Risk of Heart Failure and Death After Prolonged Smoking Cessation: Role of Amount and Duration of Prior Smoking

A Systematic Review of risk factors for major adverse cardiovascular events in patients with coronary heart disease who underwent percutaneous coronary intervention

Objective

This study aims to systematically review the risk factors for major adverse cardiovascular events (MACE) in patients with coronary heart disease who have undergone percutaneous coronary intervention (PCI).

Design

Systematic review and meta-analysis.

Data sources

The Cochrane Library, PubMed, Web of Science, China National Knowledge Infrastructure (CNKI), Wanfang Database, and VIP Database for Chinese Technical Periodicals (VIP) were screened until December 2024.

Eligibility criteria for selecting studies

Case-control studies or cohort studies on the risk factors for MACE in patients with coronary heart disease who underwent PCI. Data extraction and synthesis: The literature review, data extraction, and quality evaluation were conducted by two independent researchers, and the meta-analysis was performed using RevMan 5.4 software.

Main outcomes

The main outcome was that MACE occurred during the follow-up period.

Results

A total of 40 articles were included. The meta-analysis erevealed that dyslipidemia (OR = 1.50; 95% CI [1.19, 1.89], p = 0.0007), diabetes mellitus (OR = 1.70; 95% CI [1.43, 2.02], p < 0.00001), hypertension (OR = 1.62; 95% CI [1.35, 1.96], p < 0.0001), history of smoking (OR = 2.08; 95% CI [1.51, 2.85], p < 0.0001), poorer ventricular function (OR = 2.39; 95% CI [2.17-2.64], p < 0.0001), impaired left ventricular ejection fraction (LVEF) (OR = 1.86; 95% CI [1.71-2.03], p < 0.0001), door to balloon (D-to-B) time (OR = 0.61; 95% CI [0.42-0.88]; p = 0.009), thrombolysis in myocardial infarction (TIMI) (OR = 1.41; 95% CI [1.17, 1.70], p = 0.0004), renal dysfunction (OR = 1.82; 95% CI [1.37, 2.43], p < 0.0001), and multi-vessel coronary artery disease (OR = 0.41; 95% CI [0.37, 0.46], p < 0.0001) were significantly associated with MACE after PCI.

Conclusion

The independent risk factors of MACE after PCI are dyslipidemia, hypertension, diabetes mellitus, smoking history, Killip class > II, LVEF ≤40%, D-to-B time >90 min, TIMI flow grade ≤ II, renal insufficiency, and multivessel disease.

Health and economic evaluation of herbal medicines for heart failure: A population-based cohort study

BACKGROUND

Heart failure (HF) represents an advanced stage of various cardiovascular disorders, with its elevated admission rates and resultant health economic burden posing an ongoing global concern.

PURPOSE

To evaluate the health and economic benefits of herbal medicine (HM) for patients with HF.

STUDY DESIGN

Population-based cohort study.

METHODS

A five-year retrospective cohort study was carried out at a nationally recognized hospital in China. The study utilized propensity score matching (PSM) to match patients with HF. Chi-square tests were used to analyze dichotomous variables, and t-tests were employed for continuous variables. Logistic regression was used to examine hospital readmission rates, while multiple linear regression was utilized to evaluate direct medical costs. Statistical significance was set at p < 0.05.

RESULTS

After implementing PSM, 1924 HF patients were included in the analysis. The study identified two significant risk factors affecting the readmission rates: age over 65 years (adjusted odds ratio (OR) = 1.25, 95 % confidence interval (CI) [1.02, 1.53]) and smoking (adjusted OR = 1.31, 95 % CI [1.01, 1.70]). Additionally, patients who received adjunctive HM treatment exhibited a significantly lower readmission rate compared to those without HM treatment (adjusted OR = 0.76, 95 % CI [0.64, 0.92]). Furthermore, the use of HM during patient hospitalization did not significantly impact direct medical expenses but instead provided positive health economic benefits (incremental cost-effectiveness ratio (ICER) = 98.52). Factors influencing direct routine medical costs included over 65 years of age (Coef = 60.78, 95 % CI [36.25, 85.31]), and cardiac function classification (New York Heart Association (NYHA) III: Coef = 1979.92, 95 % CI [1401.82, 2558.03]; NYHA IV: Coef = 6052.48, 95 % CI [5166.59, 6938.38]).

CONCLUSIONS

The integration of HM in patients with HF reduced readmission rates without a notable increase in direct medical costs, and the expense of HM remains an economically range indicating positive health economic outcomes.

Examining the potential causal relationships among smoking behaviors, blood DNA methylation profiles, and the development of coronary heart disease and myocardial infarction

BACKGROUND

Smoking has been identified as a standalone risk factor for coronary heart disease (CHD) and myocardial infarction (MI), but the precise underlying mechanisms remain incompletely elucidated.

