Beating cardiovascular disease — the role of Europe’s environment

Understanding the issue

Cardiovascular disease (CVD) impacts the lives of many European residents. It is the most common cause of death in EEA member countries. Every year in the EU, more than 6 million new cases of CVD are diagnosed and over 1.7 million people die from diseases of the circulatory system, representing around 37% of all deaths (Timmis et al., 2022; WHO, 2022). The burden of disease from CVD is generally higher in central and eastern Europe than in northern, southern and western Europe (IHME, 2020; Timmis et al., 2022).

CVDs are a large and complex group of illnesses, encompassing often interrelated disorders of the heart and blood vessels. Some of the most common CVDs include ischaemic heart disease (heart attacks) and cerebrovascular diseases (strokes).

The causes of CVD are also complex. Some of the known individual determinants for cardiovascular disease, such as age, sex, race/ethnicity and family history, are intrinsic to the individual and cannot be modified, whereas others are external and can be at least partially modified. Established risk factors that can be modified to reduce CVD risks include:

• clinical risk factors such as high blood pressure, high blood cholesterol, excess weight and obesity, and diabetes. Some of these may be partly hereditary;
• behavioural risk factors such as unhealthy diet, lack of physical activity, smoking and alcohol use;
• environmental risk factors like exposure to air pollution, noise and chemicals in the environment and the workplace, second-hand smoke, some infectious agents, thermal stress, and limited accessibility to settings that facilitate physical activity like green spaces.

Clinical CVD risk factors are affected through a variety of biological mechanisms as well as behavioural and environmental factors. Both are heavily influenced by socioeconomic factors like low levels of income and education, unemployment or insecure employment, and related psychosocial problems (see figure 1). Clinical and behavioural CVD risk factors are the main modifiable contributors to CVD and are thus typically the target of prevention and policy efforts towards cardiovascular health.

Figure 1. Cardiovascular disease: modifiable risk factors and individual determinants

Source: Adapted from Fawzy and Lip, 2021; Hadley et al., 2022; Alves-Silva et al., 2021

The situation regarding CVDs in Europe has improved in recent decades. Since 1990, CVDs have become less lethal: age-standardised mortality rates from CVD have declined in double digits in all EEA member and collaborating countries, mostly due to improved screening, treatment, medications and lifestyles (e.g. less smoking). However, CVD morbidity has not decreased much, with only small declines in the age-standardised incidence of CVD. These sustained rates are driven by an ageing population, particularly in high-income European countries (Timmis et al., 2022).

Against this backdrop, reducing environmental risk factors can greatly help further decrease the burden of CVDs. Environmental CVD risk factors are mostly preventable and can be effectively reduced through policies and interventions that benefit large population groups at once. Moreover, because people typically cannot do much to protect themselves from environmental risk factors, this protection must come from public authorities or other institutional and social actors, like employers. This report focuses on environmental risk factors for CVD and their prevention.

Environmental contribution to cardiovascular disease in Europe

In Europe (EEA member and collaborating countries^[1], over 18% of all cardiovascular disease deaths are estimated to come from key environmental factors (IHME, 2020; Prüss-Üstün et al., 2016; Vaduganathan M et al., 2022). There is significant variation across EEA member and collaborating countries, with higher proportions of CVD deaths due to the environment estimated in eastern and south-eastern European countries, and Turkey (see Figure 2).

Figure 2. Percentage of preventable cardiovascular disease deaths attributable to environmental risks in Europe

Note: The environmental risks included in the source study for this map are outdoor and indoor air pollution, heat and cold, second-hand smoke and lead.

Source: Based on the Global Burden of Disease Study (IHME, 2020).

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This estimate (18% of preventable CVD deaths attributable to the environment) is likely an underestimate. This is because it includes only a selection of environmental factors for which enough data is available for most EEA member and collaborating countries (i.e. outdoor and indoor air pollution, heat and cold, second-hand smoke and lead). It does not include known CVD risk factors from exposures that may happen at the workplace (see box 1 below), nor does it include the effect of environmental noise (a major environmental risk in Europe), or of toxic chemicals other than lead (see chemicals section). Though we do not have Europe-wide estimates of the overall cardiovascular disease burden from many of these factors, in this report we nevertheless highlight existing scientific knowledge on their cardiovascular effects.

Figure 3. Prevalence of work-related cardiovascular diseases (disability adjusted life years (DALYs)^[2]) in the EU by country, 2000 and 2016

Source: (EUOSHA, 2023a)

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Environmental risks and their associations with cardiovascular disease

Explore the environmental risks and their associations with cardiovascular disease:

Conclusions

Environmental cardiovascular disease risks are inherently preventable and reducing them is key to bringing down the burden of cardiovascular disease in Europe. Individuals have limited scope for protecting themselves from most environmental determinants of cardiovascular disease, making regulatory intervention and policy implementation especially relevant and necessary. Policy and regulations need to be supported by sufficient resources allocated to preventing exposures (including occupational ones) and reducing pollution.

The decreasing trends in exposure to some environmental cardiovascular risks are encouraging but insufficient. They are far from indicating a general downward trend. In addition, cardiovascular disease cases tend to reflect past exposure, so decreasing levels of exposure will take years to translate into reduced incidence of cardiovascular disease. Moreover, we don’t yet fully understand the potential cardiovascular effects of all environmental risk factors — for example, nocturnal light pollution — or the combined magnitude of cardiovascular effects arising from certain risk factors such as toxic chemicals.

While data are incomplete and uncertainties are high, the existing scientific evidence solidly supports reducing environmental exposure as an effective — and cost-effective — strategy to reduce cardiovascular disease risks. Moreover, it is likely that we considerably underestimate the actual contribution of environmental exposure to cardiovascular diseases. We do not need to fully understand every step of the causal pathway from environmental exposures to cardiovascular disease cases to take decisive action to reduce pollution.