&EPA
EPA 600/R-18-001
United States
Environmental Protection
Agency
Integrating Air Quality into
Cardiovascular Care:
Exploring Communication Between
Patients and Providers
An EPA project progress update
Release Date: February 2019

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Acknowledgements and Contributors:
US EPA: Christina Baghdikian, Wayne Cascio, Alison Davis, Stephanie Deflorio-Barker, Ray Garlington, Mary
Clare Hano, Bryan Hubbell, Stacey Katz, Elisa Lazzarino, Steve Prince, Gail Robarge, Elizabeth Sams, Susan
Stone
Industrial Economics, Inc.: Meredith Amend, Henry Roman, Natalie Weiss
Subcontractors: Delores Albarracin, Madeline Scammell, Mike Welsh
Disclaimer: The views expressed in this report are those of the authors and do not necessarily reflect
the views or policies of the U.S. Environmental Protection Agency.

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Contents
Acknowledgements and Contributors:	2
Overview	4
Focus Group Objectives & Design	5
Focus Group Participants	6
Summary of Discussions	7
Patients Focus Group	7
Non-Physician Providers Focus Group	8
Physicians Focus Group	9
Conclusion	10
Limitations	10
Next Steps	10
Appendix A: Handouts During Focus Groups	12
Patients Group	12
Health Care Providers Group	12
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Overview
Adverse cardiovascular effects are associated with exposure to poor air quality in recent studies.1 As cardiac
rehabilitation patients have already experienced an initial adverse cardiac event, they are recognized as
being at increased risk for future adverse health events associated with exposure to poor air quality.
Consequently, cardiac rehabilitation patients represent a special population that would benefit from focused
air quality health risk communication efforts and interventions. This document provides a progress update
to stakeholders of a U.S. Environmental Protection Agency (EPA) project that explores this topic further.
Health organizations are increasingly aware of air pollution as a risk factor for cardiovascular disease and
are calling for more information about public health initiatives. As part of broader efforts to protect human
health and the environment, the EPA works with partner organizations on air quality and communicating
health risks. In 2016, EPA's Office of Research and Development held two workshops: the "Preventing Air
Pollution-related Cardiopulmonary Illnesses: Innovative, Cross-disciplinary Solutions" workshop, and the
"Wildfire Smoke Health Risk Communication" workshop. The following spring, a call to action was published
in the Journal of the American Medical Association emphasizing the need to expand the evidence base of
effective strategies to mitigate adverse effects of air pollution on cardiovascular health.2 Additionally, leading
organizations like the American Heart Association (AHA), the Million Hearts 2022 initiative
[https: //millionhearts.hhs.gov/] co-led by the U.S. Department of Health and Human Services Centers for
Disease Control (CDC) and Centers for Medicare and & Medicaid Services, and the European Society of
Cardiology have recently included short- and long-term exposure to fine particulate matter less than 2.5 [im
(PM2.5) as a risk factor for cardiovascular disease.3
In the summer of 2018, EPA conducted a pilot study that sought to better understand how air quality
information could be integrated into cardiac rehabilitation care. A team of researchers from EPA and
Industrial Economics Inc. (IEc) conducted three focus groups in Raleigh, North Carolina. Each focus group
consisted of a different set of participants involved in a cardiac rehabilitation program. One included cardiac
rehabilitation patients, a second with non-physician cardiac rehabilitation health care providers, and the
third with cardiologists and primary care providers who spend at least 30% of their time working with
patients over the age of 65. This study investigated the experiences, attitudes, and beliefs regarding the risk
of poor air quality on cardiovascular health. Further, this study explored the experiences, attitudes, and
beliefs regarding the use of portable HEPA air purifiers, a technology that may reduce adverse health effects
associated with poor air quality.
1	Reid, C. E., Brauer, M., Johnston, F. H., Jerrett, M., Balmes, J. R., & Elliott, C. T. (2016). Critical review of health impacts of
wildfire smoke exposure. Environmental health perspectives, 124(9), 1334; Cascio, W. E. (2018). Wildland fire smoke and
human health. Science of the Total Environment, 624, 586-595; Wettstein, Z. S., Hoshiko, S., Fahimi, J., Harrison, R. J.,
Cascio, W. E., & Rappold, A. G. (2018). Cardiovascular and cerebrovascular emergency department visits associated with
wildfire smoke exposure in California in 2015. Journal of the American Heart Association, 7(8), e007492.
