Document Type : Original Article(s)


1 PhD Candidate, Neurology Research Center, Kerman University of Medical Sciences, Kerman, Iran

2 Associate Professor, Environmental Health Engineering Research Center, Kerman University of Medical Sciences, Kerman, Iran

3 Assistant Professor, Department of Biostatistics and Epidemiology, School of Public Health, Kerman University of Medical Sciences, Kerman, Iran

4 Assistant Professor, Department of Environmental Health Engineering, School of Health, Arak University of Medical Sciences, Arak, Iran


BACKGROUND: Outdoor air pollution has been considered as one of the most serious health concerns over the last decade. This study aimed to investigate the association between ambient air pollution and cardiovascular hospital admissions. METHODS: This investigation was carried out from January 1, 2010 to December 31, 2016, in the urban population of Arak, Iran. Daily records of concentrations of air pollutants including particulate matter less than 10 µm (PM10), nitrogen dioxide (NO2), particulate matter less than 2.5 µm (PM2.5), ozone (O3), carbon monoxide (CO), and sulfur dioxide (SO2) as well as the daily number of hospital admissions due to cardiovascular disease were inquired from the Arak Department of Environment and two major hospitals, respectively. Time-series regression analysis was used to evaluate the effect of the pollutants on cardiovascular hospital admissions with different lag structures, controlling for weather variables, seasonality and long-term time trends, and day of the week. RESULTS: Each 10 µg/m3 increase in PM10 and NO2 and 1 mg/m3 increase in CO concentrations at lag 0 (day) were significantly associated with an increase of 0.7% (P = 0.004), 3.3% (P = 0.006), and 9.4% (P < 0.001), respectively in overall cardiovascular hospital admissions. The elderly were more susceptible than those under 60 years to exposure to the pollutants (especially NO2) with regard to cardiovascular hospital admission. CONCLUSION: The results of this study showed that hospital admission for cardiovascular disease is partly related to the levels of ambient air pollutions in Arak. Susceptibility to air pollutants varies by age groups and sex. 


