{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T21:46:12Z","timestamp":1790718372312,"version":"4.1.0"},"reference-count":45,"publisher":"MDPI AG","issue":"17","license":[{"start":{"date-parts":[[2022,8,24]],"date-time":"2022-08-24T00:00:00Z","timestamp":1661299200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Birla Nagar Jana Seva Trust","award":["IN-DL30606394456526T"],"award-info":[{"award-number":["IN-DL30606394456526T"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Air pollution is a global public health threat. Evidence suggests that increased air pollution leads to increased cardiovascular morbidity and mortality. The aim of this review was to systematically review and synthesize scientific evidence to understand the effect of performing outdoor physical activity (PA) in a polluted environment on cardiovascular outcomes. This review was developed and reported in accordance with the PRISMA guidelines. Electronic searches in Embase, Web of Science, and PubMed were undertaken through March 2021 initially, and later updated through to 31st January 2022, for observational studies published in peer-reviewed journals that report cardiovascular mortality or morbidity due to outdoor PA in air polluted environment. These searches yielded 10,840 citations. Two reviewers independently reviewed each citation for its eligibility. Seven studies were found to be eligible. Of these, five were cohort studies and two were cross-sectional studies. Pollutants measured in the selected studies were Particulate Matter (PM)\u2014PM10, PM2.5, nitrogen oxides (NOx), and ozone (O3). The most common study outcome was myocardial infarction, followed by cardiovascular mortality, hypertension and heart rate variability. Six studies emphasized that the PA has beneficial effects on cardiovascular outcomes, though air pollutants attenuate this effect to an extent. Two studies showed that walking, even in the polluted environment, significantly reduced the heart rate and heart rate variability indices. The beneficial effects of outdoor PA outweigh the harmful effects of air pollution on cardiovascular health, though the benefits reduce to an extent when PA is carried out in a polluted environment. Because a limited number of studies (n = 7) were eligible for inclusion, the review further emphasizes the critical need for more primary studies that differentiate between outdoor and indoor PA and its effect on cardiovascular health.<\/jats:p>","DOI":"10.3390\/ijerph191710547","type":"journal-article","created":{"date-parts":[[2022,8,24]],"date-time":"2022-08-24T21:03:51Z","timestamp":1661375031000},"page":"10547","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":23,"title":["Outdoor Physical Activity in an Air Polluted Environment and Its Effect on the Cardiovascular System\u2014A Systematic Review"],"prefix":"10.3390","volume":"19","author":[{"given":"Taruna","family":"Juneja Gandhi","sequence":"first","affiliation":[{"name":"MAMTA Health Institute for Mother and Child, B-5, Greater Kailash Enclave II, New Delhi 110048, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Priyanka Rani","family":"Garg","sequence":"additional","affiliation":[{"name":"MAMTA Health Institute for Mother and Child, B-5, Greater Kailash Enclave II, New Delhi 110048, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1287-1404","authenticated-orcid":false,"given":"Kauma","family":"Kurian","sequence":"additional","affiliation":[{"name":"MAMTA Health Institute for Mother and Child, B-5, Greater Kailash Enclave II, New Delhi 110048, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jonas","family":"Bjurgert","sequence":"additional","affiliation":[{"name":"Lund University, Box 117, SE-221 00 Lund, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sirazul Ameen","family":"Sahariah","sequence":"additional","affiliation":[{"name":"MAMTA Health Institute for Mother and Child, B-5, Greater Kailash Enclave II, New Delhi 110048, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sunil","family":"Mehra","sequence":"additional","affiliation":[{"name":"MAMTA Health Institute for Mother and Child, B-5, Greater Kailash Enclave II, New Delhi 110048, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4312-7058","authenticated-orcid":false,"given":"Gayatri","family":"Vishwakarma","sequence":"additional","affiliation":[{"name":"Indian Spinal Injuries Centre Sector-C, Vasant Kunj, New Delhi 110070, India"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2022,8,24]]},"reference":[{"key":"ref_1","unstructured":"World Health Organization (2021, November 15). Ambient (Outdoor) Air Pollution. Available online: https:\/\/www.who.int\/news-room\/fact-sheets\/detail\/ambient-(outdoor)-air-quality-and-health."