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Progress in Cardiovascular Diseases 53 (2011) 369 – 378 www.onlinepcd.

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Progress of Ambient Air Pollution and Cardiovascular Disease Research in Asia
Ta-Chen Sua , Szu-Ying Chenb,c , Chang-Chuan Chanc,⁎
Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan b Department of Anesthesiology, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan c Institute of Occupational Medicine and Industrial Hygiene, College of Public Health, National Taiwan University, Taipei, Taiwan
a

Abstract

Asian countries are with deteriorating air quality accompanying the rapid economic and social development of the past decades, and the potential health impacts of air pollution have been noticed by researchers in the region. We reviewed the scientific literature on air pollution and cardiovascular diseases (CVD) published by Asian researchers in English since the 1980s to determine whether the findings in Europe and North America can be extrapolated to Asia. Epidemiological studies show that short-term particulate matter pollution is a strong predictor for CVD morbidity and mortality and suggestive on cerebrovascular morbidity and mortality in newly developed countries in Asia. Multicountry epidemiological studies are needed to fully appreciate the extent of air pollution on CVD in Asia, especially less developed Asian countries. New cohort studies should be initiated to improve our understanding of particulate matter's toxicological pathways, long-term exposure effects, and gene-environment interaction on CVD among the Asian population. (Prog Cardiovasc Dis 2011;53:369-378) © 2011 Elsevier Inc. All rights reserved.
Cardiovascular disease; Air pollution; Epidemiology; Panel study; Asia

Keywords:

Background: A knowledge gap in environmental cardiology Cardiovascular disease (CVD) is the leading cause of mortality and a major health burden in developed countries and has the same profile in many Asian countries, such as China and India.1 Cardiovascular diseases, cerebrovascular diseases, and cancers are the top 3 causes of death over the past 2 decades in China and Taiwan.2,3 The increasing rate of CVD morbidity and mortality, in particular, has become a major focus of public health policies and epidemiological studies among

The work reported was done from National Taiwan University. ⁎ Address reprint requests to Chang-Chuan Chan, ScD, Professor, Institute of Occupational Medicine and Industrial Hygiene, College of Public Health, National Taiwan University, Rm. 722, 17 Xu-Zhou Road, Taipei 100, Taiwan. E-mail address: ccchan@ntu.edu.tw (C.-C. Chan).

Asian countries. The causes of CVD are very complex, and disease susceptibility is closely associated with both genetic traits and environmental factors. Environmental cardiology is gaining recognition as an important field to uncover environmental risk factors for CVD and providing useful medical knowledge for both public health practitioners and clinicians in their management of a rising epidemic of CVD worldwide. Environmental epidemiological and panel studies are the 2 most frequently used research types to investigate the relation between air pollution and CVD in environmental cardiology. Numerous epidemiological studies have consistently reported that ambient air pollution, especially particulate matters (PM), is associated with cardiovascular morbidity and mortality in North America and Europe.4-9 The World Health Organization (WHO) published an air quality guideline in 2005, providing detailed information on health risk–associated air pollutants including PM. The American Heart Association (AHA) has also issued 2

