{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,23]],"date-time":"2026-06-23T05:48:16Z","timestamp":1782193696202,"version":"3.54.5"},"reference-count":48,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,6,23]],"date-time":"2026-06-23T00:00:00Z","timestamp":1782172800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Endocrinol."],"abstract":"\n Background<\/jats:title>\n The longitudinal associations between air pollution exposure and incident cardiovascular diseases (CVDs) among individuals with cardiovascular\u2013kidney\u2013metabolic (CKM) syndrome remains limited. This study aimed to estimate the associations of long-term exposure to air pollution with the incidence of total CVDs, heart disease, and stroke among Chinese individuals with CKM syndrome stages 0\u20133.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n \n This population-based cohort study used data from the China Health and Retirement Longitudinal Study (CHARLS, 2011\u20132018), matching air pollutant data from the China High Air Pollutants dataset. We applied single\n \u2013<\/jats:bold>\n and multiple\n \u2013<\/jats:bold>\n pollutant Cox proportional hazards model with time-varying to investigate whether annual mean exposure to PM\n 1<\/jats:sub>\n , PM\n 2.5<\/jats:sub>\n , PM\n 10<\/jats:sub>\n , O\n 3<\/jats:sub>\n , and NO\n 2<\/jats:sub>\n affects total CVDs and its major subtypes. Subgroup and mediation analyses were also performed to further evaluate the interactions among these factors.\n <\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n Among 7400 adults with CKM syndrome stages 0\u20133, 1611 (21.8%) reported CVD events (1212 heart disease and 551 stroke) during a 7-years follow-up survey. Per 10-\u03bcg\/m\n 3<\/jats:sup>\n increase in PM\n 1<\/jats:sub>\n , PM\n 2.5<\/jats:sub>\n , PM\n 10<\/jats:sub>\n , O\n 3<\/jats:sub>\n , and NO\n 2<\/jats:sub>\n corresponded to a 14.8% (hazard ratio [HR], 1.148 [95% CI, 1.086\u20131.214]), 9.6% (HR, 1.096 [95% CI, 1.064\u20131.128]), 6.8% (HR, 1.068 [95% CI, 1.052\u20131.084]), 2.5% (HR, 1.025 [95% CI, 0.962\u20131.091]), and 12.4% (HR, 1.124 [95% CI 1.063\u20131.189]) higher incident risk of CVD, respectively, whereas O\n 3<\/jats:sub>\n showed no significant association. We detected significant effect modification by education in the associations of incident CVD and heart disease with PM\n 1<\/jats:sub>\n , PM\n 2.5<\/jats:sub>\n , PM\n 10<\/jats:sub>\n , and NO\n 2<\/jats:sub>\n (P interaction &lt;0.05), suggesting that those with lower education level were more vulnerable. Metabolic syndrome partially mediated the association between air pollution exposure and CVD, highlighting its significance in CVDs risk assessment.\n <\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n \n In this nationwide cohort, long-term exposure to PM\n 1<\/jats:sub>\n , PM\n 2.5<\/jats:sub>\n , PM\n 10<\/jats:sub>\n , and NO\n 2<\/jats:sub>\n was associated with a higher risk of incident CVD among middle-aged and older Chinese adults with CKM syndrome stages 0\u20133, which was partially mediated by metabolic syndrome. These findings highlight the potential vulnerability of individuals with lower educational attainment within preclinical CKM syndrome population and underscore the contribution of metabolic syndrome to pollution-related CVD risk.\n <\/jats:p>\n <\/jats:sec>","DOI":"10.3389\/fendo.2026.1852623","type":"journal-article","created":{"date-parts":[[2026,6,23]],"date-time":"2026-06-23T05:27:11Z","timestamp":1782192431000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Association between air pollution and incident cardiovascular diseases among a population with cardiovascular-kidney-metabolic syndrome stages 0\u20133: the first evidence from the China Health and Retirement Longitudinal Study"],"prefix":"10.3389","volume":"17","author":[{"given":"Hongbo","family":"Huang","sequence":"first","affiliation":[{"name":"Department of Breast and Thyroid Surgery, The First Affiliated Hospital of Chongqing Medical University","place":["Chongqing, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yunhai","family":"Li","sequence":"additional","affiliation":[{"name":"Department of Breast and Thyroid Surgery, The First Affiliated Hospital of