  1. Xu Q, Li X, Wang S, Wang C, Huang F, Gao Q, et al. Fine particulate air pollution and hospital emergency room visits for respiratory disease in urban areas in Beijing, China, in 2013. PLoS One 2016; 11(4): e0153099.
  2. Nasser Z, Salameh P, Nasser W, Abou Abbas L, Elias E, Leveque A. Outdoor particulate matter (PM) and associated cardiovascular diseases in the Middle East. Int J Occup Med Environ Health 2015; 28(4): 641-61.
  3. Daryanoosh SM, Goudarzi G, Omidi Khaniabadi Y, Armin H, Bassiri H, Omidi Khaniabadi F. Effect of Exposure to PM10 on Cardiovascular Diseases Hospitalizations in Ahvaz, Khorramabad and Ilam, Iran During 2014. Iranian Journal of Health, Safety & Environment, 2016; 3(1): 428-33.
  4. Pope CA 3rd, Dockery DW. Health effects of fine particulate air pollution: Lines that connect. J Air Waste Manag Assoc 2006; 56(6): 709-42.
  5. Mohammadi A, Azhdarpoor A, Shahsavani A, Tabatabaee H. Investigating the Health Effects of Exposure to Criteria Pollutants Using AirQ2.2.3 in Shiraz, Iran. Aerosol Air Qual Res 2016; 16(4): 1035-43.
  6. World Health Organization. Ambient (outdoor) air quality and health [Online]. [cited 2014]; Available from: URL:
  7. Vahedian M, Khanjani N, Mirzaee M, Koolivand A. Associations of short-term exposure to air pollution with respiratory hospital admissions in Arak, Iran. J Environ Health Sci Eng 2017; 15: 17.
  8. Rezaei S, Khanjani N, Mohammadi Senjedkooh S, Darabi Fard Z. The effect of air pollution on respiratory disease visits to the emergency department in Kerman, Iran. J Health Dev 2015; 4(4): 306-14.
  9. Hoek G, Brunekreef B, Goldbohm S, Fischer P, van den Brandt PA. Association between mortality and indicators of traffic-related air pollution in the Netherlands: A cohort study. Lancet 2002; 360(9341): 1203-9.
  10. Pope CA 3rd, Burnett RT, Thurston GD, Thun MJ, Calle EE, Krewski D, et al. Cardiovascular mortality and long-term exposure to particulate air pollution: Epidemiological evidence of general pathophysiological pathways of disease. Circulation 2004; 109(1): 71-7.
  11. Khanjani N, Ranadeh Kalankesh L, Mansouri F. Air pollution and respiratory deaths in Kerman, Iran (from 2006 till 2010). Iran J Epidemiol 2012; 8(3): 58-65.
  12. Dadbakhsh M, Khanjani N, Bahrampour A. "Death from respiratory diseases and air pollutants in Shiraz, Iran (2006-2012). Journal of Environment Pollution and Human Health 2015; 3(1): 4-11.
  13. Dastoorpoor M, Idani E, Khanjani N, Goudarzi G, Bahrampour A. Relationship between air pollution, weather, traffic, and traffic-related mortality. Trauma Mon 2016; 21(4): e37585.
  14. Hashemi SY, Khanjani N, Soltaninejad Y, Momenzadeh R. Air pollution and cardiovascular mortality in Kerman from 2006 to 2011. American Journal of Cardiovascular Disease Research 2014; 2(2): 27-30.
  15. Hoek G, Brunekreef B, Fischer P, van Wijnen J. The association between air pollution and heart failure, arrhythmia, embolism, thrombosis, and other cardiovascular causes of death in a time series study. Epidemiology 2001; 12(3): 355-7.
  16. Kang SH, Heo J, Oh IY, Kim J, Lim WH, Cho Y, et al. Ambient air pollution and out-of-hospital cardiac arrest. Int J Cardiol 2016; 203: 1086-92.
  17. Dadbakhsh M, Khanjani N, Bahrampour A. Death from cardiovascular diseases and air pollution in Shiraz, Iran (March 2006-March 2012). J Epid Prev Med 2016; 2(1): 114.
  18. Shah AS, Langrish JP, Nair H, McAllister DA, Hunter AL, Donaldson K, et al. Global association of air pollution and heart failure: A systematic review and meta-analysis. Lancet 2013; 382(9897): 1039-48.
  19. Ma Y, Zhang H, Zhao Y, Zhou J, Yang S, Zheng X, et al. Short-term effects of air pollution on daily hospital admissions for cardiovascular diseases in western China. Environ Sci Pollut Res Int 2017; 24(16): 14071-9.
  20. World Health Organization. Cardiovascular diseases (CVDs) [Online]. [cited 2016]; Available from: URL:
  22. Ukehaxhaj A, Gjorgjev D, Ramadani M, Krasniqi S, Gjergji T, Zogaj D. Air pollution in pristina, influence on cardiovascular hospital morbidity. Med Arch 2013; 67(6): 438-41.
  23. Franchini M, Mannucci PM. Short-term effects of air pollution on cardiovascular diseases: outcomes and mechanisms. J Thromb Haemost 2007; 5(11): 2169-74.
  24. Beelen R, Hoek G, van den Brandt PA, Goldbohm RA, Fischer P, Schouten LJ, et al. Long-term effects of traffic-related air pollution on mortality in a Dutch cohort (NLCS-AIR study). Environ Health Perspect 2008; 116(2): 196-202.
  25. Tonne C, Melly S, Mittleman M, Coull B, Goldberg R, Schwartz J. A case-control analysis of exposure to traffic and acute myocardial infarction. Environ Health Perspect 2007; 115(1): 53-7.
  26. Samoli E, Atkinson RW, Analitis A, Fuller GW, Green DC, Mudway I, et al. Associations of short-term exposure to traffic-related air pollution with cardiovascular and respiratory hospital admissions in London, UK. Occup Environ Med 2016; 73(5): 300-7.
  27. Katsoulis M, Dimakopoulou K, Pedeli X, Trichopoulos D, Gryparis A, Trichopoulou A, et al. Long-term exposure to traffic-related air pollution and cardiovascular health in a Greek cohort study. Sci Total Environ 2014; 490: 934-40.
