Publish in this journal
Journal Information
Vol. 75. Issue 6.
Pages 538 (June 2022)
Not available
Vol. 75. Issue 6.
Pages 538 (June 2022)
Letter to the Editor
Full text access
Environmental factors like air pollution: not to be forgotten on the 2021 ESC guidelines of heart failure
Factores ambientales como la contaminación del aire: no debe olvidarse en la guía sobre insuficiencia cardiaca de la ESC 2021
Alberto Domínguez-Rodrígueza,
Corresponding author

Corresponding author:
, Pedro Abreu-Gonzálezb, Daniel Hernández-Vaqueroc,d
a Servicio de Cardiología, Hospital Universitario de Canarias, San Cristóbal de La Laguna, Santa Cruz de Tenerife, Spain
b Departamento de Fisiología, Facultad de Medicina, Universidad de La Laguna, San Cristóbal de La Laguna, Santa Cruz de Tenerife, Spain
c Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
d Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Asturias, Spain
Related content
Domingo A. Pascual-Figal, José Ramón González-Juanatey
This item has received
Article information
Full Text
Download PDF
Full Text
To the Editor,

The natural history of heart failure (HF) is characterized by acute decompensation episodes, which are the leading cause of hospitalization among patients older than 65 years.1 The main reasons why patients with acute HF seek urgent medical care are increasing signs and symptoms of congestion.1 Although some patients are admitted with a clear correctable trigger, in many patients, there is no clear precipitating factor. The 2021 European Society of Cardiology (ESC) Guidelines on HF have recently been published.2 Compared with the 2016 Guidelines, the new document is extremely innovative.1 However, we would like to point out an important aspect related to the effect of air pollution on acute decompensated HF, a lifestyle recommendation which should be considered in these new guidelines on HF2 and in the editorial recently published in Revista Española de Cardiología.3

Air pollutants have been estimated to be one of the 10 leading risk factors for global mortality.4 Air pollution is a heterogeneous mixture of particulate matter (PM) and gases derived from multiple sources, including fossil fuel combustion.4 PM itself is an amalgam of pollutants (eg, carbon species, sulfates, nitrates, metals) ranging in size from a few nanometers to several microns. While a variety of gases (eg, ozone) have been linked to adverse health effects, the largest body of evidence supports PM ≤ 2.5mm in diameter (PM2.5) as a major environmental threat to global public health.4

In a systematic review and meta-analysis of 35 studies, a short-term increase in gaseous components and PM2.5 was associated with increased risk of hospitalization due to HF and death.5 Specifically, an increase of 10μg/m3 in PM2.5 increased the relative risk of HF hospitalization or mortality by 2.1% (relative risk, 1.021; 95% confidence interval, 1.014 to 1.028). In a recent study from China with data from 26 cities with high PM2.5 concentrations, an interquartile increase in PM2.5 corresponded to a 1.2% increase in HF hospitalizations.6

We would have thought that the available information on air pollution and HF deserves renewed attention and focus to eliminate this risk factor. Its omission from the 2021 ESC Guidelines on HF could deprive the medical community of potentially useful information. Polices and regulations reducing air pollution should be supported, and patients should be advised about its risks.




A. Domínguez-Rodríguez: concept and writing. P. Abreu-González: critical review. D. Hernández-Vaquero: concept and critical review.



P. Ponikowski, A.A. Voors, S.D. Anker, et al.
2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) Developed with the special contribution of the Heart Failure Association (HFA) of the ESC.
Eur Heart J., 37 (2016), pp. 2129-2200
T.A. McDonagh, M. Metra, M. Adamo, et al.
2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure.
Eur Heart J., 42 (2021), pp. 3599-3726
D. Pascual Figal, J.R. González-Juanatey.
Comentarios a la guía ESC 2021 sobre el diagnóstico y tratamiento de la insuficiencia cardiaca aguda y crónica.
C. Liu, R. Chen, F. Sera, et al.
Ambient Particulate Air Pollution and Daily Mortality in 652 Cities.
N Engl J Med., 381 (2019), pp. 705-715
A.S. Shah, J.P. Langrish, H. Nair, et al.
Global association of air pollution and heart failure: a systematic review and meta-analysis.
Lancet., 382 (2013), pp. 1039-1048
H. Liu, Y. Tian, J. Song, et al.
Effect of Ambient Air Pollution on Hospitalization for Heart Failure in 26 of China's Largest Cities.
Am J Cardiol., 121 (2018), pp. 628-633
Copyright © 2022. Sociedad Española de Cardiología
Revista Española de Cardiología (English Edition)

Subscribe to our newsletter

View newsletter history
Article options
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?