Long-Term Exposure to Air Pollution Below Regulatory Standards and Cardiovascular Diseases Among US Medicare Beneficiaries: A Double Negative Control Approach

Growing evidence suggests that long-term air pollution exposure is a risk factor for cardiovascular mortality and morbidity. However, few studies have investigated air pollution below current regulatory limits, and causal evidence is limited. We used a double negative control approach to examine the association between long-term exposure to air pollution at low concentrations and three major cardiovascular events among Medicare beneficiaries aged ≥ 65 years across the contiguous United States between 2000 and 2016. We derived ZIP code-level estimates of ambient fine particulate matter (PM (2.5) ), nitrogen dioxide (NO (2) ), and warm-season ozone (O (3) ) from high-resolution spatiotemporal models. The outcomes of interest were hospitalizations for stroke, heart failure (HF), and atrial fibrillation and flutter (AF). The analyses were restricted to areas with consistently low pollutant levels on an annual basis (PM (2.5) <10 µg/m³, NO (2) < 45 or 40 ppb, warm-season O (3) < 45 or 40 ppb). For each 1 µg/m (3) increase in PM (2.5) , the hospitalization rates increased by 2.25% (95% confidence interval (CI): 1.96%, 2.54%) for stroke and 3.14% (95% CI: 2.80%, 3.94%) for HF. Each ppb increase in NO (2) increased hospitalization rates for stroke, HF, and AF by 0.28% (95% CI: 0.25%, 0.31%), 0.56% (95% CI: 0.52%, 0.60%), and 0.45% (95% CI: 0.41%, 0.49%), respectively. For each ppb increase in warm-season O (3) , there was a 0.32% (95% CI: 0.21%, 0.44%) increase in hospitalization rate for stroke. The associations for NO (2) and warm-season O (3) became stronger under a more restrictive upper threshold. Using an approach robust to omitted confounders, we concluded that long-term exposure to low-level PM (2.5) , NO (2) , and warm-season O (3) was associated with increased risks of cardiovascular diseases in the US elderly. Stricter national air quality standards should be considered.