Global warming and heat waves risks for cardiovascular diseases

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www.revportcardiol.org

Revista Portuguesa de

Cardiologia

Portuguese Journal of Cardiology

GUIDELINES

Global warming and heat waves risks for

cardiovascular diseases: A position paper of the Portuguese Society of Cardiology

Daniel Caldeira

^a^,^b^,^c^,^d^,^v^,∗,¹

, Hélder Dores

^a^,^e^,^f^,^v^,¹

, Fátima Franco

^a^,^g^,^v

,

Q1

Sérgio Bravo Baptista

^a^,^h^,ⁱ^,^v

, Soﬁa Cabral

^a^,^j^,^v

, Maria do Carmo Cachulo

^a^,^k^,^v

, António Peixeiro

^a^,^l^,^v

, Rui Rodrigues

^a^,^j^,^v

, Mário Santos

^a^,^j^,^m^,ⁿ^,^v

,

Ana Teresa Timóteo

^a^,^f^,^o^,^v

, Luis Campos

^p^,^v

, João Vasconcelos

^p^,^q^,^v

, Paulo Jorge Nogueira

^r^,^s^,^t^,^u^,^v

, Lino Gonc ¸alves

^a^,^k^,^v

aSociedadePortuguesadeCardiologia,Lisboa,Portugal Q2

bServic¸odeCardiologia,HospitalUniversitáriodeSantaMaria---CHULN,Portugal

cCardiovascularPharmacologyandTherapeuticsUnit,CentroCardiovasculardaUniversidadedeLisboa(CCUL@RISE),CEMBE, CAML,FaculdadedeMedicina,UniversidadedeLisboa,Portugal

dLaboratoryofClinicalPharmacologyandTherapeutics,FaculdadedeMedicinadaUniversidadedeLisboa,Portugal

eHospitaldaLuz,Lisbon,Portugal

fNOVAMedicalSchool,Lisbon,Portugal

gUnidadeTratamentoICAvanc¸ada(UTICA),Servic¸odeCardiologia,CentroHospitalarUniversitáriodeCoimbra,Coimbra, Portugal

hHospitalProf.DoutorFernandodaFonseca,EPE,CardiologyDepartment,Amadora,Portugal Q3

iCentroCardiovasculardaUniversidadedeLisboa(CCUL@RISE),CAML,FaculdadedeMedicina,UniversidadedeLisboa,Portugal

jDepartmentofCardiology,CentroHospitalarUniversitáriodoPorto,Porto,Portugal

kCentroHospitalareUniversitáriodeCoimbra,ICBR---FacultyofMedicine,UniversityofCoimbra,Coimbra,Portugal

lServic¸odeCardiologia,CentroHospitalareUniversitáriodaCovadaBeira(CHUCB),Covilhã,Portugal

mUMIB---UnidadeMultidisciplinardeInvestiga¸ãoc Biomédica,ICBAS---InstitutodeCieˆnciasBiomédicasAbelSalazar, UniversidadedoPorto,Porto,Portugal

nITR---LaboratoryforIntegrativeandTranslationalResearchinPopulationHealth,Porto,Portugal

oServic¸odeCardiologia,HospitalSantaMarta,CentroHospitalarUniversitárioLisboaCentral,Lisboa,Portugal

pDepartmentofInternalMedicine,HospitalCUFTejo,PortugueseCouncilforHealthandEnvironment,Lisbon,Portugal

qUniversidadedeLisboa,InstitutodeGeograﬁaeOrdenamentodoTerritório(CentrodeEstudosGeográﬁcos),Portugal

rInstitutoPolitécnicodeLeiria,Portugal

sNOVANationalSchoolofPublicHealth,PublicHealthResearchCentre,UniversidadeNOVAdeLisboa,ComprehensiveHealth ResearchCenter(CHRC),Lisbon,Portugal

tInstitutodeSaúdeAmbiental,FaculdadedeMedicina,UniversidadedeLisboa,Lisboa,Portugal

uLaboratórioAssociadoTERRA,FaculdadedeMedicina,UniversidadedeLisboa,Lisboa,Portugal

vCIDNUR---CentrodeInvestigac¸ão,Inovac¸ãoeDesenvolvimentoemEnfermagemdeLisboa,EscolaSuperiordeEnfermagemde Q4

Lisboa,Lisboa,Portugal

∗Correspondingauthor.