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as well as intervals an accompanying rapid increase in industrializaSO2 = sulfur dioxide tion. sex. As a rematters sult. Panel study is a commonly used study design to investigate the mechanisms of air pollution effects on humans by collecting pollution (usually in seconds to hours) and pathophysiologic data (eg. . this approach defines the onset time of their illness or death as “case periods” and the matched time before or after their case periods as the “control periods. we will summarize existing evidence associating ambient air pollution with CVD and cerebro- Abbreviations and Acronyms A short description of “time series. and SPM = suspended particulate motorization. now the region with the worst air pollution in the world. heart rate.4 This is an intriguAir Pollution in Asia ing phenomenon conPM = particulate matters sidering the rapidly worsening air pollution PM10 = particulate matters in many countries in with diameter b10 μm Asia.10 Most cardiologists in BP = blood pressure Asia. Su et al. increases in daily mortality or morbidity) of air pollution episodes (eg.5 μm enced enormous ecoSDNN = standard deviation of nomic and social normal-beat to normal-beat development. / Progress in Cardiovascular Diseases 53 (2011) 369–378 scientific statements on PM air pollution and AHA = American Heart CVD to medical comAssociation munities in 2004 and ADS = Asian dust storms 2010. In past decades. For each study subject. The collected data can be readily analyzed by either time-series or mixed-effects regression models. continuously monitored blood pressure or heart rate variability or periodically measured biomarkers in urine or blood) for a group of study subjects (eg. conditional logistic regressions can be used to estimate the odds ratios for the study population. to relatively less research on HF = high frequency this important issue in HRV = heart rate variability the region than the IQR = interquartile range United States and Europe. It can also be applied to analyze associations between personal air pollution exposures (usually hourly concentrations measured by either fixed monitoring sites or personal samplers) and changes in individual's physiologic functions (eg. Case-crossover is a statistical approach used to examine acute effects (eg. For example. In this article.” This method can be regarded as a variant of the traditional case-control design. dust storm days or unusual high pollution days) for a population (usually the patients covered by the service of hospitals or all residents in cities or entire country) over a period time (usually years). UFP = ultrafine particle and the health impact of VOC = volatile organic air pollution in this recompound gion has been already estimated to be substanWHO = World Health Organization tial. Such analysis can be readily performed in standard statistical packages. some of the highest TSP = total suspended levels of outdoor air particles pollution in the world are found in Asian cities. the case-crossover design has the advantage of eliminating individual's confounding factors (eg.11 There is an urgent need to fill the knowledge gap of our understanding of the impact of air pollution on health in Asia. The WHO cautioned that urban air pollution might contribute to approximately 800. and heart rate variability) for a group of people (usually in tens to hundreds) over a period (usually days to months).4 million lost life–years worldwide in 2000. Because both “case” and “control” components are from the same individuals. with two thirds of these losses occurring in rapidly developing Asian countries. adults. in part.-C. CO = carbon monoxide Such a knowledge gap CVD = cardiovascular disease is due. less LF = low frequency than 10% of studies in NO2 = nitrogen dioxide the 426 references in the AHA Scientific StateO3 = ozone ment of 2010 are from PAPA = Public Health and Asia. PM2. age.” “case crossover” and “panel study” Times-series analysis is a statistical approach used to examine associations between air pollution levels (usually daily concentrations measured at fixed monitoring sites) and changes in morbidity or mortality of cardiopulmonary diseases for a study population in several cities or even an entire country over a period (usually several years). elderly people or patients) and following them up for a period (usually days to months). blood pressure.5 = particulate matters Asian countries experiwith diameter b2.000 deaths and 6. however. and education level). and hence.370 T.4. are still CAVI = cardio-ankle vascular not fully aware of such index new findings and have CHF = congestive heart not yet linked ambient failure air pollution to CVD in their clinical practice. urbanization. children.