2	Brook, Robert D., David E. Newby, and Sanjay Rajagopalan. "The global threat of outdoor ambient air pollution to
cardiovascular health: time for intervention." JAMA cardiology2, no. 4 (2017): 353-354.
3	Brook, R. D., Rajagopalan, S., Pope III, C. A., Brook, J. R., Bhatnagar, A., Diez-Roux, A. V.,... & Peters, A. (2010). Particulate
matter air pollution and cardiovascular disease: an update to the scientific statement from the American Heart Association.
Circulation, 121(21), 2331-2378; Newby, D. E., Mannucci, P. M., Tell, G. S., Baccarelli, A. A., Brook, R. D., Donaldson, K.,... &
Hoek, G. (2014). Expert position paper on air pollution and cardiovascular disease. European heart journal, 36(2), 83-93.
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We heard from these participants that education about healthy lifestyles and avoiding future health risks is
central to cardiac patients' experiences after a cardiac event. However, environmental health and air quality
risk information is not typically included in educational resources that patients receive. Participants shared
a range of opinions regarding incorporating air quality information into the cardiac rehabilitation process.
Qualitative analysis of the transcripts from these focus groups is ongoing. Insights from this project can
complement current research and programmatic efforts in this area by informing health risk communication
among cardiac rehabilitation participants.
Focus Group Objectives & Design
This study aims to contribute to broader efforts to protect human health by increasing our understanding of
risk communication of poor air quality. Effective risk communication is especially important among
individuals who have experienced cardiac events because they are at increased risk and may experience
disproportionately adverse outcomes as a sensitive population. The specific aims of this study are to
understand: 1) how health information is shared among cardiac rehabilitation patients and providers; 2) the
extent to which health risks associated with poor air quality are currently addressed with cardiac patients
and perspectives on integrating this information into cardiac rehabilitation; and 3) perspectives on the use
of portable HEPA air purifiers as a strategy to mitigate adverse health effects related to exposure to poor air
quality.
The three groups we focused on are individuals who have experienced a cardiovascular illness or event
qualifying them for cardiac rehabilitation, and two groups of medical professionals who provide care in this
area: non-physicians (nurses, nurse practitioners, physical therapists, occupational therapists, nutritionists,
etc.), and physicians (cardiologists and internists/primary care physicians with an adult patient population).
We chose these groups because each stakeholder type offers a unique perspective on the goal of increasing
awareness about air quality and engagement in health protective behaviors among individuals in this
sensitive population. Because of these differences, each group discussion was guided by a set of questions
tailored to the perspectives of those stakeholders.
The specific questions guiding our study are outlined in Table 1. These questions were used to design scripts
that a trained focus group facilitator used to guide the discussions. Across all three groups, we explored
awareness, attitudes, and beliefs about the association between air quality and cardiovascular health. Among
patients, we also explored the learning process during rehabilitation, as well as patients' experiences,
attitudes, and beliefs about portable HEPA air purifiers. The perspectives of patients about their learning
after a serious health event may translate into insights about when and how to incorporate air quality
information into these processes in the future. We specifically asked about portable HEPA air purifiers
because of the growing body of research regarding the efficacy of these devices to mitigate effects of
exposure. Understanding the knowledge, attitudes, and beliefs of cardiac patients with respect to these
devices is important because these factors relate to adopting the behavior of using the devices.4
With both groups of medical professionals, we explored processes of communication and teaching, and
opportunities for incorporating air quality information into cardiac rehab. With the non-physician providers,
we explored the process of cardiac rehab, the variety of roles and professionals involved, and specific health
4 Ajzen, I. (1991). The theory of planned behavior. Organizational behavior and human decision processes, 50(2), 179-211.
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behavior change strategies and techniques they rely on most for encouraging behavior change. In the
physicians group, we explored attitudes and beliefs about air quality and cardiac health, and existing or
potential opportunities and barriers to integrating this information into their practice. All three focus groups
were facilitated by the same discussant and began with a review of the objectives. Each participant received
a folder with additional background materials that they could review and take home (see Appendix A).
