In an unprecedented collaboration, the European Society of Cardiology, the American College of Cardiology, the American Heart Association and the World Heart Federation have issued a joint statement calling for immediate action against environmental stressors – pollution, noise, climate stress – to reduce cardiovascular mortality.
The article, which was published simultaneously in the European Heart Journal and other leading publications, warns that we must address climate change and pollution in order to combat the leading cause of death worldwide: cardiovascular disease (CVD).
The text proposes local actions to achieve global impact. It also calls for the integration of pollution, noise, chemical compounds and climate stress into CVD prevention, putting it on the the same level as cholesterol, hypertension and tobacco use.
Over 13 millions deaths per year
For decades, cardiologists have developed treatments and prevention measures that focus solely on the individual: controlling blood pressure, lowering cholesterol, quitting smoking, and so on. Environment is also a key determinant of CVD risk, but it has been persistently overlooked. Environmental risk factors are estimated to contribute to more than 13 million deaths annually, exceeding the burden of many well-established risk factors.
According to the World Health Organisation, 99% of the world’s population breathes air that exceeds its recommended pollution levels. But air pollution is not the only risk factor – chronic exposure to noise, night-time light pollution, chemical pollutants, poor water and soil quality, and the increasingly frequent impacts of climate change such as heatwaves and fires all play a fundamental role in heart health.
The combined impacts of environmental factors accumulate over the years, affecting our overall cardiovascular health. The joint article by the cardiology societies emphasises that these factors do not act in isolation – they interact through shared biological pathways such as inflammation and oxidative stress.
Global data show us that the impacts are far from marginal. The 2019 Global Burden of Disease analysis ranked hypertension as the leading risk factor for mortality, followed by tobacco use. Air pollution was one of the leading risk factors for mortality in 4th place, and exposure to non-optimal temperatures also ranked high in 11th place.
Reducing pollution, noise and urban heat is therefore not just a matter of ecology – it literally prevents heart disease. It is also a question of justice, as these risk factors tend to disproportionately affect vulnerable populations, concentrating in neighbourhoods with more traffic, poorer housing infrastructure and less capacity for protection.
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What we can do
Given the forecast that 70% of the world’s population will live in cities by 2050, the joint article proposes designing heart-healthy cities with active transport and green spaces. It presents an action plan based on four key points:
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Policy advocacy: Align climate policies with cardiovascular health and seek funding for the most affected countries. Implement more ambitious urban standards, ensure cities have fewer combustion engines and more active transport and green spaces.
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Education: Integrate environmental health into medical curricula at the same level as traditional risk factors such as cholesterol or smoking. Record this information during consultations using simple tools, such as asking about exposures (traffic, heat, smoke, noise). Teach realistic protective measures and use environmental alerts when making decisions about vulnerable patients.
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Research: Create global observatories to monitor the relationship between pollution metrics (air quality, temperature, fires, noise) and disease in real time. By quantifying impacts, we can identify inequalities and figure out which policies are most effective.
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New guidelines: Develop harmonised recommendations for levels of particulate matter, extreme heat, noise, ozone and chemical exposures. These can be converted into operational indicators that enable early action, both for public health and in clinical settings.
Legislative setbacks
The article highlights a stark gap between scientific knowledge of environmental risks and its translation into clear, personalised and usable tools for the general population and health professionals.
At this point, the main obstacle is not scientific uncertainty, but the direct conflict between protecting our health and sustaining certain models of mobility, production and consumption. In some cases this is not just a matter of inaction, but of active regression.
On February 12, the United States Environmental Protection Agency (EPA) revoked the 2009 endangerment finding, which classed greenhouse gases as a threat to public health and underpinned emissions regulation under the Clean Air Act. This has a clear consequence: the legal basis for emissions standards, starting with those for vehicles, has been weakened, and the door opened to broader deregulation.
Reversing these standards means emissions will increase over the coming decades, with impacts on our climate, air quality and cardiovascular health.
Scientific organisations (such as the Spanish Society of Epidemiology, which the authors of this article are members of) cannot limit themselves to generating technical consensus. To prevent CVD in the 21st century, we need to broaden the focus from the individual patient to the system and environment in which they live. Reducing pollution is not just an environmental measure, it is a high-priority preventative intervention, with rapid, measurable and equitable benefits.
The field of cardiovascular epidemiology has amply demonstrated its ability to quantify risks, attributable deaths, and years of life lost. The challenge now is to turn that knowledge into a clear, compelling and politically relevant narrative.
The question is no longer whether pollution causes cardiovascular disease, but how much additional harm we are willing to accept knowing that it is, to a large extent, preventable.
This article was written in consultation with the Spanish Epidemiological Society.