According to average air quality levels between 2000 and 2003 summarized by the Clean Air Initiative Network (Fig 1). and Vietnam have the highest levels of outdoor air pollution in the world. and motorization. Air pollution and exposure in Asia Air pollution in Asia is composed of a mixture of pollutants. India.12 most Asian cities cannot comply with the WHO air quality guidelines or the US Environmental Protection Agency standards. Nitrogen Oxide (NOx). India. population structure. including cars and industries. is also an important emitted source of urban air pollution in South and Southeast Asia. Two-stroke vehicles. Fig 1. under-regulated emission standards of vehicles. . and Japan. The burning of biomass. and Thailand. carbon monoxide (CO). The average ambient air pollution levels in Asian cities between 2000 and 2003. Exposure becomes even worse because of frequent traffic congestion in Asian countries such as China. Large cities in this region are often surrounded by agricultural land. and disease pattern from those in Europe and North America.-C. Air quality in Asia has deteriorated significantly in recent decades because of rapid industrialization. Traffic emission in South Asia is especially different from that in Europe or North America. Su et al. combustion of lower-quality fuels. and PM in Taiwan with 20 million motorcycles. We will also provide an Asian perspective on whether previous study results in the West can be directly extrapolated to our understanding of air pollution on CVD in Asia. Indonesia. and the open burning of agricultural waste may also contribute directly to urban air pollution. The products of biomass burning include CO. Taiwan. the Philippines. and open burning of biomass and solid waste materials together contribute to a larger portion of emissions in many Asian countries. Data from Clean Air Initiative-Asia Network. including rice straw and garbage as well as forest fire. Pakistan. including particles and gases emitted in large quantities from many different combustion sources. exceptions are cities in more developed countries such as Singapore. 2003. which has different spectra of air pollution. urbanization. and high contents of aromatic hydrocarbons and sulfur in gasoline and diesel oils. having the largest motorcycle fleet in the world.T. Several Asian cities in China. In addition to comparatively higher air pollution levels. / Progress in Cardiovascular Diseases 53 (2011) 369–378 371 vascular diseases in this region. Asian countries have specific emission sources that are different from those in the West. The 2-stroke engines of motorcycles are an especially important source of volatile organic compounds (VOCs).

18 Air pollution may interact with such transition in population structure. Taiwan. Current findings for the associations of various cardiovascular and cerebrovascular outcomes and air pollution in Asia are discussed in further detail below.5 μm (PM2. CO. In the case-crossover design. South Korea. Japan. methane. and sulfur dioxide (SO2). Malaysia. coronary insufficiency.This design is a powerful tool in the evaluation of the association between short-term air pollution exposure and the risk of an immediate adverse health event. live in urban areas now. A growing consumption of high-fat and high-carbohydrate food among people is occurring because of the rapid expansion of fast-food restaurant chains in the region. nonmethane hydrocarbons.13 In addition. with a transition of lifestyle and diet from a traditional way to a Western pattern and universal increase in life expectancy. and other noncommunicable diseases are becoming leading causes of diseases and deaths in the region in the past 2 decades. Only about 50 studies evaluated cardiovascular outcomes to short-term air pollution exposure. from 30% to 50% of the population. CO. and Vietnam. Japan.