Greenspace visitation and risk of major adverse cardiovascular events: evidence from the Houston methodist cardiovascular learning health system registry
Weichuan Dong, Sarayu Chandra Mouli, Izza Shahid, Rakesh Gullapelli, Budhaditya Bose, Tong Zhang, Jad Ardakani, Juan C Nicolas, Zulqarnain Javed, Kai Zhang, Zhuo Chen, Sanjay Rajagopalan, Jay Maddock, Khurram Nasir, Sadeer Al-KindiAbstract
Aims
To evaluate whether mobility-derived greenspace visitation, as a behavioural measure of environmental exposure, is associated with major adverse cardiovascular events (MACE) independent of individual and neighbourhood factors.
Methods and results
We conducted a retrospective cohort study of adults in the Houston Methodist Cardiovascular Disease Learning Health System Registry (2016–2023). Greenspace visitation was defined at the census-tract level using mobility-derived foot-traffic data and modelled as annual visits per resident device. The primary outcome was incident MACE (myocardial infarction, stroke, coronary revascularization, and all-cause mortality). The Cox models, restricted cubic splines, and Kaplan–Meier curves assessed associations with sequential adjustment for demographics, comorbidities, smoking, and neighbourhood social vulnerability. Among 1 088 866 adults without baseline atherosclerotic cardiovascular disease, median (SD) age was 49 (17.6) years, and 59.9% were female. Greenspace visitation varied across neighbourhoods and by demographic and socioeconomic characteristics. Each additional 10 annual visits was associated with lower MACE risk in unadjusted models [hazard ratio (HR) 0.82; 95% confidence interval (CI): 0.81–0.83] and after adjustment for demographics, comorbidities, and smoking (HR 0.89; 95% CI: 0.88–0.91). A non-linear relationship showed risk reductions at low-to-moderate visitation, plateauing at 10–15 visits annually. After adjusting for social vulnerability, associations were attenuated and no longer significant. The Kaplan–Meier curves showed higher event-free survival in high-visitation areas, consistent across MACE components.
Conclusion
Mobility-derived greenspace visitation is associated with lower cardiovascular risk. These findings highlight greenspace engagement as a potentially modifiable behavioural exposure and support strategies to enhance access and utilization of greenspaces for cardiovascular prevention.