RESULTS

In this study, we conducted a two-sample Mendelian randomization analysis to examine the impact of smoking behaviors (including smoking initiation, age of smoking initiation, cigarettes per day, and smoking cessation) and smoking-related DNA methylation at CpG sites on CHD and MI based on the UK Biobank dataset. Additionally, we included the FinnGen and Biobank Japan datasets as replications and performed a meta-analysis to combine the results from different data sources. We further validated our results using genetic colocalization analysis. In genomic analysis, we provided compelling evidence on the association between genetically predicted smoking initiation and increased susceptibility to CHD and MI. In epigenetic analysis, we identified 11 smoking-related CpG sites linked to CHD risk and 10 smoking-related CpG sites associated with the risk of MI based on the UK Biobank dataset. Subsequently, some of these CpG sites were further replicated using the FinnGen or BBJ datasets. Ultimately, a meta-analysis was conducted to integrate findings from various data sources (3 for CHD, and 2 for MI), revealing that 7 of 11 CpG sites were linked to CHD risk; whereas, 7 of 10 CpG sites were associated with MI risk. Furthermore, we performed genetic colocalization analysis and found that cg19744173 (FBLN7), cg00395063 (ARHGEF12), and cg16822035 (MCF2L) exhibited robust evidence of colocalization with coronary heart disease; whereas, cg19529732 (DIABLO), cg26405020 (FES), and cg08940075 (CNN3) demonstrated strong colocalization evidence with the risk of myocardial infarction.

CONCLUSIONS

Our research offers a novel insight into the impact of smoking on the susceptibility to CHD and MI through the lens of epigenetic DNA methylation.

Smoking cessation only partially reverses cardiac metabolic and structural remodeling in mice

AIMS

Active cigarette smoking is a major risk factor for chronic obstructive pulmonary disease that remains elevated after cessation. Skeletal muscle dysfunction has been well documented after smoking, but little is known about cardiac adaptations to cigarette smoking. The underlying cellular and molecular cardiac adaptations, independent of confounding lifestyle factors, and time course of reversibility by smoking cessation remain unclear. We hypothesized that smoking negatively affects cardiac metabolism and induces local inflammation in mice, which do not readily reverse upon 2-week smoking cessation.

METHODS

Mice were exposed to air or cigarette smoke for 14 weeks with or without 1- or 2-week smoke cessation. We measured cardiac mitochondrial respiration by high-resolution respirometry, cardiac mitochondrial density, abundance of mitochondrial supercomplexes by electrophoresis, and capillarization, fibrosis, and macrophage infiltration by immunohistology, and performed cardiac metabolome and lipidome analysis by mass spectrometry.

RESULTS

Mitochondrial protein, supercomplex content, and respiration (all p < 0.03) were lower after smoking, which were largely reversed within 2-week smoking cessation. Metabolome and lipidome analyses revealed alterations in mitochondrial metabolism, a shift from fatty acid to glucose metabolism, which did not revert to control upon smoking cessation. Capillary density was not different after smoking but increased after smoking cessation (p = 0.02). Macrophage infiltration and fibrosis (p < 0.04) were higher after smoking but did not revert to control upon smoking cessation.

CONCLUSIONS

While cigarette-impaired smoking-induced cardiac mitochondrial function was reversed by smoking cessation, the remaining fibrosis and macrophage infiltration may contribute to the increased risk of cardiovascular events after smoking cessation.

Smoking Behavior Change and the Risk of Heart Failure in Patients With Type 2 Diabetes: Nationwide Retrospective Cohort Study

BACKGROUND

Heart failure (HF) is one of the most common initial manifestations of cardiovascular disease in patients with type 2 diabetes. Although smoking is an independent risk factor for HF, there is a lack of data for the incidence of HF according to changes in smoking behaviors in patients with type 2 diabetes.

OBJECTIVE

We aimed to examine the association between interval changes in smoking behavior and the risk of HF among patients with type 2 diabetes.

METHODS

We conducted a retrospective cohort study using the National Health Insurance Service database. We identified 365,352 current smokers with type 2 diabetes who had 2 consecutive health screenings (2009-2012) and followed them until December 31, 2018, for the incident HF. Based on smoking behavior changes between 2 consecutive health screenings, participants were categorized into quitter, reducer I (≥50% reduction) and II (<50% reduction), sustainer (reference group), and increaser groups.

RESULTS

During a median follow-up of 5.1 (IQR 4.0-6.1) years, there were 13,879 HF cases (7.8 per 1000 person-years). Compared to sustainers, smoking cessation was associated with lower risks of HF (adjusted hazard ratio [aHR] 0.90, 95% CI0.86-0.95), whereas increasers showed higher risks of HF than sustainers; heavy smokers who increased their level of smoking had a higher risk of HF (aHR 1.13, 95% CI 1.04-1.24). In the case of reducers, the risk of HF was not reduced but rather increased slightly (reducer I: aHR 1.14, 95% CI 1.08-1.21; reducer II: aHR 1.03, 95% CI 0.98-1.09). Consistent results were noted for subgroup analyses including type 2 diabetes severity, age, and sex.

CONCLUSIONS

Smoking cessation was associated with a lower risk of HF among patients with type 2 diabetes, while increasing smoking amount was associated with a higher risk for HF than in those sustaining their smoking amount. There was no benefit from reduction in smoking amount.

ΔRDW Could Predict Major Adverse Cardiovascular Events in Patients with Heart Failure with Reduced Ejection Fraction After Sacubitril/Valsartan Treatment

Objective

This study aimed to evaluate the association between red blood cell distribution width (RDW) changes and major adverse cardiovascular event (MACE) occurrences during sacubitril/valsartan treatment in patients with heart failure with reduced ejection fraction (HFrEF).

