Smoking, plasma cotinine and risk of atrial fibrillation: the Hordaland Health Study

Association between secondhand smoke exposure and incident heart failure: The Multi-Ethnic Study of Atherosclerosis (MESA)

AIMS

There are no studies on the association between secondhand smoke (SHS) exposure and incident heart failure (HF). This cohort study aimed to examine the associations of self-reported and urinary cotinine-assessed SHS exposure with incident HF.

METHODS AND RESULTS

This study included 5548 non-active smoking participants aged 45-84 years and free of known cardiovascular diseases and HF at baseline who self-reported SHS exposure time in the Multi-Ethnic Study of Atherosclerosis (MESA) at baseline (2000-2002). A cohort subset of 3376 non-active smoking participants underwent urinary cotinine measurements. HF events were verified by medical records or death certificates and ascertained from baseline through 2019. Multivariable Cox proportional hazards regression analysis was used with adjustment for demographic variables, traditional cardiovascular risk factors, physical activity, tobacco pack-years and medications. During a median follow-up of 17.7 years, 353 and 196 HF events were identified in the self-report cohort and cohort subset, respectively. In the self-report cohort, compared with the SHS unexposed group (0 h/week), the highest tertile of the SHS exposed group (7-168 h/week) was not associated with incident HF (hazard ratio [HR] 0.70, 95% confidence interval [CI] 0.49-1.00; p = 0.052). In contrast, in the cohort subset, participants with detectable urinary cotinine >7.07 ng/ml had a higher risk of incident HF than those with undetectable urinary cotinine ≤7.07 ng/ml (HR 1.45, 95% CI 1.03-2.06; p = 0.034). There were no significant heterogeneities in HF risk by age, sex, race/ethnicity, or past smoking status.

CONCLUSION

Secondhand smoke exposure reflected by modestly increased urinary cotinine (>7.07 ng/ml) rather than self-report in non-active smokers was associated with a 40-50% higher risk of any HF event.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

E-cigarettes and arrhythmogenesis: a comprehensive review of pre-clinical studies and their clinical implications

Electronic cigarette use has grown exponentially in recent years, and while their popularity has increased, the long-term effects on the heart are yet to be fully studied and understood. Originally designed as devices to assist with those trying to quit traditional combustible cigarette use, their popularity has attracted use by teens and adolescents who traditionally have not smoked combustible cigarettes. Acute effects on the heart have been shown to be similar to traditional combustible cigarettes, including increased heart rate and blood pressure. The main components of electronic cigarettes that contribute to these arrhythmic effects are found in the e-liquid that is aerosolized and inhaled, comprised of nicotine, flavourings, and a combination of vegetable glycerin (VG) and propylene glycol (PG). Nicotine can potentially induce both ventricular and atrial arrhythmogenesis, with both the atrial and ventricular effects resulting from the interactions of nicotine and the catecholamines they release via potassium channels. Atrial arrhythmogenesis, more specifically atrial fibrillation, can also occur due to structural alterations, which happens because of nicotine downregulating microRNAs 133 and 590, both post-transcriptional growth factor repressors. Liquid flavourings and the combination of PG and VG can possibly lead to arrhythmic events by exposing users to acrolein, an aldehyde that stimulates TRPA1 that in turn causes a change towards sympathetic activation and autonomic imbalance. The design of these electronic delivery devices is constantly changing; therefore, it has proven extremely difficult to study the long-term effects on the heart caused by electronic cigarettes but will be important to understand given their rising popularity. The arrhythmic effects of electronic cigarettes appear similar to traditional cigarettes as well; however, a comprehensive review has not been compiled and is the focus of this article.

Smoking, immunity, and cardiovascular prognosis: a study of plasma IgE concentration in patients with acute myocardial infarction

Background

Immunoglobulin E (IgE) is implicated in the pathogenesis of acute myocardial infarction (AMI), and smokers often exhibit elevated plasma IgE levels. However, it remains uncertain whether the role of smoking in the development and prognosis of AMI is influenced by IgE levels. This study aimed to investigate the potential contribution of IgE in mediating the association between smoking and AMI.

