Association of Estimated Long-term Exposure to Air Pollution and Traffic Proximity With a Marker for Coronary Atherosclerosis in a Nationwide Study in China

IMPORTANCE: Epidemiologic evidence of the mechanisms of the association between long-term exposure to air pollution and coronary heart disease (CHD) is limited and relies heavily on studies performed in Europe and the United States, where air pollution levels are relatively low. In particular, the association between air pollution and CHD in patients with underlying risks for CHD is understudied. OBJECTIVE: To determine whether air pollution and proximity to traffic are associated with the coronary artery calcium (CAC) score, a key atherosclerotic marker. DESIGN, SETTING, AND PARTICIPANTS: In this prospective, population-based cross-sectional study in a large-scale setting in China, 8867 consecutive patients aged 25 to 92 years with suspected CHD were recruited between November 17, 2015, and September 13, 2017. Participants were excluded if they had previous myocardial infarction, stenting, or coronary artery bypass grafting or incomplete risk factors and exposure data. Each participant underwent assessment of CAC and CHD risk factors at baseline. Data were analyzed from December 2017 to November 2018. EXPOSURES: Annual means of fine particulate matter with aerodynamic diameter less than 2.5 μm (PM(2.5)), nitrogen dioxide (NO(2)), and ozone (O(3)) were estimated at the participants’ residences using a validated geostatistical prediction model. Exposure to a nearby roadway was also estimated. MAIN OUTCOMES AND MEASURES: Computed tomography measurement of CAC score. RESULTS: The mean (SD) age of the 8867 participants was 56.9 (10.4) years; 4378 (53.6%) were men. Annual mean (SD) PM(2.5), NO(2), and O(3) measurements were 70.1 (20.0), 41.4 (14.7), and 93.9 (10.5) μg/m(3), respectively. The mean (SD) CAC score was 91.4 (322.2) Agatston units. Exposure to PM(2.5) and NO(2), adjusting for CHD risk factors and multiple pollutants, were independently associated with increases in CAC scores of 27.2% (95% CI, 10.8% to 46.1%) per 30 μg/m(3) PM(2.5) and 24.5% (95% CI, 3.6% to 49.7%) per 20 μg/m(3) NO(2). For PM(2.5), odds of both detectable CAC (Agatston score >0; odds ratio, 1.28; 95% CI, 1.13 to 1.45) and severe CAC (Agatston score >400; odds ratio, 1.59; 95% CI, 1.20 to 2.12) were increased. Associations of CAC with PM(2.5) and NO(2) were greater among male participants (PM(2.5): 42.2%; 95% CI, 24.3% to 62.7%; NO(2): 45.7%; 95% CI, 25.3% to 69.5%) and elderly participants (PM(2.5): 50.1%; 95% CI, 28.8% to 75.0%; NO(2): 55.5%; 95% CI, 31.8% to 83.6%) and those with diabetes (PM(2.5): 62.2%; 95% CI, 30.9% to 101.0%; NO(2): 31.2%; 95% CI, 13.9% to 51.0%). Independent association with CAC score was 9.0% (95% CI, −1.4% to 20.4%) for O(3) per 15 μg/m(3) and 2.4% (95% CI, −0.6% to 5.4%) for distance near roadway per 50% decrease. CONCLUSIONS AND RELEVANCE: In this large Chinese study, long-term exposures to PM(2.5) and NO(2) were independently associated with severity of CAC. This finding may provide support for the pathophysiological role of coronary atherosclerosis through which air pollution exposure may be associated with CHD.