Environmental toxic metal contaminants and risk of cardiovascular disease: systematic review and meta-analysis [环境中的有毒金属污染物与心血管疾病风险的关系：系统评价和荟萃分析]

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BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3310 (Published 29 August 2018)
Cite this as: BMJ 2018;362:k3310

Authors
Rajiv Chowdhury, Anna Ramond, Linda M O’Keeffe, Sara Shahzad, Setor K Kunutsor, Taulant Muka, John Gregson, Peter Willeit, Samantha Warnakula, Hassan Khan, Susmita Chowdhury, Reeta Gobin, Oscar H Franco, Emanuele Di Angelantonio

Abstract
Objective To conduct a systematic review and meta-analysis of epidemiological studies investigating the association of arsenic, lead, cadmium, mercury, and copper with cardiovascular disease.

Design Systematic review and meta-analysis.

Data sources PubMed, Embase, and Web of Science searched up to December 2017.

Review methods Studies reporting risk estimates for total cardiovascular disease, coronary heart disease, and stroke for levels of arsenic, lead, cadmium, mercury, or copper were included. Two investigators independently extracted information on study characteristics and outcomes in accordance with PRISMA and MOOSE guidelines. Relative risks were standardised to a common scale and pooled across studies for each marker using random effects meta-analyses.

Results The review identified 37 unique studies comprising 348 259 non-overlapping participants, with 13 033 coronary heart disease, 4205 stroke, and 15 274 cardiovascular disease outcomes in aggregate. Comparing top versus bottom thirds of baseline levels, pooled relative risks for arsenic and lead were 1.30 (95% confidence interval 1.04 to 1.63) and 1.43 (1.16 to 1.76) for cardiovascular disease, 1.23 (1.04 to 1.45) and 1.85 (1.27 to 2.69) for coronary heart disease, and 1.15 (0.92 to 1.43) and 1.63 (1.14 to 2.34) for stroke. Relative risks for cadmium and copper were 1.33 (1.09 to 1.64) and 1.81 (1.05 to 3.11) for cardiovascular disease, 1.29 (0.98 to 1.71) and 2.22 (1.31 to 3.74) for coronary heart disease, and 1.72 (1.29 to 2.28) and 1.29 (0.77 to 2.17) for stroke. Mercury had no distinctive association with cardiovascular outcomes. There was a linear dose-response relation for arsenic, lead, and cadmium with cardiovascular disease outcomes.

Conclusion Exposure to arsenic, lead, cadmium, and copper is associated with an increased risk of cardiovascular disease and coronary heart disease. Mercury is not associated with cardiovascular risk. These findings reinforce the importance of environmental toxic metals in cardiovascular risk, beyond the roles of conventional behavioural risk factors.