Methods

This study retrospectively analyzed the medical records of patients with HFrEF hospitalized from April 2018 to February 2021. The patients were divided into two groups according to the inclusion of sacubitril/valsartan in the personal drug treatment regimen, the traditional and the sacubitril/valsartan group. RDW values before and after sacubitril/valsartan treatment were recorded respectively as RDW1 and RDW2. ΔRDW was defined as the difference between RDW2 and RDW1. The patients in the sacubitril/valsartan group were divided into two subgroups according to ΔRDW >0 or ≤0. MACEs, such as readmission for HF, acute myocardial infarction, ischemic stroke, and malignant arrhythmia and death, were recorded during the 1-year follow-up period in each group.

Results

MACE development was lower in patients treated with sacubitril/valsartan than those treated with conventional therapy (log-rank, P<0.001). The incidence of cardiac events during the follow-up period was greater in the group with ΔRDW >0 than in the group with ΔRDW ≤0 (Breslow, P<0.001). Increased RDW was associated with a higher likelihood of developing MACE than decreased RDW (odds ratio [OR] =2.055, 95% confidence interval [CI]:1.301-3.246), and the risk of developing MACE increased by 22.1% for each unit increase in RDW (OR=1.221, 95% CI:1.074-1.389).

Conclusion

Sacubitril/valsartan treatment is effective in reducing the risk of MACEs in HFrEF. Additionally, RDW changes are predictors of MACEs after sacubitril/valsartan treatment.

Preventing new-onset heart failure: Intervening at stage A

Heart failure (HF) prevention is an urgent public health need with national and global implications. Stage A HF patients do not show HF symptoms or structural heart disease but are at risk of HF development. There are no unique recommendations on detecting Stage A patients. Patients in Stage A are heterogeneous; many patients have different combinations of risk factors and, therefore, have markedly different absolute risks for HF. Comprehensive strategies to prevent HF at Stage A include intensive blood pressure lowering, adequate glycemic and lipid management, and heart-healthy behaviors (adopting Life's Essential 8). First and foremost, it is imperative to improve public awareness of HF risk factors and implement healthy lifestyle choices very early. In addition, recognize the HF risk-enhancing factors, which are nontraditional cardiovascular (CV) risk factors that identify individuals at high risk for HF (genetic susceptibility for HF, atrial fibrillation, chronic kidney disease, chronic liver disease, chronic inflammatory disease, sleep-disordered breathing, adverse pregnancy outcomes, radiation therapy, a history of cardiotoxic chemotherapy exposure, and COVID-19). Early use of biomarkers, imaging markers, and echocardiography (noninvasive measures of subclinical systolic and diastolic dysfunction) may enhance risk prediction among individuals without established CV disease and prevent chemotherapy-induced cardiomyopathy. Efforts are needed to address social determinants of HF risk for primordial HF prevention.Central illustrationPolicies developed by organizations such as the American Heart Association, American College of Cardiology, and the American Diabetes Association to reduce CV disease events must go beyond secondary prevention and encompass primordial and primary prevention.

Smoking and cardiovascular outcomes after percutaneous coronary intervention: a Korean study

BACKGROUND AND AIMS

The authors investigated the impact of smoking and its cessation after percutaneous coronary intervention (PCI) on cardiovascular outcomes.

METHODS

Using a nationwide database from the Korean National Health Insurance System, 74 471 patients undergoing PCI between 2009 and 2016 were classified as non-, ex-, or current smokers, depending on smoking status at the first health check-up within 1 year after PCI. The primary outcome was major adverse cardiovascular and cerebrovascular event (MACCE), a composite of all-cause death, myocardial infarction, coronary revascularization, and stroke.

RESULTS

During 4.0 years of follow-up, current smokers had a 19.8% higher rate of MACCE than non-smokers [adjusted hazard ratio (aHR) 1.198; 95% confidence interval (CI) 1.137-1.263], and ex-smokers tended to have a comparable rate with that of non-smokers (aHR 1.036; 95% CI .992-1.081). For 31 887 patients with both pre- and post-PCI health check-up data, the effects of smoking cessation were analysed. Among quitters who stopped smoking after PCI, quitters with cumulative smoking exposure of <20 pack-years (PYs) tended to have a comparable rate of MACCE with that of persistent non-smokers. However, the rate in quitters with cumulative exposure of ≥20 PYs was comparable with that of persistent smokers [aHR (95% CI) for <10 PY, 1.182 (.971-1.438); 10-20 PYs 1.114 (.963-1.290); 20-30 PYs 1.206 (1.054-1.380); ≥ 30 PYs 1.227 (1.113-1.352); persistent smokers 1.223 (1.126-1.328), compared with persistent non-smokers, respectively, P for interaction <.001].

CONCLUSIONS

Smoking is associated with a higher risk of adverse outcomes in patients undergoing PCI. Quitters after PCI with <20 PYs were associated with a risk comparable with that of non-smokers.

Influence of standard modifiable risk factors on ventricular tachycardia after myocardial infarction

Background

Inducible ventricular tachycardia (VT) at electrophysiology study (EPS) predicts sudden cardiac death because of ventricular tachyarrhythmia, the single greatest cause of death within 2 years after myocardial infarction (MI).

Objectives

We aimed to assess the association between standard modifiable risk factors (SMuRFs) and inducible VT at EPS early after MI.

Methods

Consecutive patients with left ventricle ejection fraction ≤40% on days 3-5 after ST elevation MI (STEMI) who underwent EPS were prospectively recruited. Positive EPS was defined as induced sustained monomorphic VT cycle length ≥200 ms for ≥10 s or shorter if hemodynamically compromised. The primary outcome was inducibility of VT at EPS, and the secondary outcome was all-cause mortality on follow-up.