E-mailaddress:dgcaldeira@hotmail.com(D.Caldeira).

1 Co-primaryauthorship.

https://doi.org/10.1016/j.repc.2023.02.002

Please cite this article as: D. Caldeira, H. Dores, F. Franco et al., Global warming and heat waves risks for cardiovascular diseases: A position paper of the Portuguese Society of Cardiology, Revista Portuguesa de Cardiologia,

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KEYWORDS Globalwarming;

Heatwave;

Airpollution;

Cardiovascular disease;

Ischemicheart disease;

Cerebrovascular disease;

Burdenofdisease

Abstract Globalwarmingisaresultoftheincreasedemissionofgreenhousegases.Thisclimate changeconsequencethreatenssociety,biodiversity,foodandresourceavailability.Theconse- quencesinhealthinvolvetheincreasedriskofcardiovascular(CV)diseaseandcardiovascular mortality.

Inthispositionpaperwesummarizethedatafromthemainstudiesthatassessedtherisksof temperatureincreaseorheatwavesinCVevents(CVmortality,myocardialinfarction,heartfailure,stroke,andCVhospitalizations),aswellasthedataconcerningairpollutionasanenhancer oftemperature-relatedCVrisks.Thedatacurrentlysupportsthatglobalwarming/heatwaves (extremetemperatures)arecardiovascularthreats.Achievingtheneutralityintheemissions topreventglobalwarmingisessentialanditislikelytohaveaneffectintheglobal health, includingthecardiovascularhealth.Simultaneously,urgentstepisrequiredtoadaptthesociety andindividualtothisnewclimatecontextpotentiallyharmfulforthecardiovascularhealth.

Multidisciplinaryteamsshouldplanandinterveneinheat-relatedhealthcareandadvocatefor environmentalhealthpolicychange.

by-nc-nd/4.0/).

PALAVRAS-CHAVE Aquecimentoglobal;

Ondasdecalor;

Poluic¸ãodoar;

Doenc¸a cardiovascular;

Doenc¸acardíaca isquémica;

Doenc¸a

cerebrovascular;

Cargadadoenc¸a

Aquecimentoglobal,ondasdecaloreriscodedoenc¸ascardiovasculares:documento deposic¸ãodaSociedadePortuguesadeCardiologia

Resumo Oaquecimentoglobal éumadasconsequênciasdo aumentodaemissãodegases comefeitodeestufa.Essaconsequênciadasalteraçõesclimáticaséumaameaçaàsociedade, àbiodiversidadeeàdisponibilidadederecursosealimentos.Asconsequênciasparaasaúde do aquecimento global incluem oaumento dorisco de doenças cardiovasculares (CV) e da mortalidadecardiovascular.

Neste position paper resumimos os dados dos principais estudos que avaliam o risco do aumento detemperaturaouaexposiçãoaondasde calornos eventosCV (mortalidadeCV, enfartedomiocárdio,insuficiênciacardíaca,acidentevascularcerebralehospitalizaçõesCV), assim comoosdadosrelativos àpoluiçãodoarcomo um potenciadordosriscosdeeventos CVrelacionadoscomoaumentodatemperatura.Osdadosatualmentedisponíveisconfirmam queoaquecimentoglobaleasondasdecalor(temperaturasextremas)sãoameaçascardio- vasculares.Nessecontexto,aneutralidadenasemissõesdeveserumobjectivoprioritário,de modoareduzir oaquecimentoglobale,dessemodo,reduziroseuimpactonasaúdeglobal, inclusiveasaúdecardiovascular.Simultaneamente,deverãoserempreguesmedidasurgentes deadaptaçãosetorialaonovocontextoclimático,potencialmentemaisnefastoparaasaúde cardiovascular. Equipesmultidisciplinaresdevemplaneareintervir enoscuidadosdesaúde relacionadosaocalorediscutiraspolíticasdesaúderelacionadascomoambiente.

by-nc-nd/4.0/).