Methods

We conducted a prospective study involving 348 consecutive patients with chest discomfort who underwent coronary angiography. Plasma cotinine, an alkaloid present in tobacco, and IgE levels were measured. The patients were followed up for mean 39-months to assess their long-term prognosis based on major adverse cardiac and cerebrovascular events (MACCE).

Results

Our findings indicate that patients with AMI had higher plasma levels of cotinine and IgE. Univariate analyses demonstrated a positive association between plasma cotinine (OR = 1.7, 95% CI: 1.27-2.26, P < 0.001) and IgE (OR = 2.8, 95% CI: 1.75-4.39, P < 0.001) with AMI. Receiver operating characteristics analyses showed that the combined use of cotinine and IgE (AUC: 0.677) had a larger predictive performance compared to cotinine alone (AUC: 0.639) or IgE alone (AUC: 0.657), although the improvement did not reach statistical significance. Multivariable logistic regression revealed a positive association between plasma cotinine and AMI (OR = 1.70, 95% CI: 1.04-2.78, P = 0.036). Furthermore, the inclusion of plasma IgE in the regression model led to a decrease in the OR and 95% CI of plasma cotinine (OR = 1.66, 95% CI: 1.01-2.73, P = 0.048). Process mediation analyses showed a significant indirect effect of plasma cotinine on AMI mediated through increased plasma IgE. Kaplan-Meier analysis during a mean 39-months follow-up revealed that higher plasma levels of IgE were associated with an increased risk of MACCE following AMI (P = 0.047). However, in the context of the COX regression analysis, no significant correlation was observed between IgE, cotinine and AMI.

Conclusion

Cotinine exhibits a positive association with AMI, wherein IgE plays a mediating role. Elevated plasma levels of IgE was positively associated with AMI and poor prognosis, which further confirms the adverse role of smoking on the incidence of AMI and prognosis. (Clinical trial registration: ChiCTR2100053000).

Plasma β-Alanine is Positively Associated With Risk of Ischemic Stroke: a Nested Case-Control Study

BACKGROUND

Previous studies suggested that β-alanine as a neurotransmitter could affect the pathogenesis of ischemic damage. However, the association between circulating β-alanine and risk of ischemic stroke (IS) has not been evaluated in populations.

OBJECTIVES

We aimed to examine the association between β-alanine and IS risk in a nested case-control study.

METHODS

We performed a case-control study nested within a prospective community-based cohort (n = 16457; median follow-up time: 5.3 y), which included 321 incident IS cases and 321 controls matched by age and sex. Β-alanine and other metabolites were measured in plasma after overnight fasting by LC-MS/MS. The association of β-alanine with risk of IS was evaluated by conditional logistic regression. BMI, current smoking, educational attainment, physical activity, total energy intake, family history of stroke, hypertension, diabetes, hyperlipidemia, and estimated GFR were adjusted in multivariable models.

RESULTS

There was a significant Spearman partial correlation between β-alanine and 4-pyridoxic acid (ρ = 0.239; P < 0.001). Participants with elevated β-alanine levels were more likely to develop IS with an adjusted OR of 1.26 (95% CI: 1.06-1.51; P = 0.011) (per standard deviation increment). This association remained significant after excluding the first 2 y of follow-up, and after further adjustment for red meat intake, total protein intake, medication use, or vitamin B6 indicators.

CONCLUSIONS

Our novel findings revealed that plasma β-alanine at baseline were positively associated with risk of IS and may function as an early biomarker of IS risk.

Risk factors and SCN5A-H558R polymorphism for atrial fibrillation in Tibetans living at different altitudes