-C. Indonesia. Time-invariant confounders are controlled by making within-subject comparisons.24.25 One recent report in Taipei found an increase in hospital admission for myocardial infarction with increases in O3 and NO2 concentrations in both warm and cool days.14 Long-range transported air pollution. ozone (O3).5).19 We do not intend to review all of these studies in this article. lifestyle. In addition. nearly twice that in North America. A time-series study conducted in Seoul. South Korea. lifestyle. roads. The prevalence of cancers. anecdotal emissions from manufacturing mishap can also contribute significant exposures to residents in industrial areas. nearly 75% were conducted in 4 Asian countries. such as China. Only one publication evaluates 1-year air pollution exposure on . enhance the negative health impacts. blood pressure (BP) change. and Hong Kong (China). such as Asian dust storms (ADS) in north Asia and forest fires in South Asia. Thailand. Japan. nitrogen dioxide (NO2). time-series and case-crossover designs were commonly used. Table 1 summarizes the strength of evidence for cardiovascular and cerebrovascular effects of particulate and gaseous pollutants from all Asian studies reviewed in this article. Asian countries are increasingly urbanized.21 Studies in Taiwan also showed an excess of emergency department visits for CVD with PM with diameter b2. Among these studies. NO2.26 Two timeseries studies in Hong Kong showed significant associations between hospital admissions for CVD and air Evidence for air pollution on cardiovascular effects in Asia More than 400 original epidemiological studies from Asia on health impacts of outdoor air pollution have been published in peer-reviewed English journals since the 1980s. we will focus on epidemiological studies that present key findings about short-term outdoor air pollution effects on CVD morbidity and mortality and those that elucidate the pathophysiologic mechanisms of cardiovascular effects by air pollution in general and PM in specific. and farms. The time-series design highlights the important component of repeated measurement or longitudinal data in the environmental study. / Progress in Cardiovascular Diseases 53 (2011) 369–378 carbon dioxide. NO2. Instead.372 T.23 Associations between congestive heart failure (CHF) hospitalization and PM. and disease pattern and. China. Of these. CVD.16 Residents of Asian cities are likely to have higher exposures to air pollution than those in Western nations because of their proximity to the pollution sources of industries. each individual's exposure just before the immediate adverse health event was defined as “case component” and compared with the same individual's exposure at a referent time (control component). and disease pattern in Asia According to the United Nations.15 The transitions of population structure. Hospital admissions and emergency department visits for CVD Epidemiological studies consistently demonstrate the effect of short-term air pollution on cardiovascular hospitalization in several Asian countries. the panel study is also applied to assess the short-term association between air pollution and health outcomes by repeatedly observing the same respondents over time. Su et al. The panel study is readily appreciated and understood by many practitioners than the longitudinal models. nitrogen. and China. methyl chloride.20 It was reported that NO2 and PM10 were associated with daily hospital emergency visits for angina.22. the high-density population in Asia presents a closer exposure to air pollution emissions than their Western counterparts. Korea. Aging is a general demographic trend. Singapore. Japan. Hong Kong. and myocardial infarction in Tokyo. with the exception of a still relatively young population in India and Indonesia. South Korea. more than half of these studies addressed the effects of air pollution on respiratory outcomes. including Taiwan. O3. account for additional exposure to the residents in the affected countries. found that hospital admission for ischemic heart disease was associated significantly with air pollutants of PM with diameter b10 μm (PM10). and CO were also observed. People also become more inactive in their daily life because of increasing motorized transport and farming. however. Taiwan. PM10. hence. and O3.17 The patterns of morbidity and mortality are also changing in Asian countries. and PM in various size classes.

