Latest / European Society for Vascular Surgery / The Invisible Risk Factor for PAD: Air Pollution with A. Settembrini

Transcript

The Invisible Risk Factor for PAD: Air Pollution with A. Settembrini · European Society for Vascular Surgery

• 0:01
  According to the World Health Organization data,
• 0:05
  almost 99 % of the world's population is exposed
• 0:10
  to air pollution above recommended levels. We
• 0:13
  know that air pollution contributes to respiratory
• 0:17
  disease like asthma and lung cancer. But only
• 0:21
  more recently have we begun to understand its
• 0:24
  impact on cardiovascular disease. In fact, air
• 0:28
  pollution is responsible for more than 3 million
• 0:31
  deaths each year from ischemic heart disease
• 0:35
  and stroke, which is more than traditional cardiac
• 0:38
  risk factors such as diabetes, smoking or obesity.
• 0:52
  Hello and welcome to the ESVS podcast. I'm Joana
• 0:56
  Ferreira and today we're exploring a simple question.
• 1:00
  Can the air we breathe cause peripheral arterial
• 1:04
  disease? To help us unpack this, I'm delighted
• 1:08
  to welcome Professor Settembrini. Professor Settembrini,
• 1:13
  welcome to the podcast. Thank you very much for
• 1:16
  this very kind invitation. It's really an honor
• 1:20
  for me to hear you, to be here. And I would like
• 1:25
  to thank you especially because we met a lot
• 1:28
  of times and we met since many years when I was
• 1:34
  with my father in the UNSC meetings and I'm very
• 1:38
  happy for your invitation. Thank you. It's really
• 1:41
  an honor to have you here. Would you like to
• 1:44
  introduce you to our listeners for those who
• 1:47
  don't really know you? Okay, for sure. I'm a
• 1:52
  vascular surgeon in Milan, in Multimedica, it's
• 1:56
  an academic private institute, and I'm also associate
• 1:59
  professor of vascular surgery in Unica Millus
• 2:02
  University, which is a private university in
• 2:05
  Rome, International University of Medicine in
• 2:07
  Rome. So, let's talk about your study published
• 2:11
  last year in the European Journal of Internal
• 2:13
  Medicine. We will include the full reference
• 2:17
  in show notes. You conducted a large cohort study
• 2:20
  in Rome, analyzing data from more than 1 .7 million
• 2:24
  individuals. This work explores the link between
• 2:28
  long -term exposure to air pollution and the
• 2:30
  development of PAD. So let me start with two
• 2:35
  key questions. First, what association did you
• 2:39
  find between air pollution and PAD? And second
• 2:43
  question is... that air pollution is not a single
• 2:47
  entity. It is a complex mixture of thousands
• 2:51
  of components including ozone, nitrogen dioxide,
• 2:55
  carbon monoxide and many others. Do all these
• 2:59
  pollutants affect PED risk in the same way or
• 3:03
  are some more harmful than others? Thank you
• 3:08
  for this long question. I was very happy to participate
• 3:13
  to this paper. When they proposed me to join
• 3:17
  it, it was very interesting. This paper, as you
• 3:21
  already said, was performed by more than one
• 3:26
  million people and we analyzed the different
• 3:30
  pollutants in the air and their interactions.
• 3:34
  with the patients. We know that PAD has a risk
• 3:41
  factor, the smoke of cigarettes, but also the
• 3:45
  pollutants in the last years are emerging as
• 3:48
  risk factors for the developing of peripheral
• 3:51
  arterial disease. So in the recent years, the
• 3:54
  attention toward this pollutants is growing up.
• 3:59
  We decided to analyze the population of Rome
• 4:03
  because Rome is a city with a high grade of pollution.
• 4:06
  And we analyzed specifically three different
• 4:09
  pollutants, the most frequent in the pollution.
• 4:14
  They are black carbon, PN2 .5, and nitrogen dioxide.