Introduction

Climatechangereferstoashiftinseasonaltemperatures, rainfall, drought, and wind patterns and is often associ- atedwithdisasterssuchashurricanes,wildﬁresandﬂoods.

Global warming is oneof the most prominent features of recent climate change, withthe decade 2010---2019 being thewarmestsincedataareavailable.

The global warming and the increase in extreme heat events seem to be caused by dramatic increase in the concentrationofgasesthatpromotethegreenhouseeffect, particularly carbon dioxide, methane and nitrous oxide.¹ Theoveralleffectofthisglobalwarmingisdeleteriousfor

nature (biodiversity, food and resources availability) and humanhealth.Airpollutionplaysan importantroleinthe interaction between global warming and several medical conditions,butthespeciﬁccontributionsofeachfactorare notwell established.In cardiovasculardiseases, the main causeof deathworldwide,airpollutionincreases therisk ofcardiovascularevents.²Environmental factorsincluding global warming aredeemed tohave a rolein the risk of cardiovasculardisease/events.³ This informationneeds to beemphasizedfor decision-makerstobetteracknowledge aboutpotentialconsequencesofclimatechange.Acallto furtheraction is needed tolimitglobal temperature rises and their risks for global and cardiovascular health. This

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positionpaperexploresthelinkbetweenglobalwarmingand CVdiseases,retrievingevidencefromsystematicreviewson the subject, havingthe dualgoal ofbringing attentionto this emergingproblem and providing recommendations in thisﬁeld.

Global warming and cardiovascular disease

Cold has consistently been recognized asa classical trig- ger for cardiovascular disease, and studies support this association.^4,5Inaddition,severalstudiesalsopointtothe effectofextremeheatonincreasingtheincidenceofmor- tality. In this sense, it is essential to explore the links betweenthispotentialriskfactor/triggerandcardiovascular disease.

Themainmechanismsthatexplainthewarming/heatas acardiovascularrisk factorarerelatedtoanimbalanceof the autonomic nervoussystem towardsan increased sym- pathetic toneduetothermoregulationmechanisms,blood pressure lowering, and dehydration due to the temperature. In such circumstances, the heart rate and cardiac outputincrease,whichincreasesmyocardialdemands.Fur- thermore,thesechangescaninducesystemicinﬂammation andleadtoaprothromboticstateplacingadditionalstrain onthecardiovascularsystem,⁶predisposingvulnerableindi- viduals to atherosclerotic plaque rupture and subsequent increased myocardial infarction risk. Therefore, the rela- tionship between cardiovascular disease and temperature seemstobe U-shaped(or J-shaped). The lowerrisk nadir isnotestablishedandmayvarygeographically,butinmany locations,itvariesbetween18and20^◦C.^7,8

Patientswithheart failuremaynotbecapableofcom- pensatingforthealludedincreaseinsympatheticresponse, leading to acute heart failure episodes. The association betweenheatexposureandmortalityfromrespiratorydis- eases is another possible connection that should not be disregarded.This linksuggestsincreasedtemperaturemay beassociatedwithrightheartfailure---corpulmonaletype.

Aggregated evidence for the association between increased temperatures (global warming) and cardiovascular events

In order to review the association between air pollution andcardiovascularevents,asearchwasperformedinMED- LINE and Cochrane databases (CENTRAL and Database of Systematic reviews) to retrieve the aggregated evidence from systematic reviews using Boolean combinations of thekeywords‘‘climate’’,‘‘heat’’,‘‘globalwarming’’,‘‘air pollution’’,‘‘coronary disease’’,‘‘myocardialinfarction’’,

‘‘stroke’’, ‘‘heart failure’’, as well as some variation of these terms. For each outcome of interest, the authors choseonebasedontheirupdatingandrepresentativeness.

