Environmental Health is Cardiovascular Health

Making Environmental Risk Routine

For generations, physicians have evaluated cardiovascular risk through a familiar set of factors: blood pressure, cholesterol, diabetes, smoking, family history and lifestyle.

Now, environmental exposures — extreme heat, air pollution and the environmental footprint of medical care itself—directly impact patient health and should be incorporated into medical decision-making, according to Sarju Ganatra, MD, Medical Director of Sustainability and Vice Chair, Department of Medicine (Research).

Ganatra makes his case in three recent editorials published in JAMA Cardiology, the Journal of the American College of Cardiology (JACC) and Annals of Internal Medicine.

"Just as cholesterol and blood pressure were once invisible risks later integrated into routine care, environmental exposure may represent the next frontier in cardiovascular risk assessment," Ganatra and colleagues write in JACC.

While physicians have traditionally regarded dangers such as extreme heat and air pollution as public health challenges for policymakers to address, research increasingly suggests that those exposures can directly influence cardiovascular health at the individual patient level. In JAMA Cardiology, Ganatra and his colleagues cite projections showing that the toll of heat-related cardiovascular disease could nearly triple by 2050, with some of the largest increases occurring in low-income counties as well as among older adults.

"We tend to think of heat as a weather problem or a public health problem," Ganatra said. "But the evidence increasingly shows that it has direct consequences for cardiovascular health, particularly in older adults and vulnerable communities."

A second editorial focuses on air pollution. Writing in JACC, Ganatra and colleagues — including Sumanth Khadke, MD, an internal medicine resident at Lahey Clinic and Stephen A. Mein, MD, a pulmonologist at Beth Israel Deaconess Medical Center — highlight research involving more than 26 million Medicare beneficiaries showing that even levels of fine particulate air pollution considered acceptable under current EPA standards were associated with an increased risk of hospitalization for high blood pressure. The study estimated that reducing exposure by roughly half could prevent nearly one in nine hypertension-related hospitalizations.

"These findings challenge the implicit assumption that regulatory compliance equates to clinical safety," the authors write.

The third editorial extends the argument beyond individual patient care to the guidelines that shape clinical practice. In Annals of Internal Medicine, Ganatra and colleague Sumanth Khadke, MD, an internal medicine resident at Lahey Clinic, argue that as medical societies develop clinical guidelines, they should consider the environmental footprint of their recommendations alongside their benefits for patients. The authors contend that patients deserve to have a say in how their own care impacts the environment, and as such, clinicians need better training to understand the environmental consequences of medical decisions. As they write, "Guidelines that ignore planetary health do not reflect the world in which patients live."

The message running through all three editorials is that environmental health and cardiovascular health cannot be separated.

As Ganatra and colleagues write in JAMA Cardiology, "Recognizing and integrating ambient heat and broader environmental determinants into cardiovascular research, policy, and clinical care is not a future aspiration — it is already a present responsibility."

Authors, Funding and Disclosures

Annals of Internal Medicine

Co-authors included Sumanth Khadke of Lahey Clinic; and Sanjay Rajagopalan of Sustain Health Solutions and the Harrington Heart and Vascular Institute, University Hospitals and Case Western Reserve School of Medicine.

This study received no external funding.

Declaration of interests: Disclosure forms are available with the article online; specific conflicts are not listed in the published text.

Journal of the American College of Cardiology (JACC)

Co-authors included Stephen A. Mein of Beth Israel Deaconess Medical Center; and Sumanth Khadke of Lahey Clinic.

This study received no external funding.

Declaration of interests SG — Consultant: Boehringer Ingelheim. All other authors have no interests to declare.

JAMA Cardiology

Co-authors included Sumanth Khadke of Lahey Clinic; and Sadeer Al-Kindi of Houston Methodist Hospital and Sustain Health Solutions.

This study received no external funding.

Declaration of interests SG — Consultant: Boehringer Ingelheim. All other authors have no interests to declare.

About Lahey Clinic

Lahey Clinic is a world-renowned medical center known for its integrated clinic model of care, innovative technology, pioneering medical treatments and leading-edge research. As a physician-led hospital, Lahey offers a legacy of care and education committed to putting the patient at the center through a multidisciplinary, collaborative and team-based approach. Lahey’s research efforts and clinical trials cross numerous medical disciplines, providing patients with access to the latest options in treatment and care. Lahey is home to the UMass Chan-Lahey Regional Medical School campus.

Lahey Clinic is a part of Beth Israel Lahey Health, a healthcare system that brings together academic medical centers and teaching hospitals, community and specialty hospitals, more than 4,700 physicians and 39,000 employees in a shared mission to expand access to great care and advance the science and practice of medicine through groundbreaking research and education.