Chongqing Medical University","place":["Chongqing, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ze","family":"Zhang","sequence":"additional","affiliation":[{"name":"Department of Breast and Thyroid Surgery, The First Affiliated Hospital of Chongqing Medical University","place":["Chongqing, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yijing","family":"Xu","sequence":"additional","affiliation":[{"name":"Department of Breast and Thyroid Surgery, The First Affiliated Hospital of Chongqing Medical University","place":["Chongqing, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Linfeng","family":"Xie","sequence":"additional","affiliation":[{"name":"Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University","place":["Chongqing, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ying","family":"Huang","sequence":"additional","affiliation":[{"name":"Department of Breast and Thyroid Surgery, The First Affiliated Hospital of Chongqing Medical University","place":["Chongqing, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tingting","family":"Wei","sequence":"additional","affiliation":[{"name":"Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology","place":["Wuhan, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Haonan","family":"Pan","sequence":"additional","affiliation":[{"name":"College of Public Health, Guangzhou Medical University","place":["Guangzhou, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zhiqi","family":"Hu","sequence":"additional","affiliation":[{"name":"Department of Breast and Thyroid Surgery, The First Affiliated Hospital of Chongqing Medical University","place":["Chongqing, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zhen","family":"Gong","sequence":"additional","affiliation":[{"name":"Department of Breast and Thyroid Surgery, The First Affiliated Hospital of Chongqing Medical University","place":["Chongqing, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jiaying","family":"Li","sequence":"additional","affiliation":[{"name":"Department of Breast and Thyroid Surgery, The First Affiliated Hospital of Chongqing Medical University","place":["Chongqing, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yichen","family":"Wang","sequence":"additional","affiliation":[{"name":"Department of Breast and Thyroid Surgery, The First Affiliated Hospital of Chongqing Medical University","place":["Chongqing, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aijie","family":"Zhang","sequence":"additional","affiliation":[{"name":"Department of Health Management Center, University-Town Hospital Affiliated to Chongqing Medical University","place":["Chongqing, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fan","family":"Li","sequence":"additional","affiliation":[{"name":"Department of Breast and Thyroid Surgery, The First Affiliated Hospital of Chongqing Medical University","place":["Chongqing, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,6,23]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"2982","DOI":"10.1016\/j.jacc.2020.11.010","article-title":"Global burden of cardiovascular diseases and risk factors, 1990-2019: update from the GBD 2019 study","volume":"76","author":"Roth","year":"2020","journal-title":"J Am Coll Cardiol"},{"key":"B2","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(24)00367-2","article-title":"Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the global burden of disease study 2021","volume":"403","year":"2024","journal-title":"Lancet (Lond Engl)"},{"key":"B3","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa2415879","article-title":"Global effect of cardiovascular risk factors on lifetime estimates","volume":"393","author":"Magnussen","year":"2025","journal-title":"N Engl J Med"},{"key":"B4","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(24)00757-8","article-title":"Global incidence, prevalence, years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the global burden of disease study 2021","volume":"403","year":"2024","journal-title":"Lancet (Lond Engl)"},{"key":"B5","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacc.2025.08.015","article-title":"Global, regional, and national burden of cardiovascular diseases and risk factors in 204 countries and territories, 