ArticleAnnals of internal medicine2013
Association between exposure to low to moderate arsenic levels and incident cardiovascular disease. A prospective cohort study.
Article in Annals of internal medicine, 2013. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 163 papers, 15 of them syntheses that pooled it.
What it found
Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.
The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
163 citing papers in PubMed, 15 syntheses or guidelines pooled it, 268 citations in OpenAlex.
- Prediction of Emerging CVD Biomarkers in Population Exposed to Arsenic and Their Associated Risk Factors in Humans by Systematic Review and Meta-Analysis.Biological trace element research · 2026Pooled it
- "Low-to-moderate arsenic exposure: a global systematic review of cardiovascular disease risks".Environmental health : a global access science source · 2025Pooled it
- Non-essential heavy metal effects in cardiovascular diseases: an overview of systematic reviews.Frontiers in cardiovascular medicine · 2024Pooled it
- Drinking water and the implications for gender equity and empowerment: A systematic review of qualitative and quantitative evidence.International journal of hygiene and environmental health · 2023Pooled it
- Environmental toxic metal contaminants and risk of stroke: a systematic review and meta-analysis.Environmental science and pollution research international · 2022Pooled it
- Provision of folic acid for reducing arsenic toxicity in arsenic-exposed children and adults.The Cochrane database of systematic reviews · 2021Pooled it
- Urinary arsenic and heart disease mortality in NHANES 2003-2014.Environmental research · 2021Pooled it
- Exposure to arsenic at different life-stages and DNA methylation meta-analysis in buccal cells and leukocytes.Environmental health : a global access science source · 2021Pooled it
- Use of study-specific MOE-like estimates to prioritize health effects from chemical exposure for analysis in human health assessments.Environment international · 2020Pooled it
- Positive Association of Cardiovascular Disease (CVD) with Chronic Exposure to Drinking Water Arsenic (As) at Concentrations below the WHO Provisional Guideline Value: A Systematic Review and Meta-Analysis.International journal of environmental research and public health · 2020Pooled it
- Environmental toxic metal contaminants and risk of cardiovascular disease: systematic review and meta-analysis.BMJ (Clinical research ed.) · 2018Pooled it
- A dose-response meta-analysis of chronic arsenic exposure and incident cardiovascular disease.International journal of epidemiology · 2017Pooled it
- The Association of Arsenic Metabolism with Cancer, Cardiovascular Disease, and Diabetes: A Systematic Review of the Epidemiological Evidence.Environmental health perspectives · 2017Pooled it
- Arsenic Exposure and Predicted 10-Year Atherosclerotic Cardiovascular Risk Using the Pooled Cohort Equations in U.S. Hypertensive Adults.International journal of environmental research and public health · 2016Pooled it
- Association of arsenic with adverse pregnancy outcomes/infant mortality: a systematic review and meta-analysis.Environmental health perspectives · 2015Pooled it
- Effect of an Arsenic Mitigation Program on Arsenic Exposure in American Indian Communities: A Cluster Randomized Controlled Trial of the Community-Led Strong Heart Water Study Program.Environmental health perspectives · 2024Trial
- Behavioral determinants of arsenic-safe water use among Great Plains Indian Nation private well users: results from the Community-Led Strong Heart Water Study Arsenic Mitigation Program.Environmental health : a global access science source · 2023Trial
- Evaluation of a water arsenic filter in a participatory intervention to reduce arsenic exposure in American Indian communities: The Strong Heart Water Study.The Science of the total environment · 2023Trial
- Arsenic Exposure in Relation to Ischemic Stroke: The Reasons for Geographic and Racial Differences in Stroke Study.Stroke · 2018Trial
- The Effect of Serum Trace Element Levels On Cardiovascular Diseases in Adults in the Ravansar Region (Western Iran): A Risk Assessment Study in the Context of Elevated Lipid Profiles.Cardiovascular toxicology · 2026Article
103 more citing papers are in PubMed but not listed here.
Corrections and comments
- SummaryForPatientsIn
Authors and funding
11 authors at 6 institutions in 3 countries.
Funding
Abstract
backgroundLong-term exposure to high levels of arsenic is associated with increased risk for cardiovascular disease, whereas risk from long-term exposure to low to moderate arsenic levels (< 100μg/L in drinking water) is unclear.
objectiveTo evaluate the association between long-term exposure to low to moderate arsenic levels and incident cardiovascular disease.
designProspective cohort study.
settingThe Strong Heart Study baseline visit between 1989 and 1991, with follow-up through 2008. PATIENTS: 3575 American Indian men and women aged 45 to 74 years living in Arizona, Oklahoma, and North and South Dakota. MEASUREMENTS: The sum of inorganic and methylated arsenic species in urine at baseline was used as a biomarker of long-term arsenic exposure. Outcomes were incident fatal and nonfatal cardiovascular disease.
resultsA total of 1184 participants developed fatal and nonfatal cardiovascular disease. When the highest and lowest quartiles of arsenic concentrations (> 15.7 vs. < 5.8 μg/g creatinine) were compared,the hazard ratios for cardiovascular disease, coronary heart disease, and stroke mortality after adjustment for sociodemographic factors, smoking, body mass index, and lipid levels were 1.65 (95%CI, 1.20 to 2.27; P for trend < 0.001), 1.71 (CI, 1.19 to 2.44; P for trend < 0.001), and 3.03 (CI, 1.08 to 8.50; P for trend = 0.061),respectively. The corresponding hazard ratios for incident cardiovascular disease, coronary heart disease, and stroke were 1.32 (CI,1.09 to 1.59; P for trend = 0.002), 1.30 (CI, 1.04 to 1.62; P for trend = 0.006), and 1.47 (CI, 0.97 to 2.21; P for trend = 0.032).These associations varied by study region and were attenuated after further adjustment for diabetes, hypertension, and kidney disease measures. LIMITATION: Direct measurement of individual arsenic levels in drinking water was unavailable.
conclusionLong-term exposure to low to moderate arsenic levels was associated with cardiovascular disease incidence and mortality.
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Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.