Results

In 410 eligible patients undergoing EPS soon (median of 9 days) after STEMI, 126 had inducible VT. Ex-smokers experienced an increased risk of inducible VT [multivariable logistic regression adjusted odds ratio (OR) 2.0, p = 0.033] compared with current or never-smokers, with comparable risk. The presence of any SMuRFs apart from being a current smoker conferred an increased risk of inducible VT (adjusted OR 1.9, p = 0.043). Neither the number of SMuRFs nor the presence of any SMuRFs was associated with mortality at a median follow-up of 5.4 years.

Conclusions

In patients with recent STEMI and impaired left ventricular function, the presence of any SMuRFs, apart from being a current smoker, conferred an increased risk of inducible VT at EPS. These results highlight the need to modify SMuRFs in this high-risk subset of patients.

Racial Disparity in Anthracycline-induced Cardiotoxicity in Breast Cancer Patients

Breast cancer has become the most common cancer in the US and worldwide. While advances in early detection and treatment have resulted in a 40% reduction in breast cancer mortality, this reduction has not been achieved uniformly among racial groups. A large percentage of non-metastatic breast cancer mortality is related to the cardiovascular effects of breast cancer therapies. These effects appear to be more prevalent among patients from historically marginalized racial/ethnic backgrounds, such as African American and Hispanic individuals. Anthracyclines, particularly doxorubicin and daunorubicin, are the first-line treatments for breast cancer patients. However, their use is limited by their dose-dependent and cumulative cardiotoxicity, manifested by cardiomyopathy, ischemic heart disease, arrhythmias, hypertension, thromboembolic disorders, and heart failure. Cardiotoxicity risk factors, such as genetic predisposition and preexisting obesity, diabetes, hypertension, and heart diseases, are more prevalent in racial/ethnic minorities and undoubtedly contribute to the risk. Yet, beyond these risk factors, racial/ethnic minorities also face unique challenges that contribute to disparities in the emerging field of cardio-oncology, including socioeconomic factors, food insecurity, and the inability to access healthcare providers, among others. The current review will address genetic, clinical, and social determinants that potentially contribute to this disparity.

Dynamic changing smoking habits and cardiovascular events in patients newly diagnosed with hypertension, diabetes, or dyslipidemia: a national cohort study

Background and aims

This study aimed to examine the association between dynamic smoking habit change and cardiovascular risk in a population newly diagnosed with hypertension, diabetes, and dyslipidemia.

Methods

This study included 49,320 individuals who had received health examinations provided by the Korea National Health Insurance Service. To determine the hazard ratios (HRs) and 95% confidence intervals (CIs) for incident major adverse cardiac events (MACE) and all-cause mortality based on dynamic smoking habit changes for 2 years, multivariable Cox proportional hazard models were utilized.

Results

During the follow-up, there were 1,004 (2.2%), 3,483 (7.6%), and 334 (0.7%) cases of myocardial infarction, stroke events, and cardiovascular death, respectively. The group with worsening smoking habits had an increased risk of cardiovascular events and death (HR: 1.33, 95% CI: 1.26-1.40) compared to improved smoking habits. The robustness of the results determined by a series of sensitivity analyses further strengthened the main findings.

Conclusions

Our findings suggest that worsening of smoking habits, even for a short period of time, may increase the risk of myocardial infarction, stroke, and cardiovascular death in patients diagnosed with hypertension, diabetes, and dyslipidemia. For the primary prevention of cardiovascular events in patients with underlying diseases, dynamic modification of smoking habits should be actively considered.

Regulation of endothelial function by cigarette smoke and next-generation tobacco and nicotine products

Cigarette smoking is the most important avoidable cardiovascular risk factor. It causes endothelial dysfunction and atherosclerosis and increases the risk of its severe clinical complications like coronary artery disease, myocardial infarction, stroke, and peripheral artery disease. Several next-generation tobacco and nicotine products have been developed to decrease some of the deleterious effects of regular tobacco smoking. This review article summarizes recent findings about the impact of cigarette smoking and next-generation tobacco and nicotine products on endothelial dysfunction. Both cigarette smoking and next-generation tobacco products lead to impaired endothelial function. Molecular mechanisms of endothelial dysfunction like oxidative stress, reduced nitric oxide availability, inflammation, increased monocyte adhesion, and cytotoxic effects of cigarette smoke and next-generation tobacco and nicotine products are highlighted. The potential impact of short- and long-term exposure to next-generation tobacco and nicotine products on the development of endothelial dysfunction and its clinical implications for cardiovascular diseases are discussed.

Smoking Cessation Reduces the Risk of Heart Failure: A Nationwide Cohort Study

BACKGROUND

There is a lack of data for the incidence of heart failure (HF) according to changes in smoking behaviors.

OBJECTIVES

The authors aimed to investigate the effects of smoking behavior change on development of HF.

METHODS

In this population-based, retrospective cohort study using the Korean National Health Insurance System database, the authors identified 778,608 current smokers who participated in a health screening program in 2009 and in a follow-up screening in 2011. Participants were categorized into quitters, reducers I (≥50% reduction) and II (<50% reduction), sustainers, and increasers.