1990-2023","volume":"86","year":"2025","journal-title":"J Am Coll Cardiol"},{"key":"B6","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2024.35783","article-title":"Social and environmental determinants of health and cardio-kidney-metabolic syndrome-related mortality","volume":"7","author":"Vieira de Oliveira Salerno","year":"2024","journal-title":"JAMA Netw Open"},{"key":"B7","doi-asserted-by":"publisher","DOI":"10.1016\/j.envint.2025.109459","article-title":"Air pollution, lifestyle, and cardiovascular disease risk in northwestern China: a cohort study of over 5.8 million participants","volume":"199","author":"Ji","year":"2025","journal-title":"Environ Int"},{"key":"B8","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhazmat.2023.132372","article-title":"Ambient air pollution associated with incident asthma, subsequent cardiovascular disease and death: a trajectory analysis of a national cohort","volume":"460","author":"Wang","year":"2023","journal-title":"J Hazard Mater"},{"key":"B9","doi-asserted-by":"publisher","DOI":"10.1021\/acs.est.2c00898","article-title":"Ambient air pollutants and incident microvascular disease: a cohort study","volume":"56","author":"Li","year":"2022","journal-title":"Environ Sci Technol"},{"key":"B10","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacc.2018.07.099","article-title":"Air pollution and cardiovascular disease: JACC state-of-the-art review","volume":"72","author":"Rajagopalan","year":"2018","journal-title":"J Am Coll Cardiol"},{"key":"B11","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhazmat.2024.134158","article-title":"Long-term ambient ozone exposure and incident cardiovascular diseases: National cohort evidence in China","volume":"471","author":"Zhu","year":"2024","journal-title":"J Hazard Mater"},{"key":"B12","doi-asserted-by":"publisher","DOI":"10.1016\/j.scitotenv.2023.161696","article-title":"Long-term exposure to ambient air pollution, circadian syndrome and cardiovascular disease: a nationwide study in China","volume":"868","author":"Hu","year":"2023","journal-title":"Sci Total Environ"},{"key":"B13","doi-asserted-by":"publisher","first-page":"17008","DOI":"10.1289\/EHP10967","article-title":"Exposure to air pollution during pre-hypertension and subsequent hypertension, cardiovascular disease, and death: a trajectory analysis of the UK biobank cohort","volume":"131","author":"Zhang","year":"2023","journal-title":"Environ Health Perspect"},{"key":"B14","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacc.2019.12.031","article-title":"Long-term exposure to fine particulate matter and cardiovascular disease in China","volume":"75","author":"Liang","year":"2020","journal-title":"J Am Coll Cardiol"},{"key":"B15","doi-asserted-by":"publisher","DOI":"10.1161\/CIR.0000000000001184","article-title":"Cardiovascular-kidney-metabolic health: a presidential advisory from the American Heart Association","volume":"148","author":"Ndumele","year":"2023","journal-title":"Circulation"},{"key":"B16","doi-asserted-by":"publisher","first-page":"1982","DOI":"10.1161\/CIR.0000000000001191","article-title":"Novel prediction equations for absolute risk assessment of total cardiovascular disease incorporating cardiovascular-kidney-metabolic health: a scientific statement from the American Heart Association","volume":"148","author":"Khan","year":"2023","journal-title":"Circulation"},{"key":"B17","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacasi.2024.12.003","article-title":"Prevalence of cardiovascular-kidney-metabolic syndrome stages among middle-aged and older adults in China","volume":"5","author":"Zhang","year":"2025","journal-title":"JACC Asia"},{"key":"B18","doi-asserted-by":"publisher","DOI":"10.1016\/j.envres.2022.114340","article-title":"Systemic inflammation accelerates the adverse effects of air pollution on metabolic syndrome: findings from the China health and retirement longitudinal study (CHARLS)","volume":"215","author":"Han","year":"2022","journal-title":"Environ Res"},{"key":"B19","doi-asserted-by":"publisher","DOI":"10.1016\/j.envint.2019.105333","article-title":"The impact of air pollution on the incidence of diabetes and survival among prevalent diabetes cases","volume":"134","author":"Paul","year":"2020","journal-title":"Environ Int"},{"key":"B20","doi-asserted-by":"publisher","DOI":"10.1016\/j.scitotenv.2023.163406","article-title":"Ambient air pollution and incidence, progression to multimorbidity and death of hypertension, diabetes, and chronic kidney disease: a national prospective cohort","volume":"881","author":"Wu","year":"2023","journal-title":"Sci Total Environ"},{"key":"B21","unstructured":"Ambient (Outdoor) Air Pollution"},{"key":"B22","doi-asserted-by":"publisher","DOI":"10.1016\/j.jare.2023.08.010","article-title":"Long-term exposure to ambient ozone and cardiovascular diseases: evidence from two national cohort studies in China","volume":"62","author":"Liang","year":"2024","journal-title":"J Adv Res"},{"key":"B23","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacc.2025.05.030","article-title":"Rising prevalence of cardiovascular-kidney-metabolic syndrome in China, 2010-2019: national cross-sectional surveys","volume":"86","author":"He","year":"2025","journal-title":"J Am Coll Cardiol"},{"key":"B24","doi-asserted-by":"publisher","DOI":"10.1093\/ije\/dys203","article-title":"Cohort profile: the China health and retirement longitudinal study (CHARLS)","volume":"43","author":"Zhao","year":"2014","journal-title":"Int J Epidemiol"},{"key":"B25","doi-asserted-by":"publisher","DOI":"10.1016\/j.scitotenv.2020.139140","article-title":"Imputation methods for addressing missing data in short-term monitoring of air pollutants","volume":"730","author":"Hadeed","year":"2020","journal-title":"Sci Total Environ"},{"key":"B26","doi-asserted-by":"publisher","DOI":"10.1016\/j.jval.2025.02.001","article-title":"Statistical methods for analyzing EQ-5D in randomized clinical trials: a systematic literature review","volume":"28","author":"Yan","year":"2025","journal-title":"Value Health: J Int Soc Pharmacoeconomics Outcomes Res"},{"key":"B27","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhazmat.2025.138105","article-title":"Air pollution increases the risk of frailty: China health and retirement longitudinal study (CHARLS)","volume":"492","author":"Chen","year":"2025","journal-title":"J Hazard Mater"},{"key":"B28","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2024.6892","article-title":"Prevalence of cardiovascular-kidney-metabolic syndrome stages in US adults, 2011-2020","volume":"331","author":"Aggarwal","year":"2024","journal-title":"JAMA"},{"key":"B29","doi-asserted-by":"publisher","DOI":"10.1016\/j.ecoenv.2024.117648","article-title":"Association between solid cooking fuels exposure and metabolic syndrome: evidence from China","volume":"289","author":"Xue","year":"2025","journal-title":"Ecotoxicol Environ Saf"},{"key":"B30","doi-asserted-by":"publisher","DOI":"10.1016\/j.envpol.2025.126955","article-title":"Air pollution, drought, and their synergistic effects on cardiovascular disease risk in China: a nationwide study","volume":"384","author":"Ling","year":"2025","journal-title":"Environ pollut (Barking Essex: 1987)"},{"key":"B31","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhazmat.2024.133944","article-title":"Causal association between long-term exposure to air pollution and incident Parkinson\u2019s disease","volume":"469","author":"Ai","year":"2024","journal-title":"J Hazard Mater"},{"key":"B32","doi-asserted-by":"publisher","DOI":"10.3390\/life13020538","article-title":"Severe acute respiratory syndrome and particulate matter exposure: a systematic review","volume":"13","author":"Podury","year":"2023","journal-title":"Life (Basel Switz)"},{"key":"B33","doi-asserted-by":"publisher","DOI":"10.1016\/j.jaci.2017.12.981","article-title":"Inflammatory health effects of indoor and outdoor particulate matter","volume":"141","author":"Wu","year":"2018","journal-title":"J Allergy Clin Immunol"},{"key":"B34","unstructured":""},{"key":"B35","doi-asserted-by":"publisher","first-page":"111","DOI":"10.1186\/s12940-024-01148-1","article-title":"Air pollution is linked to cognitive decline independent of hypersensitive C-reactive protein: insights from middle-aged and older Chinese","volume":"23","author":"Huang","year":"2024","journal-title":"Environ Health: Glob Access Sci Source"},{"key":"B36","doi-asserted-by":"publisher","DOI":"10.1016\/j.eclinm.2021.101264","article-title":"Association