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"138","DOI":"10.1097\/MCP.0000000000000248","article-title":"Pulmonary health effects of air pollution","volume":"22","author":"Kurt","year":"2016","journal-title":"Curr. Opin. Pulm. Med."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"2224","DOI":"10.1016\/S0140-6736(12)61766-8","article-title":"A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990\u20132010: A systematic analysis for the Global Burden of Disease Study 2010","volume":"380","author":"Lim","year":"2012","journal-title":"Lancet"},{"key":"ref_4","unstructured":"US EPA (2021, January 02). Linking Air Pollution and Heart Disease. United States Environmental Protection Agency, Available online: https:\/\/www.epa.gov\/sciencematters\/linking-air-pollution-and-heart-disease."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"634","DOI":"10.1016\/j.acvd.2017.05.003","article-title":"Cardiovascular effects of air pollution","volume":"110","author":"Bourdrel","year":"2017","journal-title":"Arch. Cardiovasc. Dis."},{"key":"ref_6","doi-asserted-by":"crossref","unstructured":"Hamanaka, R.B., and Mutlu, G.M. (2018). Particulate Matter Air Pollution: Effects on the Cardiovascular System. Front. Endocrinol., 9.","DOI":"10.3389\/fendo.2018.00680"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"14887","DOI":"10.3390\/ijerph121114887","article-title":"Air Pollution Exposure and Physical Activity in China: Current Knowledge, Public Health Implications, and Future Research Needs","volume":"12","author":"Liang","year":"2015","journal-title":"Int. J. Environ. Res. Public Health"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"3483","DOI":"10.1093\/eurheartj\/ehy607","article-title":"Inflammation: The new cardiovascular risk factor","volume":"39","year":"2018","journal-title":"Eur. Heart J."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"83","DOI":"10.1093\/eurheartj\/ehu458","article-title":"Expert position paper on air pollution and cardiovascular disease","volume":"36","author":"Newby","year":"2015","journal-title":"Eur. Heart J."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"e56","DOI":"10.1161\/CIR.0000000000000659","article-title":"Heart Disease and Stroke Statistics\u20142019 Update: A Report From the American Heart Association","volume":"139","author":"Benjamin","year":"2019","journal-title":"Circulation"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"717","DOI":"10.1097\/EDE.0b013e31829e3dda","article-title":"Leisure time physical activity and mortality","volume":"24","author":"Ekblond","year":"2013","journal-title":"Epidemiology"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"3109","DOI":"10.1161\/01.CIR.0000075572.40158.77","article-title":"Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: A statement from the council on clinical cardiology (subcommittee on exercise, rehabilitation, and prevention) and the council on nutrition, physical","volume":"107","author":"Thompson","year":"2003","journal-title":"Circulation"},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Kim, S.R., Choi, S., Keum, N., and Park, S.M. (2020). Combined effects of physical activity and air pollution on cardiovascular disease: A population-based study. J. Am. Heart Assoc., 9.","DOI":"10.1161\/JAHA.119.013611"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1505","DOI":"10.1007\/s40279-014-0222-6","article-title":"Physical activity, air pollution and the brain","volume":"44","author":"Bos","year":"2014","journal-title":"Sports Med."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"2331","DOI":"10.1161\/CIR.0b013e3181dbece1","article-title":"Particulate Matter Air Pollution and Cardiovascular Disease","volume":"121","author":"Brook","year":"2010","journal-title":"Circulation"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1742","DOI":"10.1056\/NEJM200012143432401","article-title":"Fine Particulate Air Pollution and Mortality in 20 US Cities, 1987\u20131994","volume":"343","author":"Samet","year":"2000","journal-title":"N. Engl. J. Med."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"175","DOI":"10.1042\/CS20070444","article-title":"Cardiovascular effects of air pollution","volume":"115","author":"Brook","year":"2008","journal-title":"Clin. Sci."