Abstract
High arsenic (As) exposure (≥ 100 µg/l) is associated with cardiovascular (CVD) outcomes, however, the CVD risk from low-to-moderate As exposure (< 100 µg/l) has been less explored. There is a paucity of systematic reviews that comprehensively evaluate both urine and water As exposure metrics in assessing As-related CVD outcomes within the general population. To fill this gap, this review sought to update and consolidate data regarding the correlation between low-to-moderate As exposure and specific CVD outcomes, including stroke, ischemic heart disease (IHD), acute myocardial infarction (AMI), and heart failure (HF). A search for peer-reviewed articles indexed in PubMed, Embase, CINAHL, the Global Medicos Index, and Web of Science and unpublished dissertations in Prospero until October 31, 2024, was performed. Nineteen studies were included. Relative risks were pooled by contrasting the highest v/s lowest exposure groups across studies. Positive associations were observed between urine As and stroke incidence, and water As with IHD incidence. Associations between water As and IHD and AMI mortality were suggestive and became stronger after excluding ecological studies. Sex-stratified analyses suggested an increased risk for all groups with strongest indication of an increased risk of AMI mortality in men. Increased risk was suggested for HF but only two studies assessed this outcome. These findings underscore potential risk for CVD outcomes in relation to low-to-moderate As exposure, and highlight the necessity for additional rigorous, well-structured studies to more clearly delineate the possible effects of low-to-moderate As exposure on different CVD outcomes.