Long-term exposure to traffic-related air pollution and stroke: A systematic review and meta-analysis

Background: Stroke remains the second cause of death worldwide. The mechanisms underlying the adverse as-sociation of exposure to traffic-related air pollution (TRAP) with overall cardiovascular disease may also apply to stroke. Our objective was to systematically evaluate the epidemiological evidence regarding the associations of long-term exposure to TRAP with stroke. Methods: PubMed and LUDOK electronic databases were searched systematically for observational epidemio-logical studies from 1980 through 2019 on long-term exposure to TRAP and stroke with an update in January 2022. TRAP was defined according to a comprehensive protocol based on pollutant and exposure assessment methods or proximity metrics. Study selection, data extraction, risk of bias (RoB) and confidence assessments were conducted according to standardized protocols. We performed meta-analyses using random effects models; sensitivity analyses were assessed by geographic area, RoB, fatality, traffic specificity and new studies. Results: Nineteen studies were included. The meta-analytic relative risks (and 95% confidence intervals) were: 1.03 (0.98-1.09) per 1 mu g/m(3) EC, 1.09 (0.96-1.23) per 10 mu g/m(3) PM10, 1.08 (0.89-1.32) per 5 mu g/m(3) PM2.5, 0.98 (0.92; 1.05) per 10 mu g/m(3) NO2 and 0.99 (0.94; 1.04) per 20 mu g/m(3) NOx with little to moderate heterogeneity based on 6, 5, 4, 7 and 8 studies, respectively. The confidence assessments regarding the quality of the body of evidence and separately regarding the presence of an association of TRAP with stroke considering all available evidence were rated low and moderate, respectively. Conclusion: The available literature provides low to moderate evidence for an association of TRAP with stroke.