In Seoul. of Studies) Hospital admission for CVD (14) Mortality of CVD (15) Hospital admission for cerebrovascular disease (3) Mortality for cerebrovascular disease (2) Systemic inflammation and thrombosis (2) HRV (5) Cardiac contractility (1) BP (4) Aortic pulse wave velocity (1) TSP +++ + PM10 +++ +++ + + + + + PM2. Mortality of CVD An increasing number of epidemiological studies have been independently conducted in several Asian countries.48 Asian studies. SO2. the pollution effects were even more evident in the cool season and among females. including South Korea. SO2.4% and 6. CO. however. Shanghai. NO2 and CO was significantly associated with hospital admission for ischemic stroke in 9 US cities. and Wuhan. China.31.41 This multicity study concluded that a 10-mg/m3 increase in PM10 level was associated with a 0. Su et al. and O3 with cardiovascular mortality.30 Multicity studies demonstrated the positive associations between suspended PM (SPM) and cardiovascular mortality in Japan.9% increase in daily rates of cardiovascular mortality. SO2. Japan.35 There was a significant decline of 2.28 These studies confirm the association between increases in cardiovascular hospitalization and short-term PM and gaseous pollutant exposures of less than 1 week.85% per 10 mg/m3 of PM2.24. +++ indicates the strong consistence of overall epidemiological evidence. South Korea. and low educational residents. SPM. In South Korea.42 It should be mentioned that the effects of the 4 pollutants.32 Another study in Tokyo. pollutants of PM10. + indicates inconsistent or weak epidemiological evidence. but such associations were not observed in hemorrhagic stroke.27 There is one study showing that cardiovascular hospital admissions were associated with gaseous pollutants (SO2 and NO2). showed inconsistent associations between air pollution and cerebrovascular diseases.3% in cardiovascular and cerebrovascular diseases.40 In Shanghai. PM10. which was more significant in areas with middle or high social deprivation. and Taiwan. CO.38 The Shanghai and Wuhan studies found that PM10. NO2. NO2.44 Mortality and hospital admissions for cerebrovascular diseases European studies showed that cerebrovascular diseases were significantly related to short-term exposure to NO2 and PM10. ++ indicates the moderate consistence of overall epidemiological evidence. a study demonstrated that air pollutants of PM10. China. particularly more evident in the cool season (from November to April) in Shanghai. Thailand.33 Studies in China demonstrated an excess risk for cardiovascular mortality by SO2 and total suspended particles (TSP). as well as the consistency.43. with higher risks for subjects older than 65 years.T.5 + + + ++ + + + UFPs SO2 +++ +++ + + ++ ++ + + NO2 +++ +++ + + + + + + CO ++ + + + + + O3 +++ ++ + + VOCs + 373 ADS + + + + + + The symbol “+” represents strength of the evidence based on the number and/or quality. SO2. / Progress in Cardiovascular Diseases 53 (2011) 369–378 Table 1 Summary of evidence for cardiovascular effects of particulate and gaseous pollutants from epidemiological studies in Asia Cardiovascular Outcomes (No.38-42 which were conducted in Hong Kong.27% to 1.49 One study in Japan found that PM with diameter b7 μm (PM7) increased the . SO2. and SO2. and O3 were significantly associated with daily mortality of ischemic stroke in different time lags. and Bangkok. China. tended to be equal or greater than those identified in studies conducted in the multicity studies in the United States. These 5 studies provide a relatively consistent picture of PM's impact on acute cardiovascular mortality in several large metropolitan areas in Asia. SO2.36 A study showed cardiovascular mortality was significantly associated with traffic-related air pollutants of NO2 and VOCs including propane.5 at a lag 0 to 1 day. of the relevant studies. Japan. respectively. The Hong Kong study found significant associations of NO2. also found that myocardial infarction deaths were associated with an increased SPM concentrations.37 The Public Health and Air Pollution in Asia (PAPA) studies. NO2 and O3. NO2. PM10.39 The Bangkok study showed an excess risk for cardiovascular mortality by PM10.39.47% to 0. which have consistently demonstrated the positive associations between short-term PM exposure and cardiovascular mortality ranging from 0. O3. NO2. and O3 increased cardiovascular mortality. and O3 increased excess mortality in general and for patients with CHF particularly. to document excess risks of daily cardiovascular mortality by short-term air pollution. and benzene in Taiwan.0% in deaths from CVD after reducing sulfur content in fuel oil in Hong Kong since 1990. are the first coordinated multicity analyses of air pollution and daily mortality in Asia. Blank indicates lack of evidence.29 Another study in South Korea showed that PM10 was associated with increases of 4.34. isobutane. the elderly.-C.45-47 Acute exposure of PM10.

