We share the reflection and concern regarding the effect of environmental pollution, particularly that of air pollution on heart failure (HF) and its decompensation and the lack of reflection in the recent guidelines.1 In fact, it is not only a question of HF; the air pollution we breathe is associated with increased all-cause mortality, making it a major risk factor recognized by the World Health Organization (WHO) and associated with premature mortality.2

The key question is how to approach this problem in clinical practice guidelines whose main purpose is to translate the scientific evidence to specific recommendations for professionals in their routine practice. It is true that the guidelines cannot recommend masks or moving house to individual patients with HF, nor is there evidence on the benefit of these interventions, but they can provide recommendations for the population setting and health and social care policy. This is the most important point in relation to the letter. In fact, in our comments we highlighted the lack of organizational recommendations with a global health impact on the disease. More specifically, the inclusion of recommendations aimed at society as a whole and its political leaders may represent a step forward in the current concept of guidelines. There have been several calls to action and a recent specific guideline published by the WHO and medical societies calling for a reduction in air pollution,3 but their inclusion in professional guidelines would increase the impact and awareness of them. Not only regarding pollution, but also the other environmental factors.

In summary, the letter highlights the need for the guidelines to coordinate specific recommendations for professionals and patients, with population-level recommendations aimed at those responsible for health and social care policies.