Mixtures of long-term exposure to ambient air pollution, built environment and temperature and stroke incidence across Europe

Jeroen de Bont*, Regina Pickford, Christopher Åström, Fabian Colomar, Konstantina Dimakopoulou, Kees de Hoogh, Dorina Ibi, Klea Katsouyanni, Erik Melén, Federica Nobile, Göran Pershagen, Åsa Persson, Evangelia Samoli, Massimo Stafoggia, Cathryn Tonne, Jelle Vlaanderen, Kathrin Wolf, Roel Vermeulen, Annette Peters, Petter Ljungman

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review


Introduction: The complex interplay of multiple environmental factors and cardiovascular has scarcely been studied. Within the EXPANSE project, we evaluated the association between long-term exposure to multiple environmental indices and stroke incidence across Europe. Methods: Participants from three traditional adult cohorts (Germany, Netherlands and Sweden) and four administrative cohorts (Catalonia [region Spain], Rome [city-wide], Greece and Sweden [nationwide]) were followed until incident stroke, death, migration, loss of follow-up or study end. We estimated exposures at residential addresses from different exposure domains: air pollution (nitrogen dioxide (NO2), particulate matter < 2.5 μm (PM2.5), black carbon (BC), ozone), built environment (green/blue spaces, impervious surfaces) and meteorology (seasonal mean and standard deviation of temperatures). Associations between environmental exposures and stroke were estimated in single and multiple-exposure Cox proportional hazard models, and Principal Component (PC) Analyses derived prototypes for specific exposures domains. We carried out random effects meta-analyses by cohort type. Results: In over 15 million participants, increased levels of NO2 and BC were associated with increased higher stroke incidence in both cohort types. Increased Normalized Difference Vegetation Index (NDVI) was associated with a lower stroke incidence in both cohort types, whereas an increase in impervious surface was associated with an increase in stroke incidence. The first PC of the air pollution domain (PM2.5, NO2 and BC) was associated with an increase in stroke incidence. For the built environment, higher levels of NDVI and lower levels of impervious surfaces were associated with a protective effect [%change in HR per 1 unit = −2.0 (95 %CI, −5.9;2.0) and −1.1(95 %CI, −2.0; −0.3) for traditional adult and administrative cohorts, respectively]. No clear patterns were observed for distance to blue spaces or temperature parameters. Conclusions: We observed increased HRs for stroke with exposure to PM2.5, NO2 and BC, lower levels of greenness and higher impervious surface in single and combined exposure models.

Original languageEnglish
Article number108136
Number of pages11
JournalEnvironment International
Early online date9 Aug 2023
Publication statusPublished - Sept 2023


  • Stroke
  • Multiple environmental exposures
  • Urban exposome
  • Meta-analysis
  • Air pollution
  • Green space


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