Preventing cardiovascular disease through a healthy environment

Introduction 

Cardiovascular disease impacts many lives in Europe. It is the most common cause of death in the EU: over 1.7 million people died from it in 2022, making up one third of all deaths within the bloc that year (EUROSTAT, 2025; Timmis et al., 2022; WHO, 2022). In addition, more than 6 million new cases of cardiovascular diseases are diagnosed every year, costing Europe about EUR 282 billion (Luengo-Fernandez et al., 2023). 

The causes of cardiovascular disease are complex, with several factors contributing to the clinical variables that affect cardiovascular health (see Figure 1). Some cardiovascular risks, such as age, and family history, are intrinsic to the individual and cannot be changed. Other risk factors, mainly behavioural and environmental ones, are modifiable through interventions and policies. Addressing them is crucial for prevention.

Figure 1. Cardiovascular disease: focus on environmental risk factors 

Environmental cardiovascular risk factors

In the EU, key environmental factors, including air pollution, extreme temperatures and chemicals, are estimated to cause at least 18% of all cardiovascular disease deaths and almost 17% of the cardiovascular burden of disease, a combined measure of death and disease (IHME, 2024; Prüss-Üstün et al., 2016; Vaduganathan et al., 2022). This burden is unequally distributed across the EU, reflecting differences in exposure to key environmental risk factors (see Figure 2). Moreover, these proportions are likely underestimates, as they do not include exposure to environmental noise and many cardiotoxic chemicals (both of which are discussed further below).

Figure 2. Cardiovascular disease deaths attributable to select environmental risks in the EU

Below is an overview of the most important environmental risk factors for cardiovascular disease in the EU and their impacts.

Air pollution

Air pollution causes around 8% of the cardiovascular deaths in the EU (IHME, 2024), and PM_2.5 alone causes over 130,000 ischaemic heart disease (IHD) and stroke deaths each year (EEA, 2024a). It also leads to over 1 million years of life lost annually. Fine particulate matter (PM_2.5), nitrogen dioxide (NO₂), and ozone (O₃) are the three key pollutants linked to cardiovascular disease in Europe. Long-term exposure to these pollutants contributes significantly to premature mortality and chronic cardiovascular conditions, including heart attacks, strokes and heart failure. In addition, air pollution is unequally distributed; for example, PM_2.5 levels are consistently higher in the EU’s poorer regions.

Noise pollution from transport

Long-term exposure to transport noise — from road, rail and air traffic — in Europe is associated with cardiovascular deaths and new cases of cardiovascular disease each year. Noise triggers stress responses and disrupts sleep, contributing to systemic inflammation. Over time, these effects raise the risk of developing a range of health conditions, particularly cardiovascular diseases such as IHD, stroke and heart failure (Münzel et al., 2025b). It is estimated that around 66,000 premature deaths annually in the EU are attributable to transport noise exposure, with more than 30% due to cardiovascular causes. Additionally, approximately 50,000 new cases of cardiovascular disease are linked to transport noise, representing about 0.7% of all cardiovascular disease cases in Europe (EEA, 2025a).

Chemical exposure

Exposure to toxic chemicals in the European environment, including in workplaces, also increases the risk of developing cardiovascular disease. Heavy metals such as arsenic, copper, cadmium, mercury and especially lead are linked to cardiovascular disease, even at very low exposure levels, if extended over a longer time (Shrivastav et al., 2024). Diseases include IHD, stroke and atrial fibrillation – an alteration of the heart rhythm that increases the risk of serious cardiovascular illness. Lead alone accounts for an estimated 2% to 4% of cardiovascular deaths in the EU (IHME, 2024). In various European countries, the level of lead already found in people’s blood can increase cardiovascular risk (Plass et al., 2024). Benzene and polycyclic aromatic hydrocarbons (PAHs), common air pollutants, are also associated with increased risks of heart attack and hypertension. This is particularly the case in workplaces with high exposure levels.  

Increasingly, evidence links exposure to endocrine-disrupting chemicals to harm to the cardiovascular system (Assenza et al., 2025). One phthalate alone (DEHP), a known endocrine disruptor, was estimated to result in over 27,000 cardiovascular deaths in Europe among people between 55 and 64 years old (Hyman et al., 2025). Emerging evidence is linking "forever chemicals" like per- and polyfluoroalkyl substances (PFAS), some of which are increasingly accumulating in the environment and in humans, with cardiovascular risks (Arredondo Eve et al., 2024; Zhu et al., 2024). Some of those pollutants are the target of controls under the updated water framework directive. However, we do not have a complete picture of how toxic chemicals affect cardiovascular disease. Epidemiological studies cover only a tiny fraction of the chemicals in our surroundings. Standardised test methods used to document chemical safety are often inadequate when it comes to detecting cardiovascular disease (Schaffert et al., 2023). This means we are likely to significantly underestimate how exposure to chemicals affects the cardiovascular system.

