The Effects of Air Pollution on Atrial Fibrillation: A Systematic Review

Background: Atrial fibrillation (AF) is the most common arrhythmia globally and is increasingly recognized as being influenced by environmental exposures. While air pollution is a well-established risk factor for cardiovascular disease, its specific relationship to AF remains undetermined. This systematic review aims to synthesize current evidence on the association between air pollution and AF, identifying key pollutants, exposure patterns, and population vulnerabilities. Methods: Following PRISMA guidelines, a comprehensive search of PubMed, Embase, CINAHL, Web of Science, and other databases was conducted to identify cohort, case-crossover, and time-series studies examining the effects of ambient air pollutants (PM 2.5 , PM 10 , NO 2 , SO 2 , CO, and O 3 ) on AF outcomes in adults. Data on study design, pollutant levels, AF metrics, and population characteristics were extracted and the Joanna Briggs Institute Critical Appraisal Checklist was used to evaluate the selected study quality. Results: Thirty-one studies met inclusion criteria, encompassing over 63 million participants across North America, Europe, and Asia. PM 2.5 was the most studied and most consistently associated pollutant, with 21 of 29 studies showing significant positive associations with AF risk. Several studies identified elevated AF incidence even at pollutant levels below WHO air quality guidelines. Subgroup analyses revealed that individuals with comorbidities (eg, diabetes, obesity, hypertension), women, and older adults may be more vulnerable to pollution-related AF. Study methodologies varied widely in terms of pollutant measurement, AF detection, and temporal resolution, affecting comparability. Conclusions: This review affirms a significant association between air pollution, particularly PM 2.5 and NO 2 , and the risk of atrial fibrillation. The findings suggest that even pollutant concentrations deemed “safe” may increase AF risk, particularly in vulnerable populations. Future research should standardize exposure assessment and explore understudied pollutants and effect modifiers. These results underscore the importance of air quality regulations as a public health intervention to reduce AF burden and support cardiovascular health.