Table 1: Focus Group Research Questions
RQ
CR Patients
Non-Physician Providers
Physicians
1
What is the volume, timing, and
content of new information a
cardiac rehabilitation patient
receives after their
cardiovascular event and in
rehab? What is that learning
curve like from a patient's
perspective?
What roles do non-physician
providers fulfill in cardiovascular
rehabilitation programs and
beyond?
What does cardiovascular
rehabilitation patient care look like
from the physician's perspective -
timeline, key players,
roles/responsibilities, etc.?
2
To what extent is information on
air quality, associated health
effects, and strategies to reduce
exposure currently part of that
learning process?
What does the patient
communication system look like?
Do providers know about the
connection between air quality and
cardiovascular health? Where do
providers look for new information
on a topic to be discussed with
patients?
To what extent is information on
air quality and cardiovascular
health integrated into current care?
What are some factors that may
influence that integration?
3
What kinds of questions do
individuals have about a HEPA
air purifier - its purpose, proper
use, impact on their health?
What strategies or techniques have
been successful at motivating
behavior change?
What are the existing and potential
windows of opportunity to
incorporate new information into
the communication system?
Focus Group Participants
Group 1 included nine participants who had experienced a recent cardiac episode and had participated in a
cardiac rehabilitation program within the last twelve to eighteen months. All participants were over the age
of 65 and were currently non-smokers. Participants were excluded from this focus group if they had a
background in environmental science, health care, or related fields. Within these criteria, we recruited a mix
of genders and socioeconomic backgrounds. The focus on those greater than 65 years old was largely based
on practicality. With the small number of subjects who participate in a focus group, the rationale was to get
as many inputs as possible from one age demographic and with the highest susceptibility to the adverse
effects of air particle pollution. Then moving forward, we would expand the inclusion criteria to broader
groups adversely impacted by air pollution.
Groups 2 and 3 also each included nine participants and were composed of health care providers who work
with cardiac rehabilitation patients. Group 2 included a mix of non-physician health care providers, including
two nutritionists, two physical therapists, three nurses or nurse practitioners, one social worker, and one
exercise physiologist Group 3 included six cardiologists and three primary care physicians who spend at
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least 30% of their time working with patients over the age of 65. All but one participant in Groups 2 and 3
had more than ten years of experience working with cardiac patients.
Summary of Discussions
Patients Focus Group
The primary objectives of the patient focus group were to understand (1) how they received and interpreted
information following their cardiac event, (2) what knowledge they might have about air quality-related
health risks, and (3) their knowledge, attitudes, and beliefs about air purifiers as a tool to reduce exposure.
While cardiovascular patients may have received and sought out a large volume of information in various
forms, air quality information was not included. There was generally low awareness of air quality and risks,
but patients were receptive to the idea of taking action to reduce exposure to poor air quality.
A majority of participants stated that they remembered being overwhelmed by the amount of material and
information they received following their cardiac event There was also a wide variety of learning styles
represented in the group. For example, some participants read all of the informational materials that were
provided to them and did additional research on their own. In contrast, other participants did not read any
of the materials and instead preferred verbal communication or hearing personal stories. Most participants
stated that key messages were repeated multiple times by a variety of health care providers. With respect to
lifestyle changes, most participants stated that they at least tried to make all of the recommended changes.
However, the hardest changes involved weight loss and dietary changes. This had to do with the difficulty of
implementing the changes, and their impact on participants' social lives.
During the discussion, all participants stated that they had not received information from their doctors or
other health care providers about the health risks associated with poor air quality for cardiac patients.
However, one participanthad read online that air quality and other environmental factors can impact cardiac
health. A few had received some information about air quality in reference to their lung conditions. Other
participants had been told by their doctor to wear a mask while mowing the lawn or had the general
knowledge to stay indoors on bad air quality days.
Upon reviewing the EPA handout on cardiovascular health risks from poor air quality, the majority of the
participants were receptive to the information. They all agreed that there was nothing confusing or
unbelievable about the information. One participant even mentioned that they were particularly interested
in the AirNow website where they could get information on daily air quality, while another noted that she
found the AHA statement to be a particularly credible source. However, some misconceptions persisted in
the group, with one participant stating that you should be able to tell if the air was good or bad by simply
stepping outside.