Several studies have found associations of genes with atrial fibrillation (AF), including SCN5A-H558R. However, there are limited data of these associations among populations living at different altitudes. We investigated the relationship between the SCN5A-H558R polymorphism and AF in Tibetans living at different altitudes in Qinghai, China. General clinical and genotype data were obtained from 72 patients with AF and 109 non-AF (NAF) individuals at middle altitudes, and from 102 patients with AF and 143 NAF individuals at high altitudes. Multifactor logistic regression was performed to determine associations and AF risk factors. SCN5A-H558R genotypes differed significantly between the AF and NAF groups (P < .0125) and the G allele was an independent AF risk factor (P < .05) at both altitudes, with no significant differences according to altitude (P > .0125). At middle altitudes, age, red blood cell distribution width (RDW-SD), left atrial internal diameter (LAD), and G allele were independent AF risk factors. At high altitudes, age, smoking, hypertension, RDW-SD, free triiodothyronine, LAD, and G allele were independent AF risk factors (P < .05). The G allele of SCN5A-H558R might be an independent risk factor of AF both high and middle altitude, but there are some differences in other clinical risk factors of AF.

Secondhand tobacco smoke exposure, urine cotinine, and risk of incident atrial fibrillation: The multi-ethnic study of atherosclerosis

BACKGROUND

Secondhand tobacco smoke (SHS) exposure may reduce heart rate variability and lead to atrial fibrillation (AF); however prior study findings have not been confirmed using objective measures for both SHS and AF events.

METHODS

We prospectively examined the association between SHS exposure and incident AF in 5731 participants, ages of 45-84 years and free of known AF and other cardiovascular diseases (CVD) at baseline (2000-2002), who were followed through 2015 in the Multi-Ethnic Study of Atherosclerosis (MESA). SHS weekly exposure time was identified by self-report. Urine cotinine was collected in a cohort subset of 3237 current non-smoking cohort participants. AF events were identified using Medicare claims, hospital records, and 12‑lead electrocardiographic findings. A multivariable Cox proportional hazards regression analysis was used with simultaneous adjustment for demographic factors, educational level, health insurance status, active smoking status, tobacco pack-years, traditional CVD risk factors, depressive symptoms and medications.

RESULTS

During a median follow-up of 14.0 years, 856 and 452 AF events were identified in the overall and the cohort subset, respectively. No association of SHS exposure time or urine cotinine with incident AF was observed. However, a higher AF risk with greater urine cotinine (8.53-442.0 ng/mL) compared with lower urine cotinine (≤7.07 ng/mL) was observed in never smokers [hazard ratios (HR) and 95% confidence intervals: 1.60 (1.16, 2.19)], but not in former smokers [HR: 0.88 (0.63, 1.23)] (p-value for multiplicative interaction: 0.009 and for additive interaction: 0.017, respectively).

CONCLUSION

Objectively measured greater SHS exposure expressed by urine cotinine might be associated with 1.6-fold higher risk of incident AF in never smokers.

Harmful Impact of Tobacco Smoking and Alcohol Consumption on the Atrial Myocardium

Tobacco smoking and alcohol consumption are widespread exposures that are legal and socially accepted in many societies. Both have been widely recognized as important risk factors for diseases in all vital organ systems including cardiovascular diseases, and with clinical manifestations that are associated with atrial dysfunction, so-called atrial cardiomyopathy, especially atrial fibrillation and stroke. The pathogenesis of atrial cardiomyopathy, atrial fibrillation, and stroke in context with smoking and alcohol consumption is complex and multifactorial, involving pathophysiological mechanisms, environmental, and societal aspects. This narrative review summarizes the current literature regarding alterations in the atrial myocardium that is associated with smoking and alcohol.

Social Risk Factors and Atrial Fibrillation

Modifiable risk factor management is becoming one of the 3 treatment pillars in atrial fibrillation management along with anticoagulation as well as conventional rate and rhythm control strategies. Preventive therapies, such as reducing blood pressure and treating obstructive sleep apnea, are paramount in the strategy of preventing atrial fibrillation. Identification of new modifiable risk factors and triggers also could help in the global strategy to reduce atrial fibrillation. This article covers alcohol intake, tobacco smoking, caffeine, chocolate, cannabis use, and air pollution as social risk factors related to lifestyle habits that potentially could contribute to atrial fibrillation development.

Association of Self-Reported and Cotinine-Verified Smoking Status with Atrial Arrhythmia

BACKGROUND

The relationship between self-reported and urinary cotinine-verified smoking status and atrial arrhythmia (AA) is unclear. The aim of this study was to evaluate the association of self-reported and urine cotinine-verified smoking status with AA.