Threesystematicreviewsprovidedtheriskestimatesfor cardiovascular events associated withincreased temperature(Table1andFigure1).

Phung et al. published in 2016 included 64 studies evaluatingthedose-responserelationshipofcardiovascular hospitalizationaccordingtothetemperature.⁹Theauthors concludedthatasigniﬁcantrelationshipexistsbetweencold

exposure,heatwaves,andvariationindiurnaltemperature andtheriskofcardiovascularhospitalizations.⁹

Cheng etal. evaluatedthe cardiovascularand respira- torymorbidityassociatedwithheatwaves.¹⁰Usingthedata from54 studies performed in 20countries, we concluded thatheatwaveswereassociatedwithanincreasedriskof mortalityofbothcardiovascularandrespiratorydiseases.¹⁰ Thepatient’scharacteristicsassociatedwithincreasedmor- talityweretheage(elderly)andthepresenceofcoronary arterydisease,stroke,heartfailureorchronic obstructive pulmonarydisease.¹⁰

The largest systematic review with meta-analysis on theeffects ofheat exposureonCV riskswaspublishedin 2022 by Li et al. in Lancet PlanetHealth.¹¹ This system- aticreviewincluded266studies.⁸Heatexposureexpressed as an increase of 1^◦C in temperature was shown to increase by 2.1% the relative risk of overall cardiovascular mortality.¹¹ The risks of death due tocoronary artery disease,strokeandheartfailurewerealsoincreased.The risk of cardiovascular death was high in people aged 65 or older (an increase of 1.7% in the relative risk) compared with those less than 65 years old (an increase of 0.9%). Lower-middle-income countries also had increased cardiovascular mortality risks compared to high-income countries.¹¹ Regarding cardiovascular morbidity (hospital admissions, emergency department admissions or ambu- lancecall-outs),thisoutcomewassigniﬁcantlyincreasedby 0.5%(RR1.005,95%CI1.003---1.008),despitethereduction intheincidenceofmorbidityduetohypertensivedisease.

Onceagain,lower-middleincomecountrieshadthehighest increasesincardiovascularmorbidityrisk.

The cardiovascular risks of heat waves were also ascertained.¹¹Heatwaveswereassociatedwithasigniﬁcan- tlyincreasedrisk of11.7%(RR1.117,95%CI1.093---1.141) with a higher risk gradient according to the heat wave’s intensity.

Overall, using the Navigation Guide framework, the authorsconcludedthatthecurrentevidenceisofhighqual- itytolinkhightemperaturesandheatwavestoCVmortality, andmoderate quality tolink high temperatures andheat wavestoCVmorbidity.¹¹

Evidence about the interaction of air pollution with temperature and cardiovascular

outcomes.

Datasuggestthatthevariationofairpollutantsandtemper- atureanditsassociationwithcardiovascularoutcomesmay sufferfromconfoundingbiasduetocollinearity.¹² Meaning that pollution may inﬂuence the temperature and vice- versa,varyinginthesamedirectionregardingcardiovascular risks.^13,14Nevertheless,thereisenoughevidencetoconsent thatbothfactorsexertanindependentorsynergisticeffect onhealthoutcomes(Table1).¹⁵

We considered important tohighlight twostudies that haveascertained thepotential interactionsbetween tem- peratureandairpollutionincardiovascularoutcomes.^16,17

ThePHASEprojectpublishedin2018evaluatedthedaily data of nine European countries (Valencia and Barcelona were the closest cities to Portugalin this study).¹⁶ Using arandomeffectmeta-analysis,theauthorsconcludedthat

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Table1 Systematicreviewsevaluatingtheimpactoftemperatureand/orheatwavesoncardiovascularmorbi-mortalityand theinteractionwithairpollution.

