ESC Congress 2026 Abstract · Oct 26, 2026
Association of Multiple Environmental Exposures and Acute Coronary Syndrome Outcomes
By Ashri S, Cohen G, Keinan Boker L et al.
Background: The impact of a cumulative favorable environment across the cardiovascular risk spectrum, from primary prevention of acute coronary syndrome (ACS) to secondary prevention of recurrence and mortality, remains unclear. We evaluated the association between a favorable multi-exposure scale and these outcomes. Methods: We pooled four cohorts (N=17,216), including two ACS patient registries (1992-1993; 2004-2014) and two Israeli population surveys (1999-2001; 2005-2006, excluding participants with prevalent cardiovascular disease), to capture individuals both with and without prior ACS. We assessed four environmental exposures—greenness, traffic-related air pollution, residential socioeconomic status, and walkability—calculating a cumulative score based on the number of exposures in the most favorable quartile. Mortality and ACS hospitalization data were obtained from the Ministry of Health (through December 2021). Incident ACS was identified among those without prior disease, and recurrent events within the ACS registries. Cox regression models, using age as the time scale and adjusting for potential confounders, were used to estimate hazard ratios (HRs) for all-cause mortality and ACS hospitalization associated with number of favorable exposures. Results: A total of 14,887 individuals [median age 67 (IQR 56–76) years; 32% female] were followed for a median of 15.6 (IQR 11.7–16.0) years; 6,359 (42.7%) deaths and 5,402 (36.3%) ACS events were recorded. Number of favorable exposures was associated with lower mortality risk in a dose-response fashion (p-for-trend<.005), with no effect modification by prior ACS status (Table). In the ACS cohorts, the number of favorable exposures was monotonically associated with a lower risk of subsequent ACS hospitalization; no such association was observed among the ACS-free cohort (p-for-interaction=.09; Table). Conclusions: A higher number of favorable environmental exposures was associated with lower risks of mortality and recurrent ACS events, but not with incident ACS events. These findings support the role of a favorable environment in secondary prevention of ACS.Table