METHOD

A total of 201,788 participants (106,375 men, mean age 37 years) who had both a urinary cotinine measurement and electrocardiogram were included. Cotinine-verified current smoking was defined as a urinary cotinine level above 50 ng/mL. Individuals were divided into three groups based on self-reported smoking and two groups based on cotinine-verified smoking status.

RESULTS

Among overall subjects, 505 had documented AA (0.3%) and 135 had atrial fibrillation (AF) (0.1%). Self-reported current smoking was associated with an increased risk of AA (odds ratio [OR], 1.42; 95% confidence interval [CI], 1.06-1.91; P = 0.019) and AF (OR, 2.20; 95% CI, 1.24-3.90; P = 0.007), whereas self-reported former smoking had no significant association with AA (OR, 1.30; 95% CI, 0.97-1.73; P = 0.078) and AF (OR, 1.74; 95% CI, 1.00-3.04; P = 0.051). Cotinine-verified current smoking showed no significant association with AA (OR, 1.24; 95% CI, 0.98-1.58; P = 0.080) and AF (OR, 1.20; 95% CI, 0.79-1.83; P = 0.391).

CONCLUSION

Self-reported current smoking was associated with AA and AF, while self-reported former smoking and cotinine-verified current smoking showed no significant association with AA and AF.

Angiotensin II Type I Receptor Antagonism Attenuates Nicotine-Induced Cardiac Remodeling, Dysfunction, and Aggravation of Myocardial Ischemia-Reperfusion Injury in Rats

Increased exposure to nicotine contributes to the development of cardiac dysfunction by promoting oxidative stress, fibrosis, and inflammation. These deleterious events altogether render cardiac myocytes more susceptible to acute cardiac insults such as ischemia-reperfusion (I/R) injury. This study sought to elucidate the role of angiotensin II type I (AT1) receptors in cardiac injury resulting from prolonged nicotine administration in a rat model. Male Sprague-Dawley rats were given nicotine (0.6 mg/kg ip) for 28 days to induce cardiac dysfunction, alone or in combination with the AT1 receptor antagonist, irbesartan (10 mg/kg, po). Vehicle-treated rats were used as controls. Rat hearts isolated from each experimental group at study endpoint were examined for changes in function, histology, gene expression, and susceptibility against acute I/R injury determined ex vivo. Rats administered nicotine alone exhibited significantly increased cardiac expression of angiotensin II and angiotensin-converting enzyme (ACE) in addition to elevated systolic blood pressure (SBP) and heart rate. Furthermore, nicotine administration markedly reduced left ventricular (LV) performance with concomitant increases in myocardial oxidative stress, fibrosis, and inflammation. Concomitant treatment with irbesartan attenuated these effects, lowering blood pressure, heart rate, oxidative stress, and expression of fibrotic and inflammatory genes. Importantly, the irbesartan-treated group also manifested reduced susceptibility to I/R injury ex vivo. These findings suggest that AT1 receptors play an important role in nicotine-induced cardiac dysfunction, and pharmacological approaches targeting cardiac AT1 receptors may thus benefit patients with sustained exposure to nicotine.

Relationships of Long-Term Smoking and Moist Snuff Consumption With a DNA Methylation Age Relevant Smoking Index: An Analysis in Buccal Cells

INTRODUCTION

Currently, there is no widely accepted, non-self-report measure that simultaneously reflects smoking behaviors and is molecularly informative of general disease processes. Recently, researchers developed a smoking index (SI) using nucleated blood cells and a multi-tissue DNA methylation-based predictor of chronological age and disease (DNA methylation age [DNAm-age]). To better understand the utility of this novel SI in readily accessible cell types, we used buccal cell DNA methylation to examine SI relationships with long-term tobacco smoking and moist snuff consumption.

METHODS

We used a publicly available dataset composed of buccal cell DNA methylation values from 120 middle-aged men (40 long-term smokers, 40 moist snuff consumers, and 40 nonsmokers). DNAm-age (353-CpGs) and SI (66-CpGs) were calculated using CpG sites measured using the Illumina HumanMethylation450 BeadChip. We estimated associations of tobacco consumption habits with both SI and DNAm-age using linear regression models adjusted for chronological age, race, and methylation technical covariates.