In the final section of the focus group, the moderator briefly stepped out so that the participants could view
and interact with two air purifiers that were brought in and turned on. Following that brief break, the group
discussed their reactions to the air purifiers and how likely they would be to use something like this in their
own homes. Most of the participants agreed that, if this device were really to reduce both their exposure risk
for future cardiovascular events, they would use it However, they noted several potential barriers. Their
primary concern was financial, including the cost of purchasing and operating the device, as well as ongoing
maintenance. Other barriers included the noise generated by the machines, and most participants said they
would need additional justification before they would consider using one. For example, several participants
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wanted to be able to assess the air quality in their homes through professional testing before purchasing a
device. They also wanted to know how many units might be necessary to make a difference, or if other
changes to their house (e.g., window upgrades) would also be necessary for the air purifiers to be effective.
None of the participants had any concerns about their ability to operate or maintain the devices.
Non-Physician Providers Focus Group
The primary objectives of the non-physician health care providers focus group were to understand (1) what
roles do non-physician providers fulfill during and after cardiac rehabilitation; (2) what patient-provider
communication looks like; (3) what strategies have been successful for motivating behavior change. Cardiac
rehabilitation programs are typically structured, fitness-oriented programs that meet three days each week
for twelve weeks. Cardiac rehabilitation providers often meet with patients face-to-face, in group settings
where they communicate motivational behavioral and fitness messages through interpersonal exchanges.
However, there remains a low awareness and understanding of the connection between air quality and
cardiovascular health.
Although this focus group included a wide variety of specialties, all of them participated in some level of
patient education with the goal of enabling patients to maintain their health.
All participants agreed that cardiac rehabilitation is a team approach, with several health care providers
working together with the same patient. They also tend to have a high number of interactions with the patient
since cardiac rehabilitation treatment usually occurs three days per week for each patient While they
recommend outside resources to their patients, their own interactions are usually limited to scheduled
sessions unless communications from patients have become sporadic. They also noted that patients often
form friendships with each other and share information.
When it comes to risk communication, most of the participants rely on familiar and popularly understood
risks e.g., smoking, hypertension, obesity, and sedentary lifestyle. They provide written educational
materials to patients, but also frequently use verbal repetition (both in person and over the phone) because
they know some patients will not read the materials. Only one of the participants mentioned using social
media, and most agreed that electronic media (email, MyChart, etc.) was not a primary mode of
communication with their patients.
Almost none of the participants were familiar with the cardiovascular health risks associated with poor air
quality. After reading the handout from EPA, they still had questions about how particle pollution triggers an
event, as well as whether the risk is acute or chronic. They felt that without that information, they would
have trouble communicating this risk to their patients. However, they were all receptive to additional
information. The providers also noted that many of the symptoms listed in the EPA handout are regular
occurrences for cardiac patients, even on good air quality days.
The remainder of the discussion focused on strategies that these health care providers use to motivate
behavioral changes. Common strategies included cheerleading, repetition, and talking to patients about how
they will maintain adherence after rehabilitation. For example, the physical therapists mentioned that at
most appointments they make sure that their patients have a water bottle and periodically drink from it In
addition, when a patient is close to completing rehabilitation, the provider helps the patient outline a plan
for continuing the exercise program outside the rehabilitation program. There is also an educational
component, which entails some participants using a lot of informative signs and posters in their facilities or
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hosting extra educational classes that patients can attend. The majority of participants agreed that patients
are receptive to their suggestions, but also noted that sometimes psychological factors, such as depression,
can be an obstacle to behavior change following cardiac episodes.
Physicians Focus Group
The primary objectives of the physicians focus group were to understand (1) what cardiac rehabilitation
looks like from the physician perspective, (2) the extent to which information about air quality and
cardiovascular health is integrated into patient care, and (3) opportunities within cardiovascular care to
integrate air quality information. While cardiologists and primary care physicians are integral at the early
stages immediately following the cardiovascular event, cardiac rehabilitation as a program is something they
prescribe to their patients. Like the non-physicians group, information about air quality and cardiovascular
health is not currently part of their patient care. The physicians discussed opportunities and barriers to
incorporating this information into the limited time they have with patients.
