Growing evidence links lifelong environmental exposures to the development and progression of heart failure, but integrating these risks into clinical care remains a challenge.
This article was originally published in Nature and is reposted here with permission.
Heart failure affects more than 55 million people worldwide and remains a leading cause of illness and death.
Traditionally, research has focused on internal drivers: genetic predisposition, hypertension and diabetes and neurohormonal dysregulation. But a large 2026 review in Nature Reviews Cardiology suggests this view is incomplete, placing environmental exposures alongside biology as key determinants of disease risk and trajectory.
The review centers on the exposome: the sum of environmental factors influencing health across a human’s lifespan, including air, noise and light pollution, climate factors and social conditions. These exposures interact with genetic susceptibility and biological pathways to shape cardiovascular health.
“The field lacks a unified framework to connect these factors,” says Dr. Sadeer Al-Kindi, a preventive cardiologist at Houston Methodist DeBakey Heart and Vascular Center and senior author of the review. “Without one, it’s difficult to link it patho-mechanistically.”
The analysis suggests that multiple environmental exposures, acting together over time, shape both the onset and progression of heart failure.
Impacts on the heart
Environmental exposures linked to heart failure include pollution, toxic metals and extreme temperatures.
Air pollution in particular is associated with adverse cardiovascular effects, including increased heart failure incidence, myocardial tissue scarring and accelerated disease progression. “Our prior studies have shown an association between air pollution and recurrent heart failure hospitalization,” says Dr. Al-Kindi. “This may result from systemic inflammation or myocardial stress.”
Temperature extremes may exacerbate heart failure symptoms by impairing vascular function and thermoregulation. Noise pollution from road traffic and aircraft also increases cardiovascular strain by disrupting autonomic balance. Artificial light at night can disrupt circadian rhythms and promote metabolic dysfunction, increasing heart failure risk.
People can inhale or ingest toxic metals, such as cadmium and lead (from drinking water, cigarettes and other sources), as well as have imbalances in essential metals such as copper and zinc — all of which can contribute to oxidative stress, endothelial dysfunction and myocardial damage. The adverse effects of these metals remain underrepresented in heart failure research. Environmental exposures may also interact with social determinants of health, such as socioeconomic status, placing a disproportionate burden on disadvantaged communities.
Over time, these exposures can reshape gene expression through epigenetic mechanisms, including DNA methylation and histone modifications, leading to lasting cardiovascular effects. Yet because they are rarely assessed together, it remains “hard to quantify which one is most impactful,” Dr. Al-Kindi notes. A more integrated view of how they interact may help clarify the risk drivers.
Clinical outlook
Translating these insights into clinical impact remains a challenge.
Looking ahead, mechanistic studies and large trials, supported by advanced analytics, artificial intelligence and omics technologies, will help disentangle the cumulative effects of environmental exposures. A better understanding of underlying biological pathways could help identify targets for intervention and inform strategies to mitigate environmental risk in heart failure.
Clinicians could apply exposome research to enhance patient care, yet Dr. Al-Kindi warns that a lack of awareness often limits integration of environmental hazards into routine clinical practice.
“There’s a huge need to incorporate climate and environmental health into medical schools’ curricula.”
Dr. Sadeer Al-Kindi, MD
Beyond education, advancing this field will require greater investment. “Reducing air pollution and addressing climate change are the most impactful macro-level interventions, while adaptation strategies such as targeted alert systems and healthcare preparedness offer local solutions,” says Dr. Al-Kindi. “Stronger funding and advocacy are needed to translate research into policy.”