RESULTS

During a median follow-up of 6.3 years, there were 23,329 HF events (4.8 per 1,000 person-years). Compared with sustainers, the risk of HF was increased among increasers (adjusted hazard ratio [aHR]: 1.06 [95% CI: 1.02-1.10]). By contrast, quitters had a reduced risk for HF (aHR: 0.86 [95% CI: 0.83-0.90]). Even heavy smokers who quit smoking had a lower risk for HF than those who sustained heavy smoking (aHR: 0.90 [95% CI: 0.85-0.95]). In reducers, the risk of HF was not reduced but rather increased slightly (≥50% reduction, aHR: 1.06 [95% CI: 1.01-1.11]; <50% reduction, aHR: 1.04 [95% CI: 1.00-1.08]).

CONCLUSIONS

Current smokers who increased their smoking amount were associated with a higher risk for HF development compared to sustainers, whereas self-reported smoking cessation was associated with a lower risk of HF. There was no benefit from reduction in smoking amount. Self-reported smoking cessation should be reinforced whenever possible to prevent HF.

Potential Mechanisms Between HF and COPD: New Insights From Bioinformatics

Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are closely related in clinical practice. This study aimed to investigate the co-genetic characteristics and potential molecular mechanisms of HF and COPD. HF and COPD datasets were downloaded from gene expression omnibus database. After identifying common differentially expressed genes (DEGs), the functional analysis highlighted the critical role of extracellular matrix and ribosomal signaling pathways in both diseases. In addition, GeneMANIA's results suggested that the 2 diseases were related to immune infiltration, and CIBERSORT suggested the role of macrophages. We also discovered 4 TFs and 1408 miRNAs linked to both diseases, and salbutamol may positively affect them.

Does Cardiovascular Disease Risk Decrease after Smoking Cessation in Occupational Risk Groups?

Objectives

Smoking cessation is very important for workers due to the possibility of exposure to additional environmental risks in the workplace environment. This study was performed to determine the changes in the Framingham Risk Score (FRS) and 10-year risk of cardiovascular disease (CVD) of employees before smoking cessation and after 6 months.

Materials and Methods

Five hundred and sixty-two employees who want to quit smoking were included in the study. In this prospective study, the baseline and 6-month FRS, and 10-year risk of CVD of workers were calculated. Furthermore, the Hospital Anxiety and Depression Scale was used for assessments of employees' anxiety and depression symptoms.

Results

After 6 months, 37% of the participants quit smoking. It was determined that 11.9% of employees have a high CVD risk and 10.6% moderate CVD risk. After 6 months, there was a statistically significant reduction in FRS who quit smoking (P < 0.001). In addition, within the 6 months after smoking cessation, 10-year coronary heart disease risk reduction was higher in quitters than those who cannot quit smoking (47.6% decrease in quitters and 14.9% in nonquitters, P < 0.001). Significant decreases in fasting blood glucose levels were determined after smoking cessation (P = 0.003).

Conclusions

The FRS and CVD risk of smoker employees were decreased 6 months after smoking cessation. In 6 months, CVD risk is reduced in almost half of those who quit smoking. Even in the short term, it is possible to reduce the CVD risk of a worker who quits smoking.

Assessment of Lung Cancer Risk Among Smokers for Whom Annual Screening Is Not Recommended

Importance

The US Preventive Services Task Force does not recommend annual lung cancer screening with low-dose computed tomography (LDCT) for adults aged 50 to 80 years who are former smokers with 20 or more pack-years of smoking who quit 15 or more years ago or current smokers with less than 20 pack-years of smoking.

Objective

To determine the risk of lung cancer in older smokers for whom LDCT screening is not recommended.

Design, Settings, and Participants

This cohort study used the Cardiovascular Health Study (CHS) data sets obtained from the National Heart, Lung and Blood Institute, which also sponsored the study. The CHS enrolled 5888 community-dwelling individuals aged 65 years and older in the US from June 1989 to June 1993 and collected extensive baseline data on smoking history. The current analysis was restricted to 4279 individuals free of cancer who had baseline data on pack-year smoking history and duration of smoking cessation. The current analysis was conducted from January 7, 2022, to May 25, 2022.

Exposures

Current and prior tobacco use.

Main Outcomes and Measures

Incident lung cancer during a median (IQR) of 13.3 (7.9-18.8) years of follow-up (range, 0 to 22.6) through December 31, 2011. A Fine-Gray subdistribution hazard model was used to estimate incidence of lung cancer in the presence of competing risk of death. Cox cause-specific hazard regression models were used to estimate hazard ratios (HRs) and 95% CIs for incident lung cancer.

Results

There were 4279 CHS participants (mean [SD] age, 72.8 [5.6] years; 2450 [57.3%] women; 663 [15.5%] African American, 3585 [83.8%] White, and 31 [0.7%] of other race or ethnicity) included in the current analysis. Among the 861 nonheavy smokers (<20 pack-years), the median (IQR) pack-year smoking history was 7.6 (3.3-13.5) pack-years for the 615 former smokers with 15 or more years of smoking cessation, 10.0 (5.3-14.9) pack-years for the 146 former smokers with less than 15 years of smoking cessation, and 11.4 (7.3-14.4) pack-years for the 100 current smokers. Among the 1445 heavy smokers (20 or more pack-years), the median (IQR) pack-year smoking history was 34.8 (26.3-48.0) pack-years for the 516 former smokers with 15 or more years of smoking cessation, 48.0 (35.0-70.0) pack-years for the 497 former smokers with less than 15 years of smoking cessation, and 48.8 (31.6-57.0) pack-years for the 432 current smokers. Incident lung cancer occurred in 10 of 1973 never smokers (0.5%), 5 of 100 current smokers with less than 20 pack-years of smoking (5.0%), and 26 of 516 former smokers with 20 or more pack-years of smoking with 15 or more years of smoking cessation (5.0%). Compared with never smokers, cause-specific HRs for incident lung cancer in the 2 groups for whom LDCT is not recommended were 10.54 (95% CI, 3.60-30.83) for the current nonheavy smokers and 11.19 (95% CI, 5.40-23.21) for the former smokers with less than 15 years of smoking cessation; age, sex, and race-adjusted HRs were 10.06 (95% CI, 3.41-29.70) for the current nonheavy smokers and 10.22 (4.86-21.50) for the former smokers with less than 15 years of smoking cessation compared with never smokers.

