A cross-disciplinary evaluation of evidence for multipollutant effects on cardiovascular disease

Abstract Background The current single-pollutant approach to regulating ambient air pollutants is effective at protecting public health, but efficiencies may be gained by addressing issues in a multipollutant context since multiple pollutants often have common sources and individuals are exposed to more than one pollutant at a time. Objective We performed a cross-disciplinary review of the effects of multipollutant exposures on cardiovascular effects. Methods A broad literature search for references including at least two criteria air pollutants (particulate matter [PM], ozone [O 3 ], oxides of nitrogen, sulfur oxides, carbon monoxide) was conducted. References were culled based on scientific discipline then searched for terms related to cardiovascular disease. Most multipollutant epidemiologic and experimental (i.e., controlled human exposure, animal toxicology) studies examined PM and O 3 together. Discussion Epidemiologic and experimental studies provide some evidence for O 3 concentration modifying the effect of PM, although PM did not modify O 3 risk estimates. Experimental studies of combined exposure to PM and O 3 provided evidence for additivity, synergism, and/or antagonism depending on the specific health endpoint. Evidence for other pollutant pairs was more limited. Conclusions Overall, the evidence for multipollutant effects was often heterogeneous, and the limited number of studies inhibited making a conclusion about the nature of the relationship between pollutant combinations and cardiovascular disease.