Barriers preventing consideration of environmental risk factors by cardiologists.

Environmental exposures such as air pollution, soil and water pollution, climate change, noise, and chemical contaminants including plastic are increasingly recognized as significant contributors to cardiovascular morbidity and mortality.1,2 A substantial body of research has demonstrated that these environmental risk factors are associated with increased incidence of ischaemic heart disease, stroke, arrhythmias, and heart failure.3 The 2019 Global Burden of Disease study estimated that air pollution alone accounts for over 3 million cardiovascular deaths annually worldwide.4 Yet, translation of this evidence into routine clinical practice remains limited. Indeed, environmental risk factors are rarely assessed alongside traditional determinants like hypertension, diabetes, or dyslipidaemia.5,6 Understanding why environmental risk is overlooked in risk assessment, and how to address the barriers preventing its integration into clinical practice by cardiologists and physicians at large, is critical for advancing preventive strategies and reducing the global burden of cardiovascular disease (Figure 1). Barriers preventing consideration of environmental risk factors in cardiology. Key obstacles limiting the integration of environmental determinants into cardiovascular care, including limited clinician awareness, perceived low clinical relevance, lack of standardized assessment tools and risk models, restricted access to exposure data, and uncertainty about effective mitigation strategies The first barrier is the limited awareness and training among clinicians. Most cardiology curricula continue to prioritize classical modifiable risk factors such as smoking, diet, hypertension, and physical inactivity, while environmental determinants receive little or no systematic attention in clinical curricula. Although the scientific literature increasingly demonstrates the impact of air pollution, extreme temperatures, noise, and chemical contaminants on cardiovascular outcomes, the available evidence has not yet translated into core medical education. Consequently, many cardiologists may be unfamiliar with the magnitude and causal strength of these associations, and this knowledge deficit reduces the likelihood that clinicians will routinely assess environmental exposures or recognize them as risk factors and contributors to disease progression. Without basic training, environmental health considerations may be perceived as peripheral rather than integral to cardiovascular risk assessment, prevention, and management. The second barrier is the perceived lack of clinical relevance. Environmental exposures are often conceptualized as broad societal or public health issues and therefore seem distant from the scope of individual patient care. In busy clinical settings dominated by time constraints and treatment-oriented priorities, clinicians may understandably prioritize interventions with immediate therapeutic consequences such as pharmacologic therapy or invasive procedures. As a result, they may question whether counselling on air quality levels or heat-related risks can meaningfully influence clinical outcomes. This perception persists despite emerging evidence suggesting that behavioural adaptation and personalized exposure reduction strategies can reduce cardiovascular events, particularly among vulnerable populations. The third barrier is the lack of standardized cardiovascular risk scores that incorporate environmental determinants. Unlike blood pressure, cholesterol levels, or smoking history, environmental exposures are not easily quantified in routine clinical practice and only marginally discussed in current prevention guidelines. Accordingly, there are no widely accepted or validated environmental cardiovascular risk scores to support risk stratification or decision-making. Information such as local air quality indices, residential noise exposure, or heat vulnerability scores may exist through public monitoring systems, yet these data are rarely accessible at the point of care. Moreover, they are not integrated into electronic health records (EHRs), limiting their usability and preventing clinicians from systematically incorporating them into management plans. The fourth barrier is uncertainty regarding effective interventions. Even when environmental risks are identified, cardiologists may lack confidence in recommending evidence-based mitigation strategies. Suggestions such as limiting outdoor activity during high pollution episodes, improving indoor ventilation, or using protective masks may seem modest relative to the broader structural drivers of exposure. This uncertainty may leave clinicians reluctant to engage in discussions that appear to offer limited impact compared with pharmacologic or procedural interventions, ultimately discouraging the integration of environmental risk counselling within cardiovascular care. Incorporating environmental cardiology into under-graduate, post-graduate, and continuing medical education represents a foundational step to address the existing knowledge gap.7 Training programmes should not only highlight the epidemiological evidence linking pollutants, temperature extremes, noise, and chemical exposures to cardiovascular morbidity and mortality, but also emphasize the clinical implications for vulnerable populations such as those with heart failure, ischaemic heart disease, or arrhythmias. Targeted modules on air pollution, climate change–related stressors, and toxic exposure pathways could be integrated into cardiology curricula, professional society conferences, and board certification requirements. Additionally, simulation-based learning and case-based discussions could familiarize trainees with environmental history-taking and practical mitigation counselling. Raising awareness among practising cardiologists requires both professional leadership and public health communication. Cardiologists, epidemiologists, and environmental health experts can collaborate to amplify key messages on environmental determinants through patient education materials, hospital information campaigns, and community-focused initiatives. National and international cardiology societies could play a central role by publishing scientific statements, consensus documents, or clinical guidelines that outline best practices for environmental risk assessment and counselling. Standardized checklists for environmental exposure history-taking, covering air quality, heat vulnerability, occupational hazards, and local pollution sources, could be recommended as part of patient intake procedures, normalizing their use in routine cardiovascular evaluations. Embedding exposome into EHR can facilitate cardiovascular risk assessment in clinical settings. Automated incorporation of local air quality indices, temperature alerts, or traffic-related pollution estimates based on patients’ addresses could enable clinicians to quickly identify relevant risks. In parallel, research efforts are needed to develop and validate clinical scores that quantify environmental cardiovascular risk, analogous to the Framingham Risk Score8 or the ESC Risk SCORE.9 Such tools should be automated and AI-enhanced to be as user-friendly as possible and compatible with routine visits to ensure widespread adoption. Cardiologists should be equipped with clear, evidence-based counselling protocols that provide practical mitigation advice. Recommendations may include avoiding strenuous outdoor activity during periods of high environmental pollution or heat episodes, using protective masks, improving indoor ventilation, and reducing exposure to household pollutants.10 Beyond individual-level guidance, professional societies should collaborate more actively with public health agencies to support community-level interventions, regulatory efforts, and environmental policy advocacy aimed at reducing cardiovascular risk at the population scale.11 Environmental risk factors are significant, yet under-recognized, contributors to cardiovascular disease. Barriers to their consideration in clinical cardiology include limited awareness, perceived irrelevance, lack of standardized tools, insufficient exposure data, and uncertainty about effective interventions. Overcoming these challenges will require education, guidelines, integration into EHRs, practical risk scores, multi-disciplinary collaboration, public health engagement, and policy support. Bridging this gap is essential for comprehensive cardiovascular prevention and for aligning clinical practice with contemporary epidemiological evidence. All authors declare no disclosure of interest for this contribution.