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More on air pollution and venous thromboembolism

Published:November 09, 2016DOI:https://doi.org/10.1016/j.ejim.2016.10.021
      We read with interest the letter by Vreugdenhil [
      • Vreugdenhil G.
      Electric vehicles. A small step towards improving air quality and mortality?.
      ] who, referring to our systematic review recently published in this Journal on the association between particulate matter (PM) and venous thromboembolism (VTE) [
      • Franchini M.
      • Mengoli C.
      • Cruciani M.
      • Bonfanti C.
      • Mannucci P.M.
      Association between particulate air pollution and venous thromboembolism: a systematic literature review.
      ], further strengthens the close link existing between exposure to air pollution and risk of developing cardiovascular diseases and cancer. His letter, which provides also possible solutions to the deleterious effects on health of PM, gives us the opportunity to offer some additional considerations. Venous thromboembolism, a life-threatening disorder with an estimated yearly incidence ranging from 0.8 to 2.7 per 1000 individuals [
      • Raskob G.E.
      • Angchaisuksiri P.
      • Blanco A.N.
      • et al.
      ISTH steering committee for World Thrombosis Day. Thrombosis: a major contributor to global disease burden.
      ], is a multifactorial disease which usually develops from a combination of genetic and environmental risk factors [
      • Raskob G.E.
      • Angchaisuksiri P.
      • Blanco A.N.
      • et al.
      ISTH steering committee for World Thrombosis Day. Thrombosis: a major contributor to global disease burden.
      ]. The overall worldwide morbidity and mortality associated to thrombosis are very significant, and VTE causes a major burden of disease across all socioeconomic classes and in low-, middle- and high-income countries [
      • Raskob G.E.
      • Angchaisuksiri P.
      • Blanco A.N.
      • et al.
      ISTH steering committee for World Thrombosis Day. Thrombosis: a major contributor to global disease burden.
      ]. Recent evidences have suggested a positive correlation between VTE and air particulate matter [
      • Martinelli N.
      • Olivieri O.
      • Girelli D.
      Air particulate matter and cardiovascular disease: a narrative review.
      ] and such clinical association has a well-documented biological plausibility, which includes PM-induced platelet activation and increased plasma levels of several coagulation factors involved in primary and secondary hemostasis [
      • Lippi G.
      • Danese E.
      • Favaloro E.J.
      • Montagnana M.
      • Franchini M.
      Diagnostics in venous thromboembolism: from origin to future prospects.
      ,
      • Emmerechts J.
      • Holyaerts M.F.
      The effect of air pollution on haemostasis.
      ]. However, a crucial question is: how many VTE cases occurring yearly are due to air pollution exposure? Unfortunately, as evidenced by our recent systematic review [
      • Franchini M.
      • Mengoli C.
      • Cruciani M.
      • Bonfanti C.
      • Mannucci P.M.
      Association between particulate air pollution and venous thromboembolism: a systematic literature review.
      ], it is not currently possible to give an answer to this question. Nevertheless, although the wide inter-study heterogeneity and the paucity of well-designed prospective trials prevented an accurate quantification of this risk [
      • Franchini M.
      • Mengoli C.
      • Cruciani M.
      • Bonfanti C.
      • Mannucci P.M.
      Association between particulate air pollution and venous thromboembolism: a systematic literature review.
      ], our impression arising from the qualitative analysis of the published literature data was clearly in favor of the existence of a link between PM and VTE. Notably, following our systematic review, other clinical studies have been published in the last few months, all documenting such an association. For instance, an adverse effect of higher concentrations of ambient air pollution on pulmonary embolism (PE) epidemiology was reported in the frame of a case-crossover study conducted in Spain from 2001 to 2013 and recently published in this Journal [
      • De Miguel-Diez J.
      • Jimenez-Garcia R.
      • Lopez de Andres A.
      • et al.
      Analysis of environmental risk factors for pulmonary embolism: a case-crossover study (2001-2013).
      ]. In addition, another recent retrospective case–control study conducted in Italy documented that the short-term exposure to high levels of air pollution was associated with a 2.5-fold increase in the risk of unprovoked proximal deep vein thrombosis (DVT) [
      • Spiezia L.
      • Campello E.
      • Maggiolo S.
      • Tormene D.
      • Simioni P.
      Short-term exposure to high levels of air pollution (nickel) and the risk of unprovoked proximal deep vein thrombosis in the legs.
      ].

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