  28. Colais P, Serinelli M, Faustini A, Stafoggia M, Randi G, Tessari R, et al. Air pollution and urgent hospital admissions in nine Italian cities. Results of the EpiAir Project. Epidemiol Prev 2009; 33(6 Suppl 1): 77-94.
  29. Bell ML, Peng RD, Dominici F, Samet JM. Emergency hospital admissions for cardiovascular diseases and ambient levels of carbon monoxide: Results for 126 United States urban counties, 1999-2005. Circulation 2009; 120(11): 949-55.
  30. Nasser Z, Salameh P, Dakik H, Elias E, Abou AL, Leveque A. Outdoor air pollution and cardiovascular diseases in Lebanon: A case-control study. J Environ Public Health 2015; 2015: 810846.
  31. Waked A, Afif C. Emissions of air pollutants from road transport in Lebanon and other countries in the Middle East region. Atmos Environ 2012; 61: 446-52.
  32. Solgi E. Assessment of copper and zinc contamination in soils of industrial estates of Arak region (Iran). Iran J Toxicol 2015; 9(28): 1277-83.
  33. Bhaskaran K, Gasparrini A, Hajat S, Smeeth L, Armstrong B. Time series regression studies in environmental epidemiology. Int J Epidemiol 2013; 42(4): 1187-95.
  34. Ye X, Peng L, Kan H, Wang W, Geng F, Mu Z, et al. Acute effects of particulate air pollution on the incidence of coronary heart disease in Shanghai, China. PLoS One 2016; 11(3): e0151119.
  35. Phung D, Hien TT, Linh HN, Luong LM, Morawska L, Chu C, et al. Air pollution and risk of respiratory and cardiovascular hospitalizations in the most populous city in Vietnam. Sci Total Environ 2016; 557-558: 322-30.
  36. Zhang Y, Wang SG, Ma YX, Shang KZ, Cheng YF, Li X, et al. Association between ambient air pollution and hospital emergency admissions for respiratory and cardiovascular diseases in Beijing: A time series study. Biomed Environ Sci 2015; 28(5): 352-63.
  37. Mustafic H, Jabre P, Caussin C, Murad MH, Escolano S, Tafflet M, et al. Main air pollutants and myocardial infarction: A systematic review and meta-analysis. JAMA 2012; 307(7): 713-21.
  38. Fung KY, Luginaah I, Gorey KM, Webster G. Air pollution and daily hospitalization rates for cardiovascular and respiratory diseases in London,
  39. Ontario. Int J Environ Stud 2005; 62(6): 677-85.
  40. Shahi AM, Omraninava A, Goli M, Soheilarezoomand HR, Mirzaei N. The Effects of Air Pollution on Cardiovascular and Respiratory Causes of Emergency Admission. Emerg (Tehran) 2014; 2(3): 107-14.
  41. Pereira Filho MA, Pereira LA, Arbex FF, Arbex M, Conceiēćo GM, Santos UP, et al. Effect of air pollution on diabetes and cardiovascular diseases in Sćo Paulo, Brazil. Braz J Med Biol Res 2008; 41(6): 526-32.
  42. Martins LC, Pereira LA, Lin CA, Santos UP, Prioli G, Luiz OC, et al. The effects of air pollution on cardiovascular diseases: Lag structures. Rev Saude Publica 2006; 40(4): 677-83.
  43. Milojevic A, Wilkinson P, Armstrong B, Bhaskaran K, Smeeth L, Hajat S. Short-term effects of air pollution on a range of cardiovascular events in England and Wales: Case-crossover analysis of the MINAP database, hospital admissions and mortality. Heart 2014; 100(14): 1093-8.
  44. Jevtic M, Dragic N, Bijelovic S, Popovic M. Cardiovascular diseases and air pollution in Novi Sad, Serbia. Int J Occup Med Environ Health 2014; 27(2): 153-64.
  45. Chang CC, Tsai SS, Ho SC, Yang CY. Air pollution and hospital admissions for cardiovascular disease in Taipei, Taiwan. Environ Res 2005; 98(1): 114-9.
  46. Hashemi SY, Khanjani N. Air Pollution and Cardiovascular Hospital Admissions in Kerman, Iran. J Heart Cardiol 2016; 2(2): 1-6.
  47. Xie J, He M, Zhu W. Acute effects of outdoor air pollution on emergency department visits due to five clinical subtypes of coronary heart diseases in shanghai, china. J Epidemiol 2014; 24(6): 452-9.
  48. Tong L, Li K, Zhou Q. Promoted relationship of cardiovascular morbidity with air pollutants in a typical Chinese urban area. PLoS One 2014; 9(9): e108076.
  49. Leem JH, Kim ST, Kim HC. Public-health impact of outdoor air pollution for 2(nd) air pollution management policy in Seoul metropolitan area, Korea. Ann Occup Environ Med 2015; 27: 7.
  50. Willocks LJ, Bhaskar A, Ramsay CN, Lee D, Brewster DH, Fischbacher CM, et al. Cardiovascular disease and air pollution in Scotland: No association or insufficient data and study design? BMC Public Health 2012; 12: 227.
  51. Dominici F, McDermott A, Daniels M, Zeger SL, Samet JM. Revised analyses of the National Morbidity, Mortality, and Air Pollution Study: Mortality among residents of 90 cities. J Toxicol Environ Health A 2005; 68(13-14): 1071-92.
  52. Zanobetti A, Franklin M, Koutrakis P, Schwartz J. Fine particulate air pollution and its components in association with cause-specific emergency admissions. Environ Health 2009; 8: 58.
  53. Jalaludin B, Morgan G, Lincoln D, Sheppeard V, Simpson R, Corbett S. Associations between ambient air pollution and daily emergency department attendances for cardiovascular disease in the elderly (65+ years), Sydney, Australia. J Expo Sci Environ Epidemiol 2006; 16(3): 225-37.