Systematic review

Design Location Exposure Searchdate Studies Mainﬁndings

ChengEnviron Res2019

Systematicreview ofobservational studies

20countries Heatwaves 2018 54 Heatwavesincrease

themortalityof cardiovascularand respiratorydiseases PhungSciTotal

Environ2016

Systematicreview oftime-series studies, case-crossover, cohortstudies

Multiples countries

Heatwaves N/R 64 Signiﬁcant

relationshipexists betweencold exposure,heat waves,andvariation indiurnal

temperatureandthe elevatedriskof cardiovascular hospitalization LiuLancet

Planet Health2022

Systematicreview ofobservational studiesusing ecologicaltime series,case crossover,orcase seriesstudies

Multiple countries

Increasein temperature;

heatwaves

2022 266 Moderate-to-high

qualityevidenceshow thatcardiovascular mortalityand morbidityare increasedinheat exposures Systematicreview Studies/estimates Interactionof

temperature/heatwith:

Overallconclusions Analitisetal.,

2018

PHASEproject

Dailyvaluesof exposureand healthoutcome fromninecities acrossEurope

PM10andcardiovascular mortality:enhancer

Evidenceofinteractive effectsbetweenheatand thelevelsofozoneand PM10intermsofmortality

Anenberg2020 39studies Airpollutionin

cardiovascularand respiratorydiseasesor mortality:enhancer

Thereissufﬁcientevidence forsynergisticeffectsof heatandairpollutionin all-causemortality, cardiovascular,and respiratoryeffects(PMand O3inparticular

N/R:notreported;PM:particulatematter.

higherlevelsof(atypeofinhalableparticles,withadiam- eter of less than 10 ␮m that constitutes an element of atmosphericpollution)furtherincrease thecardiovascular mortalityriskduetothetemperaturerise.¹⁶

Anenbergetal.evaluatedtheevidencequalitativelyand concludedthat thedatafrom36 studies wassufﬁcientto determinetheexistence ofsynergisticeffectsofheatand airpollution(particulatematterandground-levelozonein particular)inall-causemortality,cardiovascular,andrespi- ratoryeffects.¹⁷

Perspectives about global warming and cardiovascular disease

Globalwarmingresultedina1^◦Cincreaseinthemeanglobal temperaturecomparedwiththepre-industrialperiod.¹⁸

Accordingtothecurrentlyavailabledata,globalwarming (1^◦Cincrease)hasincreasedtherelativeriskofcardiovas- cular mortality by 2%, which is very relevant in absolute numbers ascardiovascularmortalityhas been the leading causeofdeathworldwide.

One of the consequences of global warming is the extreme heat events which have become more frequent insomeregionsoftheworld.Forexample,in 2018,there wasanexcessof220millionindividualheatwaveexposures comparedwiththeaverageof1986---2005.¹⁹

The2003 and2022heatwavesthatoccurredinEurope aregoodexamples. To acknowledgethemagnitudeofthe impactoftheheatwaves,itisestimatedthatin2003,more than70000deathsresultedfromthisevent(someofthem probablyduetocardiovascularcauses),withmorethanone- third occurring in France,Italy and Spain.²⁰ Thereis also evidencethatthenumberofout-of-hospitalcardiacarrests

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Figure1 Risksofcardiovasculardiseaseassociatedwithincreasedtemperatureorheatwaves.ACS:acutecoronarysyndrome;

CHD:coronaryheartdisease;CI:conﬁdenceinterval;CV:cardiovascular;HF:heartfailure;MI:myocardialinfarction;RR:relative risk

can increase 2.5-fold during heat wave compared with a referenceperiod.²¹

Themeantemperatureshavebeenincreasingatarateof 0.2^◦Cperdecade.However,anaccelerationinthetemper- atureincreaseforecastsaglobalincrementintherelative temperatureof1.5^◦Cforthenextdecades.¹⁸Keepingglobal temperaturerisebelowthethresholdof1.5^◦Cmayprevent

several complications includingcardiovascular events and deathsrelatedwithheatwaves,forexample.

