Urinary arsenic and heart disease mortality in NHANES 2003–2014

Anne E. Nigra, Katherine A. Moon, Miranda R. Jones, Tiffany R. Sanchez, Ana Navas Acien

Research output: Contribution to journalArticlepeer-review


Background: Evidence evaluating the prospective association between low-to moderate-inorganic arsenic (iAs) exposure and cardiovascular disease in the general US population is limited. We evaluated the association between urinary arsenic concentrations in National Health and Nutrition Examination Survey (NHANES) 2003–2014 and heart disease mortality linked from the National Death Index through 2015. Methods: We modeled iAs exposure as urinary total arsenic and dimethylarsinate among participants with low seafood intake, based on low arsenobetaine levels (N = 4990). We estimated multivariable adjusted hazard ratios (HRs) for heart disease mortality per interquartile range (IQR) increase in urinary arsenic levels using survey-weighted, Cox proportional hazards models, and evaluated flexible dose-response analyses using restricted quadratic spline models. We updated a previously published relative risk of coronary heart disease mortality from a dose-response meta-analysis per a doubling of water iAs (e.g., from 10 to 20 μg/L) with our results from NHANES 2003–2014, assuming all iAs exposure came from drinking water. Results: A total of 77 fatal heart disease events occurred (median follow-up time 75 months). The adjusted HRs (95% CI) of heart disease mortality for an increase in urinary total arsenic and DMA corresponding to the interquartile range were 1.20 (0.83, 1.74) and 1.18 (0.68, 2.05), respectively. Restricted quadratic splines indicate a significant association between increasing urinary total arsenic and the HR of fatal heart disease for all participants at the lowest exposure levels <4.5 μg/L. The updated pooled relative risk of coronary heart disease mortality per doubling of water iAs (μg/L) was 1.16 (95% CI 1.07, 1.25). Conclusions: Despite a small number of events, relatively short follow-up time, and high analytical limits of detection for urinary arsenic species, iAs exposure at low-to moderate-levels is consistent with increased heart disease mortality in NHANES 2003–2014 although the associations were only significant in flexible dose-response models.

Original languageEnglish (US)
Article number111387
JournalEnvironmental research
StatePublished - Sep 2021


  • Arsenic
  • Cardiovascular disease
  • Epidemiology

ASJC Scopus subject areas

  • Biochemistry
  • Environmental Science(all)


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