Climatic factors

Europe is facing unprecedented and escalating extreme climatic events, which can cause or exacerbate cardiovascular disease. For example, cardiovascular patients are especially vulnerable to heat, with a 16% increase in the risk of hospital admissions during heatwave days (Alho et al., 2024). An estimated 95% of the fatalities associated with weather and climate-related extremes recorded in Europe between 1980 and 2023 were linked to heatwaves (EEA, 2024b). And with 19% of the EU population reports being unable to keep their home comfortably cool during the summer (EEA, 2025b), vulnerable populations are particularly exposed to hazardously high temperatures. Moreover, heat and air pollution have a synergistic effect on health (EEA, 2023b). Climate change is set to enhance the formation of ground-level ozone and affect particulate matter concentrations via thermal inversions which trap pollution at the ground level (Doherty et al., 2017; Hamer et al., 2024). Since the beginning of 2025, 1,868 fires have been detected, burning more than 1 million hectares and making 2025 the worst year of wildfires on record in Europe. Wildfire smoke increases the risk of heart attack and stroke, especially in the elderly and those with pre-existing conditions (Hadley et al., 2022). Smoke and physically-strenuous tasks related to wildfire control also raise cardiovascular risks for firefighters (EU-OSHA, 2023; Groot et al., 2019). Heart attack is the second cause of death linked to floods after drowning (Petrucci et al., 2019).

Cold also remains a substantial risk to cardiovascular health. Low temperatures narrow our blood vessels, increasing blood pressure and forcing the heart to work harder. This can also make blood more viscous, elevating the risk of clots, stroke or heart attack. These risks are more relevant for those with a pre-existing cardiovascular condition (Manou-Stathopoulou et al., 2015). Almost 7% of cardiovascular deaths are attributable to low temperatures, an effect far stronger than that of heat (García-León et al., 2024) and worsened by energy poverty. In 2023, around 9.3% of the EU population (and 16.2% of low-income households) reported that they could not keep their homes warm enough (State of the Energy Union Report 2024 - European Commission, forthcoming).

Potential solutions

Environmental cardiovascular risk factors can be further reduced through policies and interventions that benefit large population groups at once. This would require specific action to tackle environmental risk factors, as well as broader action across sectors.

Reducing environmental cardiovascular risk factors:

• Air pollution: effectively implementing the revised Ambient Air Quality Directive (EU) 2024/2881 is crucial for cardiovascular protection. Specifically, the Directive will help reduce air pollution levels, bring them closer to the WHO recommendations and help achieve the ZPAP objectives. The Directive’s requirement to provide health-related information tailored to sensitive populations, including those with pre-existing health conditions, is expected to help protect cardiovascular patients.
• Environmental noise: reducing transport noise to achieve the ZPAP objectives requires large-scale interventions, stronger regulatory action, improved urban planning and greater awareness of its health impacts. Many urban planning measures that reduce noise, such as increasing access to calm, green areas and promoting active modes of transport, are de-stressing and encourage movement. These, too, can benefit cardiovascular health.
• Chemicals: reducing cardiovascular risks from chemicals depends on better enforcing chemical regulations, accelerating the phase-out of cardiotoxic substances and promoting safer alternatives to them. Monitoring and human biomonitoring should be improved, especially for emerging contaminants. It is also crucial to support research activities to increase the knowledge base, including by developing new approach methods (NAMs) to test chemicals for cardiovascular effects.
• Climate change: health systems should prepare for and mitigate climatic impacts on cardiovascular health through early warning systems, public health campaigns and targeted support for vulnerable groups (e.g. within heat-health action plans). Better integrating health into climate adaptation planning, especially at the local government level, is essential as climate risks grow. Action in this area can be supported by evidence, including case studies and indicators, available at the European Climate and Health Observatory.  

Acting in an integrated way:

• One Health approach: Integrating environmental considerations in actions to prevent non-communicable diseases could strengthen the EU One Health approach, which is based on the interconnection and interdependence between the health of humans, animals, plants and the wider environment. Strong and concerted action at both EU and global level is only possible through agile cross-sectoral collaboration between the health, chemicals, climate and environment sectors.
• Public awareness and education: public health campaigns can effectively raise awareness about cardiovascular risks from environmental stressors and promote lifestyle changes (Münzel et al., 2025). Personal actions to reduce exposure (e.g. to air pollution) can complement, not replace, system-wide emission reductions. EEA tools like the European Environment and health atlas, the Air quality index and the European city air quality viewer, as well as the zero pollution dashboards for regions and cities, can be used by patients and health practitioners.
• Health workforce awareness and engagement: while some medical schools are expanding curricula to include environmental health and climate change, most still lack formal education on these topics. As of 2020, about 75% of European medical schools did not cover climate change and health, and in 2022, most doctors and nurses in France, Germany and the UK lacked environmental literacy support (EEA, 2024c). At the same time, the success of initiatives such as the Nurses Climate Challenge Europe or the European Climate and Health Responder Course demonstrates that healthcare and public health professionals have an appetite for learning more about the intersections between health and the environment.
• Nature-based solutions: urban greening, parks, green corridors and blue spaces reduce cardiovascular risk by improving air quality, reducing noise pollution, reducing exposure to heat, encouraging physical activity and alleviating stress (WHO, 2025). Examples of nature-based solutions that protect health can be found at the European Climate and Health Observatory repositories.