Most of the physicians followed a similar pattern of action after a patient has a cardiac episode. This involves
discussing what happened with the patient, examining patient lifestyle factors and recommending lifestyle
changes, and ensuring that any new medications or courses of treatment do not conflict with their existing
health regimen. They also have limited opportunities for patient interaction, as appointments are brief and
occur with decreasing frequency after the first few weeks following the event. These participants were
supportive of cardiac rehab, and regularly prescribed it to patients as part of their care.
Most of the participants stated that they have a large amount of information to communicate to their patients
after an event, so they usually try to spread it out over several visits and make use of written materials.
Several of the participants were familiar with the respiratory health risks associated with poor air quality.
Some participants felt that air quality was "one of those uncontrollables," and did not currently discuss it
with their patients because it would be hard for them to recommend concrete changes that would mitigate
their patients' risk.
With respect to the associations between cardiovascular health and exposure to poor air quality, there was
a generally low level of awareness among these physicians. Moreover, there was hesitation to accept
information provided in fact sheets during the focus group, as participants perceived the science was not yet
clear enough, and they would need additional information before prioritizing this topic. For example, a few
participants asked about the cost per quality-adjusted life year for different types of interventions, like air
purifiers. However, others noted that while those metrics are important in weighing the cost of interventions
with benefits, it is common to recommend newer interventions that have potential benefit without the
evidence base. In spite of these reservations, some participants were open to sharing this information with
their patients in some fashion. For example, one participant uses electronic signage in his office and stated
that he would be willing to include one of EPA's infographics in the rotating set of materials.
The participants also discussed how communication occurs between different health care providers during
cardiac rehabilitation. Most of the participants supported cardiac rehabilitation and encouraged their
patients to do it However, they noted that this is not an option that is available to all patients due to insurance
or other limitations such as transportation options or work schedules. Electronic records help physicians
monitor patients' progress. They stated that different health care providers usually don't coordinate on the
type of messages that they will stress for a given patient, but that everyone usually focuses on the same
things. The remainder of the discussion concerned how physicians stayed up to date in their field.
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Participants mentioned a number of different strategies, including reading scientific journals or news
articles, attending meetings or discussions, taking continuing education courses, or having informal
discussions with colleagues.
Conclusion
Limitations
This report is a summary of observation notes across team members and does not reflect analysis of the
focus group transcripts. Participants were recruited from a limited geographic area and may not represent
the broader population. While not generalizable, analysis of these discussions may offer insights about the
integration of air quality information into cardiac rehabilitation services and potential opportunities for
growth in that area.
Next Steps
This project is part of a growing body of research about air quality, cardiovascular health, and strategies to
mitigate adverse health effects associated with poor air quality. Understanding the knowledge, attitudes, and
beliefs among cardiac rehabilitation stakeholders advances public health research and practice in this area.
Health risk communication is critical to bringing about behavior change. This study advances our knowledge
about those communication processes in the context of cardiac rehabilitation services. Moreover,
understanding perspectives on the acceptance and appropriate use of a portable HEPA air purifier builds on
current research about effectiveness and health benefits of these devices.5
These focus groups illuminated the low level of understanding and awareness of how air quality impacts
cardiovascular health, information describing this process, and how to incorporate exposure reduction
messages throughout the cardiac rehabilitation curriculum. Patients were open to receiving this information
and using a portable HEPA air purifier, and thus it is important to explore the opportunities for integrating
air quality and health risk messaging as well as options for reducing exposure into the rehabilitation process.
Given the high frequency and longer duration of interaction, which builds trust, the cardiac rehabilitation
providers may be the ideal point of entry to communicate this information to these patients. Providing clear
information to physicians is also important in order to support the dissemination through the cardiac
rehabilitation providers, however it is unlikely that physicians will communicate about air quality and health
directly to the patient, given the limited time and often exhaustive list of other competing topics for
discussion.
