Beyond Traditional Risk Factors: Environmental Drivers of Cardiovascular Disease

Innovations in Research

A landmark global scientific consensus is redefining how cardiovascular disease (CVD) risk is understood, placing environmental stressors alongside traditional clinical risk factors as major, preventable contributors to heart disease worldwide. Among the primary authors of this international effort is Sanjay Rajagopalan, MD, MBA, a physician‑scientist at University Hospitals Harrington Heart & Vascular Institute and Case Western Reserve University School of Medicine, whose research has helped shape global understanding of environmental determinants of cardiovascular health.

Sanjay Rajagopalan, MD, MBA

In 2026, a joint international statement titled Environmental Stressors and Cardiovascular Health: Acting Locally for Global Impact in a Changing World was issued collaboratively by the European Society of Cardiology (ESC), American College of Cardiology (ACC), American Heart Association (AHA), and World Heart Federation (WHF). The statement synthesizes a rapidly expanding body of evidence demonstrating that air pollution, noise, climate‑related hazards and features of the built environment play causal roles in cardiovascular morbidity and mortality.

Reflecting broad international consensus, the statement was published simultaneously in four major journals, European Heart Journal, Circulation, Journal of the American College of Cardiology and Global Heart, underscoring both the urgency and global relevance of environmental cardiovascular risk.

Reframing Cardiovascular Risk in a Changing World

Cardiovascular disease remains the leading cause of death globally, accounting for the majority of the more than 38 million annual deaths attributed to noncommunicable diseases. While established risk factors such as hypertension, dyslipidemia, diabetes, smoking, obesity, and physical inactivity remain central to prevention efforts, the new global statement emphasizes that environmental exposures substantially magnify cardiovascular risk and interact with biological, genetic, and social vulnerability across the lifespan.

The authors argue that a prevention paradigm focused exclusively on individual behaviors and clinical interventions is no longer sufficient. By situating cardiovascular disease within a broader environmental and societal context, the statement strengthens the scientific rationale for integrating environmental risk mitigation into cardiovascular medicine, population health strategies and public policy.

Environmental Stressors as Modifiable Cardiovascular Risk Factors

The statement highlights converging evidence that multiple environmental stressors act through shared biological mechanisms, including oxidative stress, chronic inflammation, autonomic imbalance, metabolic disruption and endothelial dysfunction to accelerate cardiovascular disease development.

Air pollution emerges as one of the most significant yet preventable environmental contributors to cardiovascular morbidity and mortality worldwide. Research summarized in the statement links particulate matter, traffic‑related pollution, environmental noise, chemical exposures and adverse urban design to increased risk of hypertension, myocardial infarction, arrhythmia, heart failure and stroke.

“Environmental exposures are no longer peripheral to cardiovascular medicine,” says Dr. Rajagopalan. “They are central, biologically active risk factors that must be addressed alongside traditional clinical determinants to meaningfully reduce global cardiovascular burden.”

An Exposome Framework for Cardiovascular Prevention

A central advance of the statement is the adoption of an exposome framework, integrating cumulative environmental exposures across the lifespan with genetic susceptibility, social determinants of health, and established clinical risk factors. This approach recognizes cardiovascular risk as the product of dynamic, lifelong interactions between biology and environment, rather than isolated exposures or behaviors.

Using this framework, the authors call for coordinated interventions spanning urban planning, transportation systems, housing, energy policy, food systems and health care delivery domains that collectively shape cardiovascular risk at

Clinical and Policy Recommendations

To translate scientific evidence into action, the statement proposes clinical and policy‑level strategies to reduce environmentally mediated cardiovascular risk, including:

• Integration of environmental exposure assessment into cardiovascular risk stratification and preventive care
• Expanded clinician education and training in environmental and preventive cardiology
• Increased public awareness of environmental contributors to heart disease
• Coordinated global research and surveillance initiatives focused on environmental CVD risk
• Development of climate‑resilient health systems capable of maintaining cardiovascular care during extreme weather events, such as heat waves, floods, wildfires and severe storms

The authors emphasize that addressing environmental determinants of cardiovascular disease offers a powerful opportunity to reduce disease burden while advancing health equity, particularly in disproportionately exposed populations.

Advancing Global Cardiovascular Health

Dr. Rajagopalan has published more than 300 peer‑reviewed research articles and is the recipient of the American Heart Association Distinguished Scientist Award. His work has helped shape international guidelines and advance understanding of how environmental stressors influence vascular biology and cardiovascular outcomes worldwide.

Collectively, the authors of the global statement argue that meaningful progress in cardiovascular prevention will increasingly depend on addressing the environments in which patients live, work and age. As climate change, pollution, and urbanization continue to reshape global health risks, the statement reinforces a clear conclusion: environmental risk must be treated as a core domain of cardiovascular medicine.