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"32","DOI":"10.1007\/s11906-003-0008-y","article-title":"Air pollution: The \u2018heart\u2019 of the problem","volume":"5","author":"Brook","year":"2003","journal-title":"Curr. Hypertens. Rep."},{"key":"ref_19","first-page":"495","article-title":"Airborne particulates and hospital admissions for cardiovascular disease: A quantitative review of the evidence","volume":"109","author":"Morris","year":"2001","journal-title":"Environ. Health Perspect."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1151","DOI":"10.1016\/S0140-6736(17)32152-9","article-title":"Global, regional, and national age-sex specific mortality for 264 causes of death, 1980-2016: A systematic analysis for the Global Burden of Disease Study 2016","volume":"390","author":"Naghavi","year":"2017","journal-title":"Lancet"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"264","DOI":"10.7326\/0003-4819-151-4-200908180-00135","article-title":"Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement","volume":"151","author":"Moher","year":"2009","journal-title":"Ann. Intern. Med."},{"key":"ref_22","unstructured":"Joanna Briggs Institute (2021, June 16). Critical Appraisal Tools. Available online: https:\/\/joannabriggs.org\/critical-appraisal-tools."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"557","DOI":"10.1289\/ehp.1408698","article-title":"A study of the combined effects of physical activity and air pollution on mortality in elderly urban residents: The Danish Diet, Cancer, and Health Cohort","volume":"123","author":"Andersen","year":"2015","journal-title":"Environ. Health Perspect."},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Elliott, E.G., Laden, F., James, P., Rimm, E.B., Rexrode, K.M., and Hart, J.E. (2020). Interaction between Long-Term Exposure to Fine Particulate Matter and Physical Activity, and Risk of Cardiovascular Disease and Overall Mortality in US Women. Environ. Health Perspect., 128.","DOI":"10.1289\/EHP7402"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"247","DOI":"10.1289\/ehp.1103806","article-title":"Health impacts of the built environment: Within-urban variability in physical inactivity, air pollution, and ischemic heart disease mortality","volume":"120","author":"Hankey","year":"2012","journal-title":"Environ. Health Perspect."},{"key":"ref_26","doi-asserted-by":"crossref","unstructured":"Kubesch, N.J., Therming J\u00f8rgensen, J., Hoffmann, B., Loft, S., Nieuwenhuijsen, M.J., Raaschou-Nielsen, O., Pedersen, M., Hertel, O., Overvad, K., and Tj\u00f8nneland, A. (2018). Effects of leisure-time and transport-related physical activities on the risk of incident and recurrent myocardial infarction and interaction with traffic-related air pollution: A cohort study. J. Am. Heart Assoc., 7.","DOI":"10.1161\/JAHA.118.009554"},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"Lin, Y., Yang, X., Liang, F., Huang, K., Liu, F., Li, J., Xiao, Q., Chen, J., Liu, X., and Cao, J. (2021). Benefits of active commuting on cardiovascular health modified by ambient fine particulate matter in China: A prospective cohort study. Ecotoxicol. Environ. Saf., 224.","DOI":"10.1016\/j.ecoenv.2021.112641"},{"key":"ref_28","doi-asserted-by":"crossref","unstructured":"Marmett, B., Carvalho, R.B., Nunes, R.B., and Rhoden, C.R. (2022). Exposure to O3 and NO2 in physically active adults: An evaluation of physiological parameters and health risk assessment. Environmental Geochemistry and Health, Springer Nature.","DOI":"10.1007\/s10653-021-01194-5"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"319","DOI":"10.1016\/j.ijheh.2015.01.003","article-title":"Effects of commuting mode on air pollution exposure and cardiovascular health among young adults in Taipei, Taiwan","volume":"218","author":"Liu","year":"2015","journal-title":"Int. J. Hyg. Environ. Health"},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"Tu, R., Hou, J., Liu, X., Li, R., Dong, X., Pan, M., Mao, Z., Huo, W., Chen, G., and Guo, Y. (2020). Physical activity attenuated association of air pollution with estimated 10-year atherosclerotic cardiovascular disease risk in a large rural Chinese adult population: A cross-sectional study. Environ. Int., 140.","DOI":"10.1016\/j.envint.2020.105819"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1030","DOI":"10.1016\/j.ijheh.2017.06.001","article-title":"Is physical activity a modifier of the association between air pollution and arterial stiffness in older adults: The SAPALDIA cohort