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Long term exposure to ambient air pollution and incidence of acute coronary events: prospective cohort study and meta-analysis in 11 European cohorts from the ESCAPE Project

BMJ 2014; 348 doi: (Published 21 January 2014) Cite this as: BMJ 2014;348:f7412
  1. Giulia Cesaroni, senior researcher1,
  2. Francesco Forastiere, research director1,
  3. Massimo Stafoggia, senior researcher1,
  4. Zorana J Andersen, associate professor in epidemiology23,
  5. Chiara Badaloni, research fellow1,
  6. Rob Beelen, senior researcher4,
  7. Barbara Caracciolo, researcher56,
  8. Ulf de Faire, senior professor of cardiovascular epidemiology7,
  9. Raimund Erbel, professor8,
  10. Kirsten T Eriksen, researcher2,
  11. Laura Fratiglioni, professor in geriatric epidemiology5910,
  12. Claudia Galassi, medical epidemiologist11,
  13. Regina Hampel, research fellow12,
  14. Margit Heier, research fellow1213,
  15. Frauke Hennig, research fellow14,
  16. Agneta Hilding, researcher15,
  17. Barbara Hoffmann, professor1416,
  18. Danny Houthuijs, senior researcher17,
  19. Karl-Heinz Jöckel, professor18,
  20. Michal Korek, doctoral student7,
  21. Timo Lanki, chief researcher19,
  22. Karin Leander, researcher7,
  23. Patrik K E Magnusson, professor20,
  24. Enrica Migliore, epidemiologist11,
  25. Caes-Göran Ostenson, professor15,
  26. Kim Overvad, professor2122,
  27. Nancy L Pedersen, professor of genetic epidemiology20,
  28. Juha Pekkanen J, professor19,
  29. Johanna Penell, researcher7,
  30. Göran Pershagen, professor7,
  31. Andrei Pyko, research fellow7,
  32. Ole Raaschou-Nielsen, head of research group2,
  33. Andrea Ranzi, project manager in environmental epidemiology23,
  34. Fulvio Ricceri, research fellow24,
  35. Carlotta Sacerdote, medical epidemiologist11,
  36. Veikko Salomaa, research professor25,
  37. Wim Swart, researcher17,
  38. Anu W Turunen, researcher19,
  39. Paolo Vineis, professor in epidemiology2426,
  40. Gudrun Weinmayr, research associate1427,
  41. Kathrin Wolf, research fellow12,
  42. Kees de Hoogh, senior research officer26,
  43. Gerard Hoek, associate professor4,
  44. Bert Brunekreef, professor428,
  45. Annette Peters, professor12
  1. 1Department of Epidemiology, Lazio Regional Health Service, 00198 Rome, Italy
  2. 2Danish Cancer Society Research Center, 2100 Copenhagen, Denmark
  3. 3Center for Epidemiology and Screening, Department of Public Health, University of Copenhagen, 1014 Copenhagen, Denmark
  4. 4Institute for Risk Assessment Sciences, Utrecht University, PO Box 80178, 3508 TD Utrecht, Netherlands
  5. 5Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, S-113 30 Stockholm, Sweden
  6. 6Stress Research Institute, Stockholm University, SE-106 91 Stockholm, Sweden
  7. 7Institute of Environmental Medicine, Karolinska Institutet, Box 210 SE-171 77 Stockholm, Sweden
  8. 8West German Heart Center, University Hospital of Essen, 45122 Essen, Germany
  9. 9Stockholm Gerontology Research Center, 113 30 Stockholm, Sweden
  10. 10Division of Clinical Geriatrics, Karolinska University Hospital, SE-141 86 Stockholm, Sweden
  11. 11Unit of Cancer Epidemiology, “Città della Salute e della Scienza” Hospital, University of Turin, and Center for Cancer Prevention Piemonte, 10126 Turin, Italy
  12. 12Helmholtz Zentrum München, German Research Center for Environmental Health, Institute of Epidemiology II, 85764 Neuherberg, Germany
  13. 13Central Hospital of Augsburg, MONICA/KORA Myocardial Infarction Registry, D-86156 Augsburg, Germany
  14. 14IUF-Leibniz Research Institute for Environmental Medicine, 40225 Düsseldorf, Germany
  15. 15Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, SE-171 77 Stockholm, Sweden
  16. 16Medical Faculty, University of Düsseldorf, 40225 Düsseldorf, Germany
  17. 17National Insititute for Public Health and the Environment, PO Box 1, 3720 BA Bilthoven, Netherlands
  18. 18Institute for Medical Informatics, Biometry and Epidemiology, University Hospital of Essen, D-45122 Essen, Germany
  19. 19National Institute for Health and Welfare “THL”, Department of Environmental Health, PO Box 95, FI-70701 Kuopio, Finland
  20. 20Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, SE-171 77 Stockholm, Sweden
  21. 21Section for Epidemiology, Department of Public Health, Aarhus University, DK-8000 Aarhus, Denmark
  22. 22Department of Cardiology, Cardiovascular Research Center, Aalborg University Hospital, DK-9000 Aalborg, Denmark
  23. 23Environmental Health Reference Centre-Regional Agency for Environmental Prevention of Emilia-Romagna, 41121 Modena, Italy
  24. 24Molecular and Genetic Epidemiology Unit, HuGeF-Human Genetics Foundation-Turin, 10126 Turin, Italy
  25. 25THL-National Institute for Health and Welfare, Department of Chronic Disease Prevention, POB 30, FI-00271 Helsinki, Finland
  26. 26MRC-HPA Centre for Environment and Health, Department of Epidemiology and Biostatistics, Imperial College London, St Mary’s Campus, London W2 1PG, UK
  27. 27Institute of Epidemiology and Medical Biometry, Ulm University, 89069 Ulm, Germany
  28. 28Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, Netherlands
  1. Correspondence to: G Cesaroni g.cesaroni{at}
  • Accepted 4 December 2013


Objectives To study the effect of long term exposure to airborne pollutants on the incidence of acute coronary events in 11 cohorts participating in the European Study of Cohorts for Air Pollution Effects (ESCAPE).

Design Prospective cohort studies and meta-analysis of the results.

Setting Cohorts in Finland, Sweden, Denmark, Germany, and Italy.

Participants 100 166 people were enrolled from 1997 to 2007 and followed for an average of 11.5 years. Participants were free from previous coronary events at baseline.

Main outcome measures Modelled concentrations of particulate matter <2.5 μm (PM2.5), 2.5-10 μm (PMcoarse), and <10 μm (PM10) in aerodynamic diameter, soot (PM2.5 absorbance), nitrogen oxides, and traffic exposure at the home address based on measurements of air pollution conducted in 2008-12. Cohort specific hazard ratios for incidence of acute coronary events (myocardial infarction and unstable angina) per fixed increments of the pollutants with adjustment for sociodemographic and lifestyle risk factors, and pooled random effects meta-analytic hazard ratios.

Results 5157 participants experienced incident events. A 5 μg/m3 increase in estimated annual mean PM2.5 was associated with a 13% increased risk of coronary events (hazard ratio 1.13, 95% confidence interval 0.98 to 1.30), and a 10 μg/m3 increase in estimated annual mean PM10 was associated with a 12% increased risk of coronary events (1.12, 1.01 to 1.25) with no evidence of heterogeneity between cohorts. Positive associations were detected below the current annual European limit value of 25 μg/m3 for PM2.5 (1.18, 1.01 to 1.39, for 5 μg/m3 increase in PM2.5) and below 40 μg/m3 for PM10 (1.12, 1.00 to 1.27, for 10 μg/m3 increase in PM10). Positive but non-significant associations were found with other pollutants.

Conclusions Long term exposure to particulate matter is associated with incidence of coronary events, and this association persists at levels of exposure below the current European limit values.


  • We thank Marjan Tewis, Marieke Oldenwening, Marloes Eeftens, Ulrich Quass, Lee-Jane Sally Liu for their help with exposure assessment and data management within ESCAPE.

  • For the Finnish part, additional funding came from the Academy of Finland (project number 129317). Exposure assessment was performed by Tarja Yli-Tuomi, Pekka Taimisto, and Arto Pennanen from the Department of Environmental Health. Mortality, area-level SES, and building data were provided by Statistics Finland.

  • The four Swedish cohorts (SNAC-K, SALT, 60y, SDPP) were partially funded by the Swedish Environmental Protection Agency, the Swedish Council for Working Life and Social Research and the Swedish Heart-Lung Foundation. The SALT cohort was additionally supported by NIH grant AG-08724. The 60 year cohort was additionally funded by the Stockholm County Council and the Swedish Research Council (longitudinal research and 0593). The SDPP cohort was additionally funded by the Stockholm County Council; the Swedish Research Council; the Swedish Diabetes Association; and the Novo Nordisk Scandinavia. We thank the Heinz Nixdorf Foundation, the German Ministry of Education and Science (BMBF), the German Aerospace Center (Deutsches Zentrum für Luft- und Raumfahrt (DLR)), and the German Research Foundation (DFG HO 3314/2-1 and JO170/8-1), Bonn, Germany, for their generous support of Heinz Nixdorf Recall study. The KORA research platform and the MONICA Augsburg studies were initiated and financed by the Helmholtz Zentrum München, German Research Center for Environmental Health, which is funded by the German Federal Ministry of Education and Research and by the State of Bavaria. The SIDRIA cohort study was partially funded by the Italian Ministry of Health. Giuseppe Costa provided data from the Turin Longitudinal Study for the follow-up of the SIDRIA-Turin cohort. Exposure assessment in Turin was performed by Daniela Raffaele and Marco Gilardetti. Noise assessment in Turin was performed by Daniele Grasso and Jacopo Fogola (Regional Agency for the Protection of the Environment of Piedmont). We thank Simone Bucci, Patrizio Pasquinelli, and Eleonora Zirro for exposure assessment in Rome.

  • Contributors: GC contributed to the design, exposure assessment, data analyses, and drafted the manuscript; FF contributed to the design, provided local cohort data and drafted the manuscript; MS contributed to the design, statistical script, and data analyses; ZJA, RH contributed to the statistical script and data analysis; CB, FH, EM, JPen, APy, FR, and AT contributed to the data analyses; RB, GH contributed to the design, exposure assessment and statistical script; BC, UdF, RE, LF, MH, AH, KHJ, KL, PKEM, CGO, KO, NLP, JPek, CS, and VS provided local cohort data; CG contributed to exposure assessment and provided local cohort data; BH, ORN, GP, and PV contributed to the design and provided local cohort data; MK contributed to the exposure assessment and the data analyses; KTE, DH, TL, AR, WS, and KdH contributed to exposure assessment; GW and KW contributed to the statistical script; BB and APe contributed to the design and drafted the manuscript. All authors contributed to critical reading of and comments to the manuscript, interpretation of data and approved the final draft. GC is guarantor.

  • Funding: The research leading to these results has received funding from the European Community’s Seventh Framework Program (FP7/2007-2011) under grant agreement No 211250. The sources of funding had no role in study design, data collection, analyses, interpretation, and decision to submit the article for publication.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: The original cohort studies were approved by appropriate institutional review boards complying with all relevant national, state, and local regulations.

  • Transparency statement: The lead author affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.

  • Data sharing: meta-analytic data and statistical code are available from the corresponding author.

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