RESULTS

In fully adjusted models with nonsmokers as the reference, smoking (β = 1.08, 95% CI = 0.82 to 1.33, p < .0001) but not snuff consumption (β = .06, 95% CI = -0.19 to 0.32, p = .63) was significantly associated with SI. SI was an excellent predictor of smoking versus nonsmoking (area under the curve = 0.92, 95% CI = 0.85 to 0.98). Four DNAm-age CpGs were differentially methylated between smokers and nonsmokers including cg14992253 [EIF3I], which has been previously shown to be differentially methylated with exposure to long-term fine-particle air pollution (PM2.5).

CONCLUSIONS

The 66-CpG SI appears to be a useful tool for measuring smoking-specific behaviors in buccal cells. Still, further research is needed to broadly confirm our findings and SI relationships with DNAm-age.

IMPLICATIONS

Our findings demonstrate that this 66-CpG blood-derived SI can reflect long-term tobacco smoking, but not long-term snuff consumption, in buccal cells. This evidence will be useful as the field works to identify an accurate non-self-report smoking biomarker that can be measured in an easily accessible tissue. Future research efforts should focus on (1) optimizing the relationship of the SI with DNAm-age so that the metric can maximize its utility as a tool for understanding general disease processes, and (2) determining normal values for the SI CpGs so that the measure is not as study sample specific.

[Smoking among hospital staff and the impact of the November, No Smoking Month campaign on this population]

INTRODUCTION

Smoking cessation is a public health priority. Several prevention campaigns exist, including this one of the "month without tobacco", made in November in France. Healthcare workers have an important role to play in stopping smoking, while many of the healthcare workers are themselves smokers. The purpose of this article is to study the prevalence of tobacco consumption among hospital staff and to evaluate its effects.

MATERIAL AND METHOD

It is a transversal study, carried out among the 734 agents of a French hospital, between December 2016 and January 2017, by anonymous self-questionnaires. The study included all hospital employees, whether they were caregivers or not.

RESULTS

The participation rate was 35%, of whom 193 (75.7%) were health care workers, 46 (17.6%) were administrative and 17 (6.7%) were working in technical services. There were 31% smokers and 26% forming smokers. There were no significant differences in smoking by age, or socio-occupational category. During this campaign, 66.7% of smokers had plans to quit, and 29% tried to quit.

CONCLUSION

The prevalence of smoking in this hospital was comparable to that of the general population, and among the highest in hospital in the literature. The campaign of the month without tobacco has influenced the consumption of smokers. Other studies need to analyze how to handle this population.

Cadmium exposure in First Nations communities of the Northwest Territories, Canada: smoking is a greater contributor than consumption of cadmium-accumulating organ meats

Traditional food consumption among northern populations is associated with improved nutrition but occasionally can also increase contaminant exposure. High levels of cadmium in the organs of moose from certain regions of the Northwest Territories, Canada, led to the release of consumption notices. These notices recommended that individuals limit their consumption of kidney and liver from moose harvested from the Southern Mackenzie Mountain. A human biomonitoring project was designed to better characterize exposure and risks from contaminants, including cadmium, among Dene/Métis communities of the Northwest Territories Mackenzie Valley, Canada. The project included a dietary assessment (food frequency questionnaire) to estimate moose and caribou organ (kidney and liver) consumption, as well as urine and blood sampling for the measurement of cadmium concentration using mass spectrometry. For a subset of the samples, urine cotinine was also quantified. The results from this biomonitoring research show that cadmium levels in urine (GM = 0.32 μg L-1) and blood (GM = 0.58 μg L-1) are similar to those observed in other populations in Canada. For the 38% of participants reporting eating game organs, current traditional food consumption patterns were not associated with cadmium biomarker levels. Instead, smoking appeared to be the main determinant of cadmium exposure. These results are supporting ongoing efforts at the community and territorial level to identify health priorities and design follow up plans in response to environmental monitoring data.