Heart failure affects over 64 million people globally, yet the environmental forces accelerating its progression remain poorly integrated into clinical cardiology practice. A growing body of evidence now connects atmospheric exposures — particulate matter, ground-level ozone, wildfire smoke, and thermal extremes — to measurable deterioration in heart failure incidence, hospitalization rates, and mortality, raising urgent questions about how cardiologists should counsel and monitor patients in an era of worsening environmental conditions.
This scoped narrative review, published in Monaldi Archives for Chest Disease, synthesizes the epidemiological and mechanistic literature linking climate-related stressors to heart failure outcomes. The proposed pathophysiological pathways are multifactorial: fine particulate matter (PM2.5) appears to trigger systemic inflammation and oxidative stress, disrupting endothelial function and amplifying myocardial strain; extreme heat induces hemodynamic instability through vasodilation and volume shifts that can precipitate acute decompensation; and wildfire smoke introduces a complex toxic mixture that compounds both cardiac and pulmonary burden. Autonomic imbalance — impaired heart rate variability and dysregulated sympathetic tone — emerges as another credible mechanism linking pollution exposure to arrhythmic and hemodynamic risk. The review also identifies disproportionate vulnerability in older adults, women, and socioeconomically disadvantaged populations, reflecting both biological susceptibility and reduced adaptive capacity.
This work is analytically useful but carries the inherent limitations of narrative reviews: it cannot quantify effect sizes, establish causality, or control for confounding the way a meta-analysis might. Much of the underlying mechanistic evidence derives from animal models or short-term observational studies rather than longitudinal clinical trials. Nevertheless, the convergence of epidemiological signals across diverse populations and geographies is striking. The growing frequency of heat waves and wildfire events makes this an accelerating problem rather than a stable risk factor. For clinical practice, this review reinforces the case for integrating environmental exposure history into heart failure management — a dimension currently absent from most major guidelines. Incremental in scope, but timely in framing an underappreciated dimension of cardiac risk.