Conclusions and Relevance

The findings of this cohort study suggest that there is a high risk of lung cancer among smokers for whom LDCT screening is not recommended, suggesting that prediction models are needed to identify high-risk subsets of these smokers for screening.

Lifelong smoking status, weight gain, and subsequent risk of major adverse cardiovascular events: Long-term follow-up of a middle-aged Chinese population

OBJECTIVE

The aim of this study was to explore the association of lifelong smoking status with risk of major adverse cardiovascular events (MACE) accounting for weight change in a Chinese cohort.

METHODS

The cohort of the People's Republic of China-United States of America (PRC-USA) Collaborative Study of Cardiovascular and Cardiopulmonary Epidemiology was established in 1983 to 1984, resurveyed during 1987 to 1988 and 1993 to 1994, and followed up to 2005. A total of 5,849 participants who survived in 1993 to 1994 were classified into never smokers, long-term quitters, short-term quitters, short-term relapsers and new smokers, long-term relapsers and new smokers, and persistent smokers according to the information on lifelong smoking status collected in all three surveys. The associations of lifelong smoking status with MACE in the subsequent 10 years were explored with Cox proportional hazards models.

RESULTS

During a median follow-up of 10.2 years, 694 participants had MACE. Compared with persistent smokers, the multivariable-adjusted hazard ratio of developing MACE was 0.83 (95% CI: 0.61-1.12) for short-term quitters, 0.75 (95% CI: 0.54-1.02) for long-term quitters, and 0.68 (95% CI: 0.54-0.85) for never smokers (p_trend = 0.001). In comparison, the hazard ratio was 1.03 (95% CI: 0.77-1.35) for long-term relapsers and new smokers and 0.78 (95% CI: 0.46-1.22) for short-term relapsers and new smokers (p_trend = 0.018). These associations were not significantly altered by further adjusting for weight change in the past 10 years.

CONCLUSIONS

Lifelong smoking status is significantly associated with risk of MACE. As time duration increased, health benefit to quitters would become close to that of never smokers, and harms to relapsers and new smokers would become close to that of persistent smokers.

Healthy lifestyle in older adults and life expectancy with and without heart failure

Several lifestyle factors have been linked to risk for heart failure (HF) and premature mortality. The aim of this study was to estimate the impact of a healthy lifestyle on life expectancy with and without HF among men and women from a general population. This study was performed among 6113 participants (mean age 65.8 ± 9.7 years; 58.9% women) from the Rotterdam Study, a large prospective population-based cohort study. A continuous lifestyle score was created based on five lifestyle factors: smoking status, alcohol consumption, diet quality, physical activity and weight status (assessed 1995–2008). The lifestyle score was categorized into three levels: unhealthy (reference), intermediate and healthy. Gompertz regression and multistate life tables were used to estimate the effects of lifestyle on life expectancy with and without HF in men and women separately at ages 45, 65 and 85 years (follow-up until 2016). During an average follow-up of 11.3 years, 699 incident HF events and 2146 deaths occurred. At the age of 45 years, men in the healthy lifestyle category had a 4.4 (95% CI: 4.1–4.7) years longer total life expectancy than men in the unhealthy lifestyle category, and a 4.8 (95% CI: 4.4–5.1) years longer life expectancy free of HF. Among women, the difference in total life-expectancy at the age of 45 years was 3.4 (95% CI: 3.2–3.5) years and was 3.4 (95% CI: 3.3–3.6) years longer for life expectancy without HF. This effect persisted also at older ages. An overall healthy lifestyle can have a positive impact on total life expectancy and life expectancy free of HF.

Psychosocial Risk and Health Behaviors as Predictors of Clinical Events in Patients Wait-Listed for a New Heart: Results from 7 Years of Follow-Up

We examined the long-term relationship of psychosocial risk and health behaviors on clinical events in patients awaiting heart transplantation (HTx). Psychosocial characteristics (e.g., depression), health behaviors (e.g., dietary habits, smoking), medical factors (e.g., creatinine), and demographics (e.g., age, sex) were collected at the time of listing in 318 patients (82% male, mean age = 53 years) enrolled in the Waiting for a New Heart Study. Clinical events were death/delisting due to deterioration, high-urgency status transplantation (HU-HTx), elective transplantation, and delisting due to clinical improvement. Within 7 years of follow-up, 92 patients died or were delisted due to deterioration, 121 received HU-HTx, 43 received elective transplantation, and 39 were delisted due to improvement. Adjusting for demographic and medical characteristics, the results indicated that frequent consumption of healthy foods (i.e., foods high in unsaturated fats) and being physically active increased the likelihood of delisting due improvement, while smoking and depressive symptoms were related to death/delisting due to clinical deterioration while awaiting HTx. In conclusion, psychosocial and behavioral characteristics are clearly associated with clinical outcomes in this population. Interventions that target psychosocial risk, smoking, dietary habits, and physical activity may be beneficial for patients with advanced heart failure waiting for a cardiac transplant.

