Table 1
Studies of arsenic exposure and clinical cardiovascular disease outcomes (18 new studies available after 2005 systematic review)
Study, year | Design | Population | Men (%) | Age Range (yrs) | Arsenic Assessment | Exposed vs. Reference | Endpoint Ascertainment | Outcome (s) | No. of cases/non-cases | Relative Risk | 95 % Confidence Interval | Adjustment Factors |
---|---|---|---|---|---|---|---|---|---|---|---|---|
Taiwan | ||||||||||||
Liao 2012 [27] | CO (Int) | HAA (3 villages in SW Taiwan) | 43.3 | 35–85 | CEI from village well water levels | >14.7 vs. <17.4 ppm-y | Death Registry | CVD mortality | 10 deaths | 1.89 | 0.50–7.10 | Age, sex, cigarette smoking, hypertension, diabetes, abnormal LDH elevation, Framingham CVD risk score, AST |
Cheng 2010a [34] | CO (Ext) | HAA (SW & NE Taiwan) | 56 | >35 | Village well water levels | HAA vs. general population | Death registry | Stroke mortality | 8,867 deaths | 1.11 | 1.07–1.14 | Age, sex |
Wu 2010 [33] | CO (Int) | HAA (NE Taiwan) | 47 | ≥40 | Household well water levels | 50–300 vs. ≤50 μg/L | Death registry | CVD mortality | 22 deaths | 2.07 | 0.74–5.80 | Age, sex, triglyceride, hypertension history, diabetes history, HO-1 genotype, and competing risk of death from malignant neoplasm or other specified causes |
Tseng 2005b [24] | CS | HAA (3 villages in SW Taiwan) | 45 | ≥30 | Urine total arsenic & CEI from village well water | >64.33 μg/L urine vs. 0 mg/L-y CEI | ABI | PAD prevalence | 54/425 | 3.84 | 0.86–17.25 | Age, sex, BMI, alcohol drinking, cholesterol |
Horng & Lin 1997a [35] | CC | HAA | 53 | NR | Urine total arsenic | >75th vs. <25th p (15.3 μg/L vs. 5.1 μg/L) | Blackfoot disease patients | BFD prevalence | 32/32 | 1.85 | 1.43–2.40 | — |
Other high exposure areas (Bangladesh, Chile, Inner Mongolia, and Pakistan) | ||||||||||||
Chen 2011 [28••] | CO (Int) | Araihazar, Bangladesh | NR | 18–75 | Baseline individual well water levels | >80th vs. <20th p (mean 266 μg/L vs. mean 3.7 μg/L) | Verbal autopsy, medical records | CVD mortality | 106 deaths | 1.46 | 0.96–2.20 | Age, sex, education, BMI, smoking status |
CHD mortality | 40 deaths | 1.94 | 0.99–3.84 | |||||||||
Stroke mortality | 41 deaths | 1.07 | 0.54–2.12 | |||||||||
Baseline urine total arsenic levels (μg/g creatinine) | >80th vs. <20th p (mean 642 μg/g vs. mean 69 μg/g) | CVD mortality | 90 deaths | 1.55 | 1.01–2.37 | |||||||
CHD mortality | 34 deaths | 1.90 | 0.91–3.98 | |||||||||
Stroke mortality | 35 deaths | 1.03 | 0.53–2.03 | |||||||||
Khan 2010a [36] | CS | 1 village in Bangladesh | 50 | ≥30 | Village drinking water levels | >50 μg/L w/arsenicosis vs. <50 μg/L w/out arsenicosis | ABI | PAD prevalence | 19/221 | 5.8 | 1.26–26.85 | Age, sex, smoking, BMI, diabetes, blood pressure status |
Sohel 2009 [29•] | CO (Int) | Matlab, Bangladesh | 50 | ≥15 | Household well levels | >300 vs. <10 μg/L | Verbal autopsy | CVD mortality | 281 deaths | 1.37 | 1.07–1.77 | Age, sex, education, asset score (SES) |
Yuan 2007a [37] | CO (Ext) | Regions of Chile in 1958–1970 (peak arsenic exposure in Region II) | NR | ≥20 | Approximate population- weighted drinking water levels | Region II vs. Region V | Death certificate | CVD mortality | 6,164 deaths | 1.01 | 0.88–1.17 | Age, sex |
CHD mortality | 2,196 deaths | 1.23 | 1.00–1.45 | |||||||||
Stroke mortality | 1,624 deaths | 0.89 | 0.78–1.00 | |||||||||
PAD mortality | 790 deaths | 1.03 | 0.84–1.21 | |||||||||
Wade 2009c [30] | CO (Int) | Inner Mongolia (1 village) | 50 | 0–>80 | Household, shared, or community well levels | >300 vs. <5 μg/L | Verbal autopsy & medical record review | CVD mortality | 152 deaths | 2.47 | 0.50–12.18 | Age, sex, education, smoking, drinking, and farm work |