• 4:19
  The results of our study were very interesting
• 4:23
  because the different pollutants have different
• 4:28
  behaviors. related to the pad especially the
• 4:32
  black carbon and pm2 2 .5 has quite similar behavior
• 4:38
  in the interaction to the development of pad
• 4:41
  meanwhile the nitrogen dioxide has a more interaction
• 4:47
  with a high grade of concentration of nitrogen
• 4:53
  dioxide there is a quite linear interaction between
• 4:58
  nitrogen dioxide and the increasing of PAD. So
• 5:02
  higher is the concentration of nitrogen dioxide,
• 5:06
  higher is the risk of the relation with PAD.
• 5:09
  Meanwhile, black carbon and PM2 curve with high
• 5:16
  grade of interaction with medium concentration
• 5:21
  and the higher concentration has a lower interaction
• 5:25
  with PAD. Okay, so the quantities of the molecules
• 5:30
  have an impact on the disease, is that? And it's
• 5:33
  not the same in all molecules, as I understood.
• 5:37
  That's interesting. So we know that are both
• 5:41
  the environment factors and individual factors
• 5:44
  at play. Do you think some people are simply
• 5:47
  more susceptible to defects of pollution on PAD
• 5:51
  disease? About the environment, yes. We analyzed
• 5:57
  that the men with age between 55 and 69 years
• 6:02
  old are more affected with the interaction between
• 6:08
  pollutants and PAD. We saw also an interaction
• 6:14
  with low grade, with a low deprivation index.
• 6:20
  which is an index in which you consider not only
• 6:23
  the clinical condition of the patients, but also
• 6:26
  the lifestyle of the patients and the social
• 6:30
  quality of the life of the patients. Okay, that's
• 6:35
  interesting. So, and talking about the cardiovascular
• 6:38
  risk factor, according to the European Society
• 6:41
  of Cardiology, patients with obesity may be at
• 6:45
  higher risk of the cardiovascular effect of PM2
• 6:49
  .5. In your experience and from your head read
• 6:54
  from the literature, does air pollution amplify
• 6:57
  the impact of traditional cardiovascular risk
• 7:00
  factors such as obesity, diabetes, smoking or
• 7:04
  hypertension? For sure, because we know that
• 7:07
  the pollutants have a direct interaction with,
• 7:11
  for example, pancreatic beta cells or with adipocytes.
• 7:17
  causing an increasing of the development of obesity
• 7:21
  and also the evolution of the diabetes. So the
• 7:26
  interaction between pollutants and the common
• 7:29
  risk factors is for sure positive. And also we
• 7:35
  should consider that atherosclerosis is an inflammatory
• 7:38
  disease and the pollutants cause a high -grade
• 7:41
  inflammation to the arteries. So we should consider
• 7:45
  pollutants. pollutants in a positive relationship
• 7:50
  with the development of PAD, but also of the
• 7:53
  common risk factors of atherosclerosis. When
• 7:57
  I was preparing this podcast, I read an idea
• 8:02
  that I didn't know, it's quite interesting, that
• 8:05
  someone living in a heavy polluted city could
• 8:09
  have the same cardiovascular risk as a person
• 8:12
  smoking 40 cigarettes a day. Is traffic the new
• 8:17
  tobacco? Sure. You should consider that, for
• 8:21
  example, in our paper, we consider nitrogen dioxide
• 8:24
  and black carbon, which are both traffic -related
• 8:28
  pollutants. For this reason, we can say that
• 8:31
  traffic cities have a higher risk of... Erotic
• 8:37
  risk factors. And if you live in a high grade
• 8:40
  of pollution city, it's quite similar to smoke
• 8:44
  more than 40 cigarettes per day. Unfortunately.
