Climate policy has become increasingly relevant to cardiovascular prevention, yet regulatory rollback threatens environmental health protections. While climate regulation has been characterized as an environmental, economic, and legal issue, it should also be recognized as cardiovascular prevention infrastructure. On February 12, 2026, the U.S. Environmental Protection Agency (EPA) finalized its rescission of the 2009 Greenhouse Gas Endangerment Finding, weakening a key legal basis for federal greenhouse-gas regulation under the Clean Air Act [1]. Patients with heart failure (HF) are especially vulnerable to these changes because short-term exposure to particulate air pollution and wildfire smoke has been associated with cardiovascular events, including heart-failure-related emergency care and hospitalization [2]. A recent study further estimated that exposure to long-term wildfire-smoke particulate matter less than 2.5 μm in diameter (PM2.5) corresponded to 20,238 additional heart-failure cases annually among older U.S. adults [3]. At a time when climate change is prolonging wildfire smoke season, increasing air pollution, and intensifying extreme temperatures, regulatory rollbacks can potentially lead to foreseeable cardiovascular consequences [4,5]. In short, the Endangerment Finding has therefore functioned not only as climate policy, but also as cardiovascular prevention infrastructure.

Regulatory stability is itself a structural determinant of health. The 2009 Endangerment Finding concluded that six greenhouse gases endanger public health as well as welfare, noting that emissions from new motor vehicles contribute to that pollution. As a result, the finding established a legal basis for regulating the greenhouse gases according to Section 202(a) of the Clean Air Act [5]. Limiting this authority may change the rate at which emissions will be reduced and the trajectory of population-level exposure. For patients with HF, this is more than an issue of policy change. Climate governance determines exposure to heat, smoke, and air pollution that can destabilize clinically vulnerable patients, increasing their likelihood of emergency care, hospitalization, and death. As air pollution has been linked to 7.9 million deaths worldwide in 2023, preserving the authority to reduce greenhouse-gas emissions should remain a priority for reducing exposure to pollutants that harm the heart and lungs [6]. Consequently, the rollback should be evaluated not only as a regulatory decision, but also as a decision with cardiopulmonary consequences.

PM2.5, a byproduct of fossil fuel combustion, has been a major driver of adverse cardiovascular outcomes [7] For instance, exposure to PM2.5 has been associated with higher blood pressure, insulin resistance, inflammation, oxidative stress, and endothelial injury, pathways that may contribute to atherosclerosis, coronary artery disease, and HF [7] Beyond its contributions to HF incidence, PM2.5 exposure has also been linked to higher mortality [2, 8]. In a cohort of 23,302 patients with HF, each 1 μg/m³ increase in average geographic PM2.5 correlated with higher all-cause mortality [8]. Additionally, an updated systematic review and meta-analysis of 51 studies and more than 7.5 million patients similarly found that each 10 μg/m³ increase in PM2.5 was associated with higher heart-failure hospitalization or mortality [9]. Because patients with HF already face high risks of hospitalization and death, additional burdens from pollution, inflammation, and extreme temperatures may further destabilize an already clinically fragile population.

Exposure pathways often fall disproportionately on racial and ethnic minorities as well as populations of lower socioeconomic status (SES) due to a history of redlining and residential segregation [10]. In the US, the EPA has highlighted evidence that White populations are exposed to lower-than-average PM2.5 concentrations from source types contributing 60% of overall exposure, whereas people of color experience greater-than-average exposures from source types contributing 75%, with Black Americans experiencing the highest exposure [11]. These exposure disparities may worsen existing inequities in HF, as socioeconomic factors such as low income and low education have been independently associated with higher mortality and readmission risk among patients hospitalized with HF [12]. Climate-driven PM2.5 and wildfire smoke may act as risk factors in communities with fewer resources. Consequently, climate policies do not affect all communities equally; without targeted interventions, the climate burden will remain the greatest in communities already facing higher heart-failure morbidity and mortality.

Moving forward, policymakers must consider climate policy as an element of cardiovascular disease prevention. First, the management of HF patients should incorporate air quality and smoke alerts in the clinical management (i.e., EHR alerting, discharge planning, and remote monitoring). Second, healthcare providers should create action plans for smoke and heat events, given evidence linking air pollution to higher risks of hospitalization and mortality among patients with HF [2]. These plans could involve identifying high-risk HF patients before wildfire season, educating them about Air Quality Index thresholds, and providing guidance on indoor air filtration, medication adherence, symptom monitoring, and when to seek urgent medical care [13,14]. Third, regulators should assess how major climate policies affect HF across demographics and geographic populations rather than relying only on aggregate estimates. Finally, since wildfire-smoke PM2.5 has been linked to higher incident HF risk in older adults, policymakers should invest in equity-focused clean-air infrastructure (i.e., filtration support, clean-air shelters, and targeted protections) for vulnerable patients. Investments should be prioritized in communities with high PM2.5 exposure, frequent smoke days, limited access to clean indoor air, and high baseline HF burden.

Weakening climate mitigation authority should be recognized as a cardiovascular health issue as much as an environmental policy issue. Rescinding the Endangerment Finding would narrow the regulatory basis for climate-related health protection at a time when the cardiovascular consequences of heat, wildfire smoke, and air pollution are increasingly evident. For patients with heart failure, these exposures may contribute to worsening symptoms, acute care use, hospitalization, and preventable mortality. In a warming world, climate mitigation policy and heart failure prevention cannot be separated.