however. Japan. and heavy metals and all contribute to transboundary air pollution in Asia.51 The estimated relative risks were 1.53 Another important cause of transboundary air pollution in the region is the ADS.54 (95% confidence interval. A time-series study showed persons older than 65 years with previous hospital admissions for cardiorespiratory disease were significantly more likely to be rehospitalized during this event in 1997 than the prefire years of 1995 or 1996.81) and 1. PM.374 T. South Korea.32-1. low frequency [LF]. highly sensitive C-reactive protein. standard deviation of normal-beat to normalbeat intervals [SDNN] and square root of the mean squared successive normal-beat to normal-beat interval differences [RMSSD]) and frequency domain (eg. A study on 23 patients with coronary heart disease and 26 patients with 2 or more cardiovascular risk factors revealed that high air pollution days with PM10 concentration greater than 100 mg/m3 during 8 to 18 hours could increase in plasma levels of plasminogen activator inhibitor-1 compared with that in low PM10 days. There is prominent ethnic difference in cerebrovascular disease between Asian and white populations and diverse impact of air pollution on cerebrovascular diseases among different populations. however. and PM2. Reduced HRV has been demonstrated to be a predictor of increased cardiovascular morbidity and mortality.5. remaining for a period of 5 to 10 days. smoky haze over a large portion of Southeast Asia.84) for primary intracerebral hemorrhage for each interquartile range (IQR) increase in PM10 and NO2. and coagulation factors. Su et al. A study in South Korea also provided positive but nonstatistically significant evidence that cardiovascular mortality was associated with ADS events during 1995 to 1998. The findings of the Asian epidemiological studies indicate further investigation is still needed to confirm whether cerebrovascular diseases can be affected by air pollution to the same degree as CVDs. 1. including multiple biomarkers such as cytokines. smoke haze caused by land and forest fires seems to be the most common problem in South Asia.60-62 which are thought to participate in the pathophysiologic mechanisms of atherosclerosis. which originate from the Gobi desert areas in China and Mongolia and affect air quality in China.31-1. except for a few in Taiwan. ratio of LF to HF [LF/HF]). during which they are transported over large distances up to 5000 to 10. CO lagged 2 days. and intracranial atherosclerosis are more common in Asian populations than in white populations.5 and PM10 lagged 3 days and were significantly associated with increased emergency admissions for cerebrovascular diseases in single-pollutant models but not multipollutant models. the study in Taiwan found that PM10 and NO2 were significantly associated with admissions for both hemorrhagic and ischemic stroke on warm days. and plasminogen activator inhibitor-1. and hence cause air pollution in the downwind areas. accounting for 10% to 16% of total deaths.66 A panel study in Taiwan showed with 1to 4-hour moving average number concentration of . Hong Kong. Between April and November of 1997. high frequency [HF]. During ADS events. 8-hydroxy-2¢-deoxyguanosine.52 A Hong Kong study.63 One panel study on 76 healthy and young adults in Taiwan demonstrated that PM10.64 Heart rate variability Heart rate variability (HRV) is a noninvasive method and widely used to investigate cardiovascular autonomic control. VOCs. A significant increase in emergency visits for CVD was observed for the 39 high Asian dust events from 1995 to 2002 in Taiwan.59 Systematic inflammation and thrombosis An increasing number of both human exposure and toxicological studies in Europe and North America have elucidated the effects of PM on systematic inflammation and thrombosis.24 Cerebrovascular disease is one of the leading causes of mortality. organics.58 a positive but nonsignificant association with ischemic stroke. some studies in Taiwan also provided weak evidence that the ADS events are associated with CVD.56 (95% confidence interval.64 In this study. Another study in Taiwan found that O3 lagged 0 day.50 However.000 km. NOx.56. and even North America. few such evaluations of inflammatory biomarkers response to air pollution were conducted in Asia. Two time-series studies estimated the effects of dust storms were increases of 3. small artery lacunar infarct. PM2. The proportions of cerebral hemorrhage.65. showed negative associations between air pollution and cerebrovascular disease. / Progress in Cardiovascular Diseases 53 (2011) 369–378 risk of death because of intracranial hemorrhage but was not associated with death because of ischemic stroke.65% and 2.-C. especially for East Asian populations. Epidemiological studies on transboundary air pollution Both naturally occurring forest fires and dust storms and man-made coal-fired power plant and biomass burning emit large amounts of SO2. Heart rate variability can be analyzed in time domain (eg. 1. finer dust particles can be lifted up as high as 1 to 3 km into the atmosphere. was also observed in association with PM fraction size and components. these effects were not statistically significant. CO. a widespread forest fire in Indonesia threw a blanket of thick.59% in excess risks for circulatory and CVD admissions in Taiwan. and PM components of sulfate and nitrate were associated with increases in highly sensitive Creactive protein. tumor necrosis factor-a.55 However. fibrinogen. Taiwan. However. an oxidative stress marker. Among these emission sources.57 Another time-series study observed a statistically significant association between ADS events and daily intracerebral hemorrhagic admissions 3 days after the event.54 The highest frequency of ADS occurrence is observed during spring (March-May).

73% to 8. as well as transboundary pollution have not been sufficiently studied yet in many Asian countries. Japan. the components of PM2. A population-based study found that the pulse pressure. Asian cohort studies are also needed to improve our understanding of population susceptibility and pollution diversity.02 to 1 μm (NC0. The associations between CVD mortality. The other panel study in Taiwan further found that. as well as morbidity. motorized.0 μm (PM0.79 This study indicates that vascular function may be more sensitive to air pollutants than the autonomic balance and CAVI can be used as a new marker of cardiovascular effects by urban air pollution. Aortic pulse wave velocity Cardio-ankle vascular index (CAVI). and BP was significantly associated with SO2 and O3 in cold season. influences cardiovascular morbidity and mortality. such as sulfate and organic carbon. O3.to 3-day lags.73 A Taiwan population-based study on 7578 subjects observed that short-term PM10 exposure was associated with slightly elevated systolic BP and that elevated O3 was associated with elevated diastolic BP. and economically developed Asian countries.75 Epidemiological studies in North America and Europe reported inverse associations between PM and BP. agricultural. were associated with HRV reduction in 46 patients with risk for CVD.76. and 2-stroke mobile sources. CO. an index of aortic pulse wave velocity.5) nor PM with diameters between 2.8% and 2. PM2.68 However. a surrogate indicator of cardiac stroke volume.5-10) replicated the effects of PM0. Hong Kong. one recent study in Taiwan found that increased 1-year-averaged particulate air pollutants of PM10. more comprehensive studies are necessary to elucidate potential hemodynamic changes in response to short-term air pollution exposure. This may bias our current understanding of air pollution effects toward more urbanized. The following priority research issues should be fully addressed in future studies.80 Conclusions and recommendations Epidemiological studies conducted in Asia show that short-term outdoor air pollution.459 Korean subjects also found that PM10 concentrations were associated with BP with a lag of 0 to 2 days in warm season. neither PM with diameters between 1.02-1) was associated with decreases in both time. in part.5.67 This is the first study to examine the effects of personal exposure to ultrafine particles (UFPs) on HRV.3 and 1. can represent the change in vascular tone and is associated with coronary atherosclerosis and left ventricular function in patients with ischemic heart disease. Su et al.5 μm (PM1.78 One recent panel study in Taiwan reported that an IQR increase in personal exposure to O3 and PM1. and important sources of air pollution. and NO2 were associated with elevated systolic and diastolic BP.5. There still is the need to conduct more epidemiological research to fill the knowledge gap of our understanding of the extent of health impacts and the physical-biologic mechanism of air pollution on health in the region.5% increase in CAVI but not with HRV change among young. Blood pressure A panel study in Taiwan found that with 1 to 3 hour of NC0.-C. indicating a decrease in cardiac contractility with short-term air pollution exposure. PM10.88% decreases in SDNN and 2. healthy mail carriers.72 This study provided some information that cardiac contractility might be altered after short-term air pollution exposure. O3.19 One communitybased study on 10. More collaborative research is especially needed to elucidate short-term and long-term air pollution effects on cardiovascular morbidity and mortality. especially PM. in addition to PM2.3 of 3 billion populations in the region). . Another Taiwanese study also observed an HRV reduction with 1.77 Apparently. there are discrepancies between air pollution and BP among studies in Asian and non-Asian studies. The success of such research requires Asian health and environmental scientists to build up collaborative multidisciplinary teams of investigators and that governments throughout Asia commit adequate long-term resources to this important public health issue.25% decreases in square root of the mean squared successive NN interval differences for an IQR of PM with diameters between 0.5.5 was associated