Drugs of Abuse and Heart Failure

Substance use is common among those with heart failure (HF) and is associated with worse clinical outcomes. Alcohol, tobacco, cannabis, and cocaine are commonly abused substances that can contribute to the development and worsening of HF. Heavy alcohol consumption can lead to dilated cardiomyopathy, whereas moderate intake may decrease incident HF. Tobacco increases the risk of HF through coronary artery disease and coronary artery disease-independent mechanisms. Continued smoking worsens outcomes for those with HF and cessation is associated with an improved risk of major adverse cardiac events. Cannabis has complex interactions on the cardiovascular system depending on the method of consumption, amount consumed, and content of cannabinoids. Delta-9-tetrahydrocannabinol can increase sympathetic tone, cause vascular dysfunction, and may increase the risk of myocardial infarction. Cannabidiol is cardioprotective in preclinical studies and is a potential therapeutic target. Cocaine increases sympathetic tone and is a potent proarrhythmogenic agent. It increases the risk of myocardial infarction and can also lead to a dilated cardiomyopathy. The use of beta-blockers in those with HF and cocaine use is likely safe and effective. Future studies are needed to further elucidate the impact of these substances both on the development of HF and their effects on those who have HF.

Effect of short-term smoking & L-arginine on coronary endothelial function assessed by cardiac magnetic resonance cold pressor testing: a pilot study

Background

The effect of smoking on coronary vasomotion has been investigated in the past with various imaging techniques in both short- and long-term smokers. Additionally, coronary vasomotion has been shown to be normalized in long-term smokers by L-Arginine acting as a substrate for NO synthase, revealing the coronary endothelium as the major site of abnormal vasomotor response. Aim of the prospective cohort study was to investigate coronary vasomotion of young healthy short-term smokers via magnetic resonance cold pressor test with and without the administration of L-Arginine and compare obtained results with the ones from nonsmokers.

Methods

Myocardial blood flow (MBF) was quantified with first-pass perfusion MRI on a 1.5 T scanner in healthy short-term smokers (N = 10, age: 25.0 ± 2.8 years, 5.0 ± 2.9 pack years) and nonsmokers (N = 10, age: 34.3 ± 13.6) both at rest and during cold pressor test (CPT). Smokers underwent an additional examination after administration of L-Arginine within a median of 7 days of the naïve examination.

Results

MBF at rest turned out to be 0.77 ± 0.30 (smokers with no L-Arginine; mean ± standard deviation), 0.66 ± 0.21 (smokers L-Arginine) and 0.84 ± 0.08 (nonsmokers). Values under CPT were 1.21 ± 0.42 (smokers no L-Arginine), 1.09 ± 0.35 (smokers L-Arginine) and 1.63 ± 0.33 (nonsmokers). In all groups, MBF was significantly increased under CPT compared to the corresponding rest examination (p < 0.05 in all cases). Additionally, MBF under CPT was significantly different between the smokers and the nonsmokers (p = 0.002). MBF at rest was significantly different between the smokers when L-Arginine was given and the nonsmokers (p = 0.035).

Conclusion

Short-term smokers showed a reduced response to cold both with and without the administration of L-Arginine. However, absolute MBF values under CPT were lower compared to nonsmokers independently of L-Arginine administration.

Antioxidants in smokers

Cigarette smoke (CS) is likely the most common preventable cause of human morbidity and mortality worldwide. Consequently, inexpensive interventional strategies for preventing CS-related diseases would positively impact health systems. Inhaled CS is a powerful inflammatory stimulus and produces a shift in the normal balance between antioxidants and oxidants, inducing oxidative stress in both the respiratory system and throughout the body. This enduring and systemic pro-oxidative state within the body is reflected by increased levels of oxidative stress and inflammation biomarkers seen in smokers. Smokers might benefit from consuming antioxidant supplements, or a diet rich in fruit and vegetables, which can reduce the CS-related oxidative stress. This review provides an overview of the plasma profile of antioxidants observable in smokers and examines the heterogeneous literature to elucidate and discuss the effectiveness of interventional strategies based on antioxidant supplements or an antioxidant-rich diet to improve the health of smokers. An antioxidant-rich diet can provide an easy-to-implement and cost-effective preventative strategy to reduce the risk of CS-related diseases, thus being one of the simplest ways for smokers to stay in good health for as long as possible. The health benefits attributable to the intake of antioxidants have been observed predominantly when these have been consumed within their natural food matrices in an optimal antioxidant-rich diet, while these preventive effects are rarely achieved with the intake of individual antioxidants, even at high doses.