study","volume":"220","author":"Endes","year":"2017","journal-title":"Int. J. Hyg. Environ. Health"},{"key":"ref_32","doi-asserted-by":"crossref","unstructured":"Li, N., Chen, G., Liu, F., Mao, S., Liu, Y., Liu, S., Mao, Z., Lu, Y., Wang, C., and Guo, Y. (2020). Associations between long-term exposure to air pollution and blood pressure and effect modifications by behavioral factors. Environ. Res., 182.","DOI":"10.1016\/j.envres.2019.109109"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"95","DOI":"10.1016\/j.envint.2019.04.037","article-title":"Associations of long-term exposure to ambient PM1 with hypertension and blood pressure in rural Chinese population: The Henan rural cohort study","volume":"128","author":"Li","year":"2019","journal-title":"Environ. Int."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"1191","DOI":"10.1161\/STROKEAHA.116.015739","article-title":"Ambient PM2.5 and stroke: Effect modifiers and population attributable risk in six low-and middle-income countries","volume":"48","author":"Lin","year":"2017","journal-title":"Stroke"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"118","DOI":"10.1136\/oem.2009.046847","article-title":"Respiratory health effects of ultrafine and fine particle exposure in cyclists","volume":"67","author":"Strak","year":"2010","journal-title":"Occup. Environ. Med."},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Weichenthal, S., Hatzopoulou, M., and Goldberg, M.S. (2014). Exposure to traffic-related air pollution during physical activity and acute changes in blood pressure, autonomic and micro-vascular function in women: A cross-over study. Part. Fibre Toxicol., 11.","DOI":"10.1186\/s12989-014-0070-4"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"223","DOI":"10.1007\/s40279-013-0108-z","article-title":"The health effects of exercising in air pollution","volume":"44","author":"Giles","year":"2014","journal-title":"Sports Med."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"153","DOI":"10.1016\/j.lfs.2018.12.036","article-title":"Exercise and air pollutants exposure: A systematic review and meta-analysis","volume":"218","author":"Qin","year":"2019","journal-title":"Life Sci."},{"key":"ref_39","doi-asserted-by":"crossref","unstructured":"Sun, Z., and Zhu, D. (2019). Exposure to outdoor air pollution and its human health outcomes: A scoping review. PLoS ONE, 14.","DOI":"10.1371\/journal.pone.0216550"},{"key":"ref_40","first-page":"8","article-title":"Built environment and health: A systematic review of studies in Germany","volume":"40","author":"Schulz","year":"2018","journal-title":"J. Public Health"},{"key":"ref_41","doi-asserted-by":"crossref","unstructured":"Cunningham, G.B., Wicker, P., and McCullough, B.P. (2020). Pollution, health, and the moderating role of physical activity opportunities. Int. J. Environ. Res. Public Health, 17.","DOI":"10.3390\/ijerph17176272"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/2046-7648-2-3","article-title":"The great outdoors: How a green exercise environment can benefit all","volume":"2","author":"Gladwell","year":"2013","journal-title":"Extrem. Physiol. Med."},{"key":"ref_43","doi-asserted-by":"crossref","unstructured":"Tainio, M., Andersen, Z.J., Nieuwenhuijsen, M.J., Hu, L., De Nazelle, A., An, R., Garcia, L.M., Goenka, S., Zapata-Diomedi, B., and Bull, F. (2021). Air pollution, physical activity and health: A mapping review of the evidence. Environ. Int., 147.","DOI":"10.1016\/j.envint.2020.105954"},{"key":"ref_44","doi-asserted-by":"crossref","unstructured":"Hahad, O., Frenis, K., Kuntic, M., Daiber, A., and M\u00fcnzel, T. (2021). Accelerated Aging and Age-Related Diseases (CVD and Neurological) Due to Air Pollution and Traffic Noise Exposure. Int. J. Mol. Sci., 22.","DOI":"10.3390\/ijms22052419"},{"key":"ref_45","unstructured":"Aromataris, E., and Munn, Z. (2017). Chapter 7: Systematic reviews of etiology and risk. Joanna Briggs Institute Reviewer\u2019s Manual, The Joanna Briggs Institute. Available online: https:\/\/reviewersmanual.joannabriggs.org\/."}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/19\/17\/10547\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T00:14:41Z","timestamp":1760141681000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/19\/17\/10547"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,8,24]]},"references-count":45,"journal-issue":{"issue":"17","published-online":{"date-parts":[[2022,9]]}},"alternative-id":["ijerph191710547"],"URL":"https:\/\/doi.org\/10.3390\/ijerph191710547","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,8,24]]}}}