• 8:49
  Sorry, Joanna. We usually consider in every time
• 8:54
  the respiratory diseases caused by the pollutions
• 9:03
  and caused by the cigarettes. And usually in
• 9:08
  my daily practice, I say to our patients, everybody
• 9:11
  consider just the lungs or the respiratory diseases,
• 9:15
  but we should change our mind and we should consider
• 9:19
  for the most the atherosclerotic diseases caused
• 9:24
  by cigarettes or pollution. So, and in your clinical
• 9:29
  practice, do you ask your patients about where
• 9:32
  they live, about pollution? and what they should
• 9:35
  do to control the exposition to pollution. Do
• 9:40
  you ask them in your clinical practice or not,
• 9:43
  not yet? Before participating to the paper, to
• 9:47
  the work, no. Now I ask them, but I work in Milan,
• 9:53
  so I visit people living in Milan, so for the
• 9:58
  most they are living in the city or in the...
• 10:03
  close to the city, which is in any way a very
• 10:06
  polluted area. And my suggestions are to increase
• 10:11
  the therapy for the atherosclerotic lesions.
• 10:15
  So, for example, in claudicants, I push them
• 10:18
  to work for a long time, for a longer time, rather
• 10:24
  than the other patients in other non -polluted
• 10:30
  areas. Best suggestion for these patients and
• 10:35
  try to go in the weekend in non very polluted
• 10:42
  areas, but nothing more. And do you think there
• 10:46
  is any room to use masks or not? I'm not sure
• 10:55
  that masks can have a key role in this approach.
• 11:01
  After COVID time, we see the masks like the Holy
• 11:08
  Grail to protect ourselves from different pathologies.
• 11:13
  But I'm not sure that our atherosclerotic patients
• 11:19
  can have a real benefit. benefit from the masks.
• 11:23
  The masks. Professor Stimbrini, from a pathophysiological
• 11:28
  perspective, what are the main mechanisms through
• 11:32
  which hair pollution contributes to atherosclerosis?
• 11:36
  Yeah, there are Several mechanisms, but we know
• 11:43
  that air pollution can induce oxidative stress
• 11:46
  and systemic inflammation, and both of which
• 11:49
  play key roles in the development of the progression
• 11:52
  of the atherosclerotic lesions. We know also
• 11:55
  that pollutants can cause endothelial dysfunctions,
• 11:59
  hormonal alterations, and as I said before, lesions
• 12:04
  to the beta cells or... directly to the adipocytes.
• 12:10
  So, as I said before, the creation of a high
• 12:13
  grade of inflammation can cause an answer by
• 12:18
  our arteries and the answers sometimes with creation
• 12:22
  of atherosclerotic lesions. We should consider
• 12:27
  also the increasing of the atherosclerotic stiffness
• 12:33
  of the arteries. So it's also an increase in
• 12:38
  inflammation. So the pollution also contributes
• 12:40
  to increase the inflammation. Yeah. Is the association
• 12:46
  between air pollution and atherosclerosis truly
• 12:49
  causal? Or could it simply be due to confounding
• 12:53
  factors? People who live in highly polluted areas
• 12:58
  often also experience high levels of stress or
• 13:02
  social deprivation or other unfavorable living
• 13:06
  conditions. Did you account for these potential
• 13:10
  confounders in your study? In our paper, we don't
• 13:13
  have significant relationship, but we have had
• 13:18
  a relationship. between, for example, the social
• 13:23
  conditions of the patients and the development
• 13:25
  of the PAD. So I think there is not a casual
• 13:30
  relationship between the two things, but I think
• 13:34
  that age, deprivation index, sometimes the educational
• 13:38
  level could affect the development of the peripheral
• 13:43
  arterial disease related to the pollution. Moving
• 13:47
  on, treatment. Air pollution is actually a significant
• 13:51
  source of exposure to heavy metals like cadmium
• 13:55
  and lead. Some studies have looked to the use
• 13:58
  of the EDTA collection therapy in patients with
• 14:02
  PAD and suggest it may help with healing chronic
• 14:06
  ulcers or even gangrene. What are your thoughts
• 14:10
  on this approach? I read the papers. And I found
• 14:15
  them very interesting. We should consider this
• 14:17
  therapy. In our hospital, we don't use this therapy,
• 14:22
  but we should consider because the results of
• 14:25
  the papers reporting the DTA therapy are very
• 14:31
  encouraging, especially for the PAD and also
• 14:34
  the angina pectoris. So if it works, we could
• 14:39
  consider in the future for the treatment of this
• 14:42
  kind of patients. We have heard from the science.
• 14:46
  Now let's hear who can actually change the hairy
• 14:50
  breath in the cities. We are going to listen
• 14:52
  to the City Council from the second biggest city
• 14:56
  in Portugal, that is Porto. Hi, I'm Hugo Beirão
• 15:01
  and I'm a Porto City Councilor for Mobility and
• 15:05
  Transportation. Mobility is a key action for
• 15:08
  Porto on next years, for many points of view.
• 15:13
  The air pollution is one of these challenges.
• 15:17
  We also want to increase the green spaces, like
• 15:21
  parks and urban trees, promoting active mobility,
• 15:26
  walking and cycling for example. Reducing traffic
• 15:31
  emissions with low emission zones and increase
• 15:35
  the number of public transport users. Urban planning
• 15:40
  decisions that reduce exposure to pollution.
• 15:45
  This is Porto's reality and commitment for our
• 15:50
  development. Thanks, Joana. We clearly need to
• 15:56
  raise awareness. among the general population,
• 15:59
  the scientific community and special public authorities
• 16:02
  about the importance of lowering exposure to
• 16:06
  pollutants that can harm cardiovascular health
• 16:09
  and to actively support initiatives that reduce
• 16:13
  this risk in all these areas. Professor Stambrini,
• 16:18
  if you had five minutes with a city mayor or
• 16:21
  an environment minister, what policies change,
• 16:24
  would you beg them to implement to better protect
• 16:28
  vascular health? In our cities, we have many
• 16:30
  problems, especially due to the traffic jams.
• 16:34
  Traffic jams means a lot of pollution. So I think
• 16:38
  that the politics should improve the public services,
• 16:41
  particularly the electric ones, to implant more
• 16:44
  trees, which are the real lungs of our cities.
• 16:50
  increase the parks but also we need to work to
• 16:53
  the home heating systems which are consuming
• 16:56
  and producing a lot of pollutants because for
• 16:59
  example in Milan we have a lot of home heating
• 17:01
  systems very old and they are producing a lot
• 17:07
  of pollutants so the works are About the environment,
• 17:13
  so the trees and to reduce the traffic, but also
• 17:18
  to check the heating system of the houses. They
• 17:22
  are good advices. Let's see if someone listens
• 17:25
  to us. So, Professor Stembrini, thank you very
• 17:29
  much for sharing your expertise. So, if you want
• 17:33
  to say something to our listeners, go ahead.
• 17:38
  Thank you, Joanna. Thank you to ESBS for this
• 17:41
  great opportunity. And I hope that our listeners
• 17:44
  join our chat and they are curious to increase
• 17:51
  their knowledge about the relationship between
• 17:54
  pollution and PAD. Professor Stembrini, thank
• 17:58
  you very much for sharing your expertise and
• 18:01
  for helping us understand the complex relationship
• 18:04
  between air pollution and Vesco disease. Thanks
• 18:08
  for listening to the ESVS podcasts. Air pollution
• 18:12
  might be invisible, but its impact on vascular
• 18:15
  disease is real, cumulative and global. Don't
• 18:20
  forget to follow us on Spotify, SoundCloud, Apple
• 18:23
  Podcasts and through the ESVS library. And if
• 18:26
  you found this episode helpful, please share
• 18:29
  it with your colleagues. Until next time, stay
• 18:34
  informed. and listen to the next episode of the
• 18:37
  ESUS Podcasts while taking a walk in a green
• 18:42
  park.