Oneofthepillarsoftheinterventiontoreducethepace ofglobalwarmingisthereductionofairpollution.TheParis Agreementin2015aimedtoreachglobalpeakingofgreen- housegasemissionsassoonaspossibletoachieveneutrality inemissionsandazero-carbonpolicyinthemiddleofthis

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century.Avoidingairpollutionispartofaplantotacklecli- matechange,aimingatprotectingsocietyandpatientsfrom globalwarming,particularlythosewithahighervulnerabil- ity of (cardiovascular) complications, namely the elderly, patients with multiple comorbidities and those with low socio-economiccondition(SupplementaryFigure1).²²

The adaptationofsociety totheglobal warmingthreat poses new challenges in different sectors. One remark- ableaspectisthereorganizationoftheurbanenvironment to tackle global warming conditions. Firstly, it is esti- matedthathalftheworld’spopulationliveinurbanareas, which are responsible for the consumption of two-thirds of global energyandmore than 70%of global greenhouse gas emissions.²³ Urban environmentsare alsopronetoair pollution/poorairquality,which contributestothedevel- opment of cardiovascular disease.² Cities are also prone toheatislandeffects.²⁴ The highnumberofbuildingsand imperviousconstructionmaterials,withconcomitantlossof trees,greenspace andreducedventilation, leads toheat accumulation.Aretrospectivestudyevaluatingtheriskfac- torscontributingtoexcessmortalityduringthe2003 heat waveinFrancefoundthathighersurfacetemperatureinthe surroundingareas to home wasassociated withincreased mortalityrisk,while thepresenceof treesandvegetation wasfoundtobeprotective.²⁴

At the individual level, despite the absence of robust dataoninterventionstopreventheat-relatedcardiovascu- lardisease,itisreasonabletoconceivethatadaptationto warmer temperatures(particularly in heat waves) can be simple.Individualsshouldprotectthemselvesfromexposure during criticalperiods, dresslightly anduselight bedding andsheets,without pillows.Theyshouldstay hydratedby ingestingwater,butavoidingtheconsumptionofalcoholic beverages.Individuals,shouldalso,coolingtechniquesand devices such asair conditioning units.^24,25 In some cases, the cooling of the dwelling through passive measures is crucial to ensure nocturnal rest and recovery Those with lackofmobilityandthosewithpreviousmedicationcondi- tions/comorbiditieswereatincreasedriskofcomplications, furtherstressingtheconceptofvulnerablesubgroupsthat mightbethetargetofpriorityinterventions.Itisalsoadvis- abletomonitorpatientsfor possibleblood pressuredrops during heat waves and instruct them how to proceed to avoid clinically relevant hypoperfusion syndromes (which mayincludeadjustmentsindrugtherapy).

A multidisciplinary collaboration framework should be carried out by policymakers and healthcare professionals (includingprimarycareandpublichealthprofessionalsand physiciansofdifferentspecialities,includingcardiologists) topromotecareforthepreventionofcardiovascularheat- related complications. Together they can plan potential communityinterventionsandawarenesscampaignsadvocat- ingfortheindividual-orcommunity-levelinterventionsand global measurestoimproveairpollution,climate changes andhealthoutcomes.

Thesemuch-neededpoliticalchangeswillreducetheCVD burdenforfuturegenerations,butwemustalsoconsiderthe immediateimplicationsforpreventingandtreatingcardio- vascular diseases.Therefore,we mustincreaseawareness and enable patients with CVD to take preventive measures.

Real-world data local evidence of global warming: the case of Lisbon, Portugal (1970---2019)

Portugaliswellknownforitsfrequentheatwavesandtheir repercussions onhuman mortalityandmorbidity. Portugal hadtheﬁrstoperationalheatwavesurveillance systemin Europesince1999.²⁶ Thissystem wasbasedonthe ÍCARO modelforLisbonandwaslaterupdated.²⁷Theupdatedver- sionincludedknowledgegatheredwiththeprolongedheat waveof2003thatwasfeltacrossEurope,anditwasused toimprovethe modelforLisbon andfourregionalmodels coveringallofPortugal’sMainland.

