Abstract
Residential green space and neighborhood walkability are important foundations of a healthy and sustainable city. Yet, their associations with atherosclerosis, the disease underlying clinical coronary heart disease (CHD), is unknown, especially in susceptible populations. We aim to explore the associations of exposure to residential green space and neighborhood walkability with coronary atherosclerosis. In this study of 2021 adults with suspected CHD, we evaluated the associations of exposure to green space (using Normalized Difference Vegetation Index [NDVI] and enhanced vegetation index [EVI] surrounding each participant's home) and neighborhood walkability (using walkability index and number of parks near home) with atherosclerosis (using coronary artery calcium score, CAC) using linear regression model adjusted for individual-level characteristics. Mediation analysis was further applied to explore potential mechanisms through the pathways of physical activity, air pollution, and psychological stress. In the primary model, an interquartile increase in annual mean NDVI and EVI within the 1-km area was associated with -15.8% (95%CI: 28.7%, -0.7%), and -18.6% (95%Cl: 31.3%, -3.6%) lower CAC score, respectively. However, an interquartile increase in the walkability index near home was associated with a 7.4% (95% CI: 0.1%, 15.2%) higher CAC score. The combined exposure to a green space area in a 1-km area and the walkability index were inversely associated with atherosclerosis, albeit with a smaller magnitude than a single-exposure model. The findings from a mediation analysis suggested that increased physical exercise and ameliorated particulate matter <2.5 μm (PM(2.5)) may partially contribute to the relationship between green space and atherosclerosis, and for walkability index, partially explained by increased PM(2.5) exposure. Our study suggested a beneficial association between green space and atherosclerosis, but an adverse association between neighborhood walkability and atherosclerosis. Therefore, urban development that aims to improve neighborhood walkability should jointly account for enhancing green space properties from a public health perspective.