Psychosocial Syndemics and Multimorbidity in Patients with Heart Failure †

Heart failure (HF) is a common cause of hospitalization and mortality in older adults. HF is almost always embedded within a larger pattern of multimorbidity, yet many studies exclude patients with complex psychiatric and medical comorbidities or cognitive impairment. This has left significant gaps in research on the problems and treatment of patients with HF. In addition, HF is only one of multiple challenges facing patients with multimorbidity, stressful socioeconomic circumstances, and psychosocial problems. The purpose of this study is to identify combinations of comorbidities and health disparities that may affect HF outcomes and require different mixtures of medical, psychological, and social services to address. The syndemics framework has yielded important insights into other disorders such as HIV/AIDS, but it has not been applied to the complex psychosocial problems of patients with HF. The multimorbidity framework is an alternative approach for investigating the effects of multiple comorbidities on health outcomes. The specific aims are: (1) to determine the coprevalence of psychiatric and medical comorbidities in patients with HF (n = 535); (2) to determine whether coprevalent comorbidities have synergistic effects on readmissions, mortality, self-care, and global health; (3) to identify vulnerable subpopulations of patients with HF who have high coprevalences of syndemic comorbidities; (4) to determine the extent to which syndemic comorbidities explain adverse HF outcomes in vulnerable subgroups of patients with HF; and (5) to determine the effects of multimorbidity on readmissions, mortality, self-care, and global health.

Clinical Characteristics and Outcomes of Patients With Heart Failure With Reduced Ejection Fraction and Chronic Obstructive Pulmonary Disease: Insights From PARADIGM-HF

Background

Chronic obstructive pulmonary disease (COPD) is a common comorbidity in heart failure with reduced ejection fraction, associated with undertreatment and worse outcomes. New treatments for heart failure with reduced ejection fraction may be particularly important in patients with concomitant COPD.

Methods and Results

We examined outcomes in 8399 patients with heart failure with reduced ejection fraction, according to COPD status, in the PARADIGM‐HF (Prospective Comparison of Angiotensin Receptor Blocker–Neprilysin Inhibitor With Angiotensin‐Converting Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure) trial. Cox regression models were used to compare COPD versus non‐COPD subgroups and the effects of sacubitril/valsartan versus enalapril. Patients with COPD (n=1080, 12.9%) were older than patients without COPD (mean 67 versus 63 years; P<0.001), with similar left ventricular ejection fraction (29.9% versus 29.4%), but higher NT‐proBNP (N‐terminal pro‐B‐type natriuretic peptide; median, 1741 pg/mL versus 1591 pg/mL; P=0.01), worse functional class (New York Heart Association III/IV 37% versus 23%; P<0.001) and Kansas City Cardiomyopathy Questionnaire–Clinical Summary Score (73 versus 81; P<0.001), and more congestion and comorbidity. Medical therapy was similar in patients with and without COPD except for beta‐blockade (87% versus 94%; P<0.001) and diuretics (85% versus 80%; P<0.001). After multivariable adjustment, COPD was associated with higher risks of heart failure hospitalization (hazard ratio [HR], 1.32; 95% CI, 1.13–1.54), and the composite of cardiovascular death or heart failure hospitalization (HR, 1.18; 95% CI, 1.05–1.34), but not cardiovascular death (HR, 1.10; 95% CI, 0.94–1.30), or all‐cause mortality (HR, 1.14; 95% CI, 0.99–1.31). COPD was also associated with higher risk of all cardiovascular hospitalization (HR, 1.17; 95% CI, 1.05–1.31) and noncardiovascular hospitalization (HR, 1.45; 95% CI, 1.29–1.64). The benefit of sacubitril/valsartan over enalapril was consistent in patients with and without COPD for all end points.

Conclusions

In PARADIGM‐HF, COPD was associated with lower use of beta‐blockers and worse health status and was an independent predictor of cardiovascular and noncardiovascular hospitalization. Sacubitril/valsartan was beneficial in this high‐risk subgroup.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT01035255.

Tobacco smoking in patients with heart failure and coronary artery disease: A 20-year experience at Duke University Medical Center

Smoking is associated with incident heart failure (HF), yet limited data are available exploring the association between smoking status and long-term outcomes in HF with reduced vs. preserved ejection fraction (i.e., HFrEF vs. HFpEF).

METHODS

We performed a retrospective analysis of HF patients undergoing coronary angiography from 1990-2010. Patients with coronary artery disease (CAD) and HF were stratified by EF (< 50% vs. ≥50%), smoking status (prior/current vs. never smoker), and level of smoking (light/moderate vs. heavy). Time-from-catheterization-to-event was examined using Cox proportional hazard modeling for all-cause mortality (ACM), ACM/myocardial infarction/stroke (MACE), and ACM/HF hospitalization with testing for interaction by HF-type (HFrEF vs. HFpEF).

RESULTS

Of 14,406 patients with CAD and HF, 85% (n = 12,326) had HFrEF and 15% (n = 2080) had HFpEF. At catheterization, 61% of HFrEF and 57% of HFpEF patients had a smoking history. After adjustment, there was a significant interaction between HF-type and the association between smoking status and MACE (interaction P = .009). Smoking history was associated with increased risk for MACE in patients with HFrEF (adjusted hazard ratio [HR] 1.18 [1.12-1.24]), but not HFpEF (HR 1.01 [0.90-1.12]). Active smokers had increased mortality following adjustment compared to former smokers regardless of HF-type (HFrEF HR 1.19 [1.06-1.32], HFpEF HR 1.30 [1.02-1.64], interaction P = .50). Heavy smokers trended towards increased risk of adverse outcomes versus light/moderate smokers; these findings were consistent across HF-type (interaction P > .12).

CONCLUSION

Smoking history was independently associated with worse outcomes in HFrEF but not HFpEF. Regardless of HF-type, current smokers had higher risk than former smokers.

Heart failure and left ventricular dysfunction in older patients with chronic kidney disease: the China Hypertension Survey (2012-2015)

Background

Heart failure (HF) is a leading cause of hospitalization and mortality for older