Currently there are some variables the reﬂect the magnitudeandfrequency ofheat waves. Oneofthe indicator is the Excess Heat Factor(EHF), an internationally used indicator, which accounts for the intensity of the temperature and also for the previous days short-term acclimatization/disruption.²⁸Anothergroupofindicatorsis composedbytheGeneralized AccumulatedThermalOver- charge (GATO) indicators which is used in the Portuguese ÍCAROModel/Surveillance System. The GATO IV is one of suchvariablesthatusesadynamicthresholdacrossthesum- merweekstoassessheatwaves.²⁷

In2020,acomparisonoftheEHFandGATOIVfortheir predictivepowerfordailycardiorespiratorymortalityinLis- bon (1980---2016) showed that both indicators were good predictorsfor heat-relatedmortality, withsigniﬁcantpre- dictiveadvantagesforGATOIV.²⁹

ThenumberofdaysexceedingtheGATOIVandEHFinLis- bonpointoutthesustainedincreaseandpotentiallyharmful effectsacrossdecades(Figure2A).SupplementaryTable1 showthatthefourGATOindicatorsusedbythePortuguese ÍCAROmodelsinLisbon(correspondingtodifferentthresh- oldsincreasingin theircomplexity) andthe EHFindicator varyintheirmagnitudes,buttheyallshowaglobalincrease overthelastdecades.

Additionally, and using the Global Historical Climatol- ogyNetwork (GHCN) daily datafromPortuguese Stations, inparticularof‘‘LisboaGeofísica’’---StationPO000008535 --- available at https://www.ncdc.noaa.gov/cdo-web/ in November 2022, we can perceivethat exists a long-term overallincreaseoftemperatureinLisbonfrom1970to2019 (Figure2B).

In conclusion, evidence exists that for Lisbon (Portu- gal),temperaturesandthenumberofdaysofextremeheat potentially-relatedtomortalityhavebeenincreasingforthe pastﬁvedecades.

Climateprojections for theLisbon regionindicatethat therewillbeasubstantialthermalaggravationinallseasons oftheyear,althoughmorepronouncedinautumnandsum- mer,withincreasesinmaximumtemperaturefrom+1.5^◦C to+3.5^◦Cby2100.³⁰Theseforecastsalsoincludemorefre- quent and persistent heat waves in Lisbon and that heat wavedayscouldincreaseby+23daysperyearattheendof thecentury.Bioclimaticcomfortprojectionsreinforcethis trend,revealing a marked decreasein cold discomfort as wellasageneralworseningofheatdiscomfortintheAML.

Thesedataledtotheeffectsofheatonhumanhealthbeing prioritizedintermsofsectoraladaptation.³⁰

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Figure2 PanelA---Evolutionofdayswithtemperaturesexceedingthethresholdforheatdays.PanelB---Evolutionoftemperature quantilesinLisbon,Portugal(1970---2019).tindexday:numberofdayssince1stJanuary1901.

Position statement/conclusion

Global warming and heat waves are consequences of the climate and increase the risk of cardiovascular diseases, includingcardiovascularmortality.

Air pollution,particularlyprevalentin cities,promotes globalwarming,increasestheriskforcardiovascularevents andisanenhanceroftheriskfortemperature-relatedcar- diovascularevents.

Multidisciplinaryteams shouldtackletheincreasedrisk andinequitiesinheat-relatedcardiovascularcomplications.

Atahigherlevel,theseteamsshouldalsoadvocatewiththe governmentandpolicymakerstheimportanceofcomplying withmeasuresthatpreventglobalwarming,suchasachiev- ingtheParisAgreement’stargetstomitigatecardiovascular andglobalhealthrisks.

Conﬂicts of interest

Theauthorshavenoconﬂictsofinteresttodeclare.

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Appendix A. Supplementary data

Supplementary material associated with this article can be found in the online version at doi:10.1016/j.repc.2023.02.002.

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