Background
Current evidence suggests an association between environmental factors such as airborne particles, green areas and noise levels and cardiovascular health.(1) Most of the studies on this topic have investigated single environmental factors in relation to cardiovascular disease incidence, prevalence or cardiovascular mortality in the general population.
Urbanisation unifies not only the environmental factors mentioned above, but also light pollution, physical activity environment and food environment. Currently, the evidence on the topic remains sparse and studies have been performed mainly in the general population.
Mental health - particularly anxiety, depression and chronic stress - is a key driver modulating cardiovascular risk and is, in turn, influenced by environmental agents linked to urbanisation. Current studies have examined the relationship between living environments and mental health, but not specifically in cardiovascular disease patients. (2)
Thus, the goal of this Study is to investigate the association between the degree of urbanisation in the living environment and mental health in cardiovascular disease patients undergoing exercise-based cardiac rehabilitation (EBCR).Further, we intend to examine whether the residential degree of urbanisation is associated with rehabilitation-related changes in mental health and functional status between admission and discharge.
Methods
We will conduct a retrospective observational cohort study of 704 cardiovascular disease patients, who have undergone inpatient EBCR after hospitalisation between 2022 and 2024. Degree of urbanisation of the residential environment will be assigned from geocoded home addresses using the Eurostat DEGURBA Level 2 grid classification and analysed as the main exposure variable. The primary outcome will be mental health at rehabilitation admission, assessed using the Hospital Anxiety and Depression Scale (HADS) total score. HADS anxiety and depression subscores will be analysed as secondary outcomes. Functional outcomes will include 6-minute walking distance and the Functional Independence Measure (FIM). Primary analyses will assess associations between degree of urbanisation and admission outcomes. Secondary analyses will examine discharge outcomes, adjusted for corresponding admission values to evaluate rehabilitation-related changesOutcomes measured at admission and discharge will be analysed using multivariable regression models.Models will be adjusted for relevant demographic and clinical covariates. Sensitivity analyses will include ordinal trend modelling of urbanisation categories, use of the broader Eurostat DEGURBA Level 1 classification, and alternative handling of sparse urbanisation categories.
Relevance of the expected results for research and clinical practice
An estimate of 68% of the world’s population living in urban areas by 2050 underlines the importance of understanding the relation between the levels of Urbanisation and aspects that shape cardiovascular risk, such as mental health and physical fitness.(3)
Literature
1. Liu M, Meijer P, Lam TM, Timmermans EJ, Grobbee DE, Beulens JWJ, u. a. The built environment and cardiovascular disease: an umbrella review and meta-meta-analysis. Eur J Prev Cardiol. 9. November 2023;30(16):1801–27. doi:10.1093/eurjpc/zwad241
2. Patel DM, Block RC, Chapman BP, Korfmacher KS, Van Wijngaarden E. Green space and mental health symptoms in a cardiac rehabilitation population. Indoor Built Environ. Dezember 2019;28(10):1431–40. doi:10.1177/1420326X19853615
3. Vereinte Nationen, Herausgeber. World urbanization prospects 2025: summary of results. New York: United Nations; 2025. 1 S.