Stroke mortality | 54 deaths | 1.02 | 0.16–6.71 | |||||||||
Xia 2009a [38] | CS | Inner Mongolia (1 village) | 50 | 0 – >80 | Household well levels | >300 vs. <5 μg/L | Self-report | CVD prevalence | 269/3,038 | 1.72 | 0.81–3.67 | Age, sex, education, smoking, household income, water source type, alcohol consumption |
Per 50 μg/L increase | Stroke prevalence | 127/12,207 | 1.03 | 0.93–1.15 | ||||||||
Afridi 2010, 2011a,d [39,40] | CC | Hyderabad, Pakistan | 57 | 45–60 | Scalp hair total arsenic levels | 75th vs. 25th p (1.28 μg/g vs. 1.14 μg/g)e | Coronary angiogram and at least one positive test of MI (stress text or echocardiography) | MI incidence | 58/61 | 3.41 | 1.67–6.99 | Age, SES |
Urine total arsenic levels | 75th vs. 25th p (6.06 μg/L vs. 3.66 μg/L)f | 58/61 | 6.62 | 2.05–21.33 | ||||||||
Low to moderate exposure areas (U.S., Spain, Slovakia, Japan) | ||||||||||||
Gong & O’Bryant 2012a [41] | CS | 3 rural counties (Texas, U.S.) | 31 | 40–96 | Estimated residential drinking water levels | 75th vs. 25th p (8.1 μg/L vs. 4.1 μg/L) | Self-reported physician diagnosis | CHD prevalence | 69/430 | 1.46 | 1.39–1.53 | AS3MT genotype, ethnicity, age, gender, education, smoking, use of antihypertensive meds, alcoholism |
Lisabeth 2010f [31•] | CO (Int) | 27 zip codes in Genesee county (Michigan, U.S.) | 50 | ≥ 45 | Population-weighted average zip code drinking water levels | 80th vs. 20th p (19–22.3 μg/L vs. 0.3–<4.5 μg/L) | Hospital inpatient database | Ischemic stroke hospitalizations | 14,033 admissions | 2.74 | 1.66–4.53 | Age, sex, income, race |
Medrano 2010 [32•] | CO (Ext) | 651 municipalities in Spain | NR | >20 | Municipal drinking water levels | >10 vs. < 1 μg/L | Death certificate | CVD mortality | 158,419 deaths | 1.03 | 0.98–1.08 | Sex, age and the following provincial level variables: income, hospital beds, CV risk factors, dietary factors, and water characteristics |
CHD mortality | 50,244 deaths | 1.05 | 0.95–1.08 | |||||||||
Stroke mortality | 42,164 deaths | 1.07 | 0.95–1.09 | |||||||||
Rapant 2009a [42] | CO (Ext) | 1 region in Slovakiag | NR | NR | Mean groundwater levels | Exposed region vs. general population | Death certificate | CVD mortality | NR | 1.08 | NR | — |
Yoshikaw a 2008a [43] | CO (Ext) | 264 municipalities in Japan | 47 | NR | 5-year average municipal environmental air levels | >90th vs. ≤10th p (≥2.70 ng/m3 vs. <0.77 ng/m3) | National health maps | CVD mortality | 14,247 deaths | 1.03 | 0.99–1.06 | Age, sex |
Stroke mortality | 13,596 deaths | 1.02 | 0.98–1.05 | |||||||||
Meliker 2007a [44] | CO (Ext) | 6 counties (Michigan, U.S.) | NR | ≥35 | Population-weighted county drinking water levels | 6 counties vs. general population | Death certificate | CVD mortality | 52,606 deaths | 1.13 | 1.11–1.15 | Age, sex, race |
CHD mortality | 26,646 deaths | 1.01 | 0.99–1.03 | |||||||||
Stroke mortality | 8,503 deaths | 1.19 | 1.16–1.23 | |||||||||
PAD mortality | 2,549 deaths | 1.03 | 0.97–1.08 |
ABI: ankle-brachial blood pressure index; AST: aspartate aminotransferase; BMI: body mass index; CABG: coronary artery bypass graft surgery; CBVD: cerebrovascular disease; CC: case-control; CEI: cumulative exposure index = Σ arsenic levels in drinking water × time of exposure (i: specific village); CI: confidence interval; CO: cohort; CS: cross-sectional; CV: cardiovascular; DAAC: diseases of the arteries, arterioles, and capillaries; ECG: electrocardiogram; Ext.: external comparisons; HAA: High arsenic area; Int.: internal comparisons; LDH: lactate dehydrogenase; MI: myocardial infarction; NR: not reported; PAD: peripheral arterial disease; PCI: percutaneous coronary intervention; p: percentile; RR: relative risk; SES: socioeconomic status.