These focus groups fit into a larger initiative to educate cardiovascular rehabilitation healthcare providers
and patients on air quality and health. There are opportunities for other organizations to partner with EPA
researchers to build on these efforts for larger implementation and evaluation studies. This research can
help inform the development of messages and communication strategies (including timing, format, and
messenger) that better prepare cardiovascular rehabilitation patients to protect their health during poor air
quality episodes. Next steps include a more in-depth analysis of the transcripts to understand more nuanced
5 Fisk, W. J., & Chan, W. R. (2017). Effectiveness and cost of reducing particle-related mortality with particle filtration.
Indoor air, 27(5), 909-920; Brugge, D., Reisner, E., Padro-Martinez, L. T., Zamore, W., Owusu, E., & Durant, J. L (2013). In-
home air filtration for improving cardiovascular health: Lessons from a CBPR study in public housing. Progress in community
health partnerships: research, education, and action, 7(1), 49.
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patterns that arose within and throughout the focus groups. This understanding will inform
recommendations for future research and outreach in this area.
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Appendix A: Handouts During Focus Groups
Patients Group
1.	"Effects Of Common Air Pollutants". 2018. www3.Epa.Gov. httpsi//www3. epa.gov/airnow/health-
prof/common-air-pollutants-2011-lo.pdf.
2.	"Heart Disease, Stroke, And Outdoor Air Pollution". 2018. www3.Epa.Gov.
https://www3.epa.gov/airnow/heartflyer.pdf.
3.	"California Certified Air Cleaning Devices". 2018. Arb.Ca.Gov.
http://www.arb.ca.gov/research/indoor/aircleaners/certified.htm
4.	"Hazardous Ozone-Generating "Air Purifiers"". 2018. Arb.Ca.Gov.
https://www.arb.ca.gov/research/indoor/ozone.htm.
5.	"Air Cleaning Devices For The Home Frequently Asked Questions". 2018.
https://www.arb.ca.gov/research/indoor/acdsumm.pdf
6.	"Facts About Reducing Your Exposure To Particle Pollution". 2018. Arb.Ca.Gov.
https://www.arb.ca.gov/research/indoor/pmfactsheet.pdf. https://www.epa.gov/indoor-air-
quality-iaq/indoor-particulate-matter
Health Care Providers Group
1.	"Particulate Matter Air Pollution and Cardiovascular Disease: An Update To The Scientific
Statement From the American Heart Association". 2010. American Heart Association Journal:
Circulation, https://www.ahaiournals.org/doi/abs/10.1161/cir.0b013e3181dbecel
*Note only the abstract was distributed
2.	"Air Pollution Linked To Cardiovascular Disease; Air Purifiers May Lessen Impact | American Heart
Association". 2018. Newsroom.HeartOrg. https://newsroom.heart.org/news/air-pollution-linked-
to-cardiovascular-disease-air-puriPiers-mav-lessen-impact
https://experts.umich.edu/en/publications/the-global-threat-of-outdoor-ambient-air-pollution-to-
cardiovascu
3.	"What Health Care Providers Should Know About Particle Pollution And Cardiovascular Risk". 2018.
Epa.Gov. https://www.epa.gov/sites/production/files/2015-
11 /documents/what health care providers should know fiver .pdf
4.	"Particle Pollution And Your Patients' Health Web Course". 2018. Epa.gov.
https://www3.epa.gOv/aiimw/fly6r-pra-coi:irse.pdf
5.	"Facts About Reducing Your Exposure To Particle Pollution". 2018. Arb.Ca.Gov.
https://www.arb.ca.gov/research/indoor/pmfactsheetpdf. https://www.epa.gov/indoor-air-
auality-iaa/indoor-particulate-matter
6.	"Air Cleaning Devices For The Home Frequently Asked Questions". 2018.
https://www.arb.ca.gov/research/indoor/acdsumm.pdf
7.	Newby, D. E., P. M. Mannucci, G. S. Tell, A. A. Baccarelli, R. D. Brook, K. Donaldson, F. Forastiere et al.
"European Association for Cardiovascular Prevention and Rehabilitation; ESC Heart Failure
Association. Expert position paper on air pollution and cardiovascular disease." Eur Heart J 36, no. 2
(2015): 83-93b. https://academic.oup.eom/eurhearti/article/36/2/83/2293343
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