with a 4. and South Korea. such as industrial. Westernized.5 and 10 μm (PM2. O3.T. because of the difficulties in invasive surgical instrumentation of human beings that measure real-time hemodynamic change with short-term air pollution exposure.and frequency-domain HRV indices in 9 healthy subjects.02-1 exposure. CO. However.71 Cardiac contractility There are only limited epidemiological studies that demonstrate the associations between air pollutants and cardiac contractility. or SO2 exposure in Taiwan. systolic and diastolic BP significantly increased in 10 patients with lung function impairment.70 One Korean study shows that subjects with metabolic syndrome had significant decreases in SDNN and HF with the CO exposure for 25 to 48 hours preceding the HRV measurements. which encompass only a small proportion of the total Asian population (0. These studies were conducted primarily in the countries with electronically available air pollution data such as Taiwan.49% to 4.74 Regarding longterm air pollution exposure.0-2. / Progress in Cardiovascular Diseases 53 (2011) 369–378 375 submicrometer particles with a size range of 0.3-1) in cardiac and hypertensive populations.0 and 2. narrowed by SO2. and NO2 at 1.69 A panel study showed that decreases in SDNN and LF HRV indices in 83 cardiovascular patients were associated with NO2 but not with PM10.0-2.3-1.

May HT. Geneva: WHO. detailed information of subject's disease status and medication need to be considered in future studies of the cardiovascular effects of urban air pollution in Asia. Limited studies have addressed the compositions of particulate pollutants and their associated health effects. Ajero M. Koppmann R. including systemic inflammation and thrombosis. References 1.350:2438-2440. Presented at 13th World Clean Air and Environmental Protection Congress and Exhibition. Taipei: Department of Health. Pope CA. vascular dysfunction and atherosclerosis. and coronary heart disease in the Nurses' Health Study.int/whr/2002/en/whr02_en.99:692-705. Circulation 2004. Available at: http://www. part I: gaseous emissions of carbon monoxide.-C. Acknowledgments This study is supported by a grant from National Science Council. Yanosky JD. August 22. Reducing risks. et al: American Heart Association council on epidemiology and prevention. 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Fabian H: Benchmarking urban air quality management in Asian cities.121:2331-2378. Additional panel studies will need to determine if these parameters are a physiologic response to underlying hemodynamic change with air pollution exposure or real risk factors linking air pollution to CVD. Puett RC. 13. 7. et al: Ischemic heart disease events triggered by short-term exposure to fine particulate air pollution. 9. Reid JS: A review of biomass burning emissions. Rajagopalan S. Available at: http://www. Taiwan. A statement for healthcare professionals from the expert panel on population and prevention science of the American Heart Association. More studies are needed to evaluate PM constituents and their relationship to cardiovascular effects and clinical outcomes.376 T. Circulation 2004.O.tw/CHT2006/DM/DM2_2_p02. et al: Chronic fine and coarse particulate exposure. Czapiewski KV.aspx?class_ no=440&now_fod_list_no=11397&level_no=-1&doc_no=76512. increase in BP.117: 1697-1701.C. can be shielded by modern cardioprotective therapy. Circulation 2010. promoting healthy life. More cohort studies are needed in Asian populations to estimate effects of long-term exposure on mortality and life expectancy. 2009. several cohort studies in Europe and North America have reported the associations of long-term PM concentrations with cardiovascular mortality and subclinical outcomes of such as BP and atherosclerosis.83 Because genetic diversity and medication patterns among patients with CVD vary widely among Asian populations. the compositions of particulate in Asia may be quite different from those in Europe or North America. Franklin B.62 Hemochromatosis genotype is also found to modify PM's effects on cardiac autonomic function. The effects of PM constituents The emission sources in Asia are much different from those in the West. N Engl J Med 2007. 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