Interpretation Long-term outdoor PM 2·5 concentrations were associated with increased risks of cardiovascular disease in adults aged 35–70 years. Air pollution is an important global risk factor for cardiovascular disease and a need exists to reduce air pollution concentrations, especially in LMICs, where air pollution levels are highest. Funding Full funding sources are listed at the end of the paper (see Acknowledgments).

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