between sarcopenia and cardiovascular disease among middle-aged and older adults: findings from the China health and retirement longitudinal study","volume":"44","author":"Gao","year":"2022","journal-title":"Eclinicalmedicine"},{"key":"B37","doi-asserted-by":"publisher","DOI":"10.1016\/j.ecoenv.2024.117555","article-title":"Impact of solid fuel use on asthma prognosis and consistent peak expiratory flow changes: evidence from China","volume":"290","author":"Chen","year":"2025","journal-title":"Ecotoxicol Environ Saf"},{"key":"B38","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2019.16591","article-title":"Association of depressive symptoms with incident cardiovascular diseases in middle-aged and older Chinese adults","volume":"2","author":"Li","year":"2019","journal-title":"JAMA Netw Open"},{"key":"B39","doi-asserted-by":"publisher","first-page":"325","DOI":"10.1186\/s12933-023-02055-4","article-title":"Triglyceride-glucose index, renal function and cardiovascular disease: a national cohort study","volume":"22","author":"Cui","year":"2023","journal-title":"Cardiovasc Diabetol"},{"key":"B40","doi-asserted-by":"publisher","first-page":"121","DOI":"10.21037\/atm.2018.02.12","article-title":"Time-varying covariates and coefficients in Cox regression models","volume":"6","author":"Zhang","year":"2018","journal-title":"Ann Transl Med"},{"key":"B41","unstructured":"Using time dependent covariates and time dependent coefficients in the cox model\n \n \n \n Therneau\n T\n \n \n Crowson\n C\n \n \n Atkinson\n E"},{"key":"B42","doi-asserted-by":"publisher","DOI":"10.1016\/j.ese.2023.100241","article-title":"Excess mortality associated with high ozone exposure: a national cohort study in China","volume":"15","author":"Yuan","year":"2023","journal-title":"Environ Sci Ecotechnol"},{"key":"B43","doi-asserted-by":"publisher","DOI":"10.3390\/jcm14082690","article-title":"Effect of metabolic dysfunction-associated steatotic liver disease (MASLD) on left ventricular mechanics in patients without overt cardiac disease: a systematic review and meta-analysis","volume":"14","author":"Sonaglioni","year":"2025","journal-title":"J Clin Med"},{"key":"B44","doi-asserted-by":"publisher","DOI":"10.1016\/j.xinn.2020.100060","article-title":"Recovery of four COVID-19 patients via ozonated autohemotherapy","volume":"1","author":"Wu","year":"2020","journal-title":"Innov (Camb (Mass,))"},{"key":"B45","doi-asserted-by":"publisher","DOI":"10.1007\/s10753-020-01184-2","article-title":"Anti-inflammatory effect of ozone therapy in an experimental model of rheumatoid arthritis","volume":"43","author":"Tartari","year":"2020","journal-title":"Inflammation"},{"key":"B46","doi-asserted-by":"publisher","DOI":"10.1016\/j.envpol.2024.123366","article-title":"U-shaped relationship between ozone exposure and preterm birth risk associated with preconception telomere length","volume":"344","author":"Zhou","year":"2024","journal-title":"Environ pollut (Barking Essex: 1987)"},{"key":"B47","doi-asserted-by":"publisher","DOI":"10.3390\/antiox12071371","article-title":"Roles of oxidative stress and Nrf2 signaling in pathogenic and non-pathogenic cells: a possible general mechanism of resistance to therapy","volume":"12","author":"Hammad","year":"2023","journal-title":"Antioxid (Basel Switz)"},{"key":"B48","doi-asserted-by":"publisher","DOI":"10.3390\/ijms20164009","article-title":"The role of Nrf2 in the antioxidant cellular response to medical ozone exposure","volume":"20","author":"Gali\u00e8","year":"2019","journal-title":"Int J Mol Sci"}],"container-title":["Frontiers in Endocrinology"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fendo.2026.1852623\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,23]],"date-time":"2026-06-23T05:27:14Z","timestamp":1782192434000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fendo.2026.1852623\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6,23]]},"references-count":48,"alternative-id":["10.3389\/fendo.2026.1852623"],"URL":"https:\/\/doi.org\/10.3389\/fendo.2026.1852623","relation":{},"ISSN":["1664-2392"],"issn-type":[{"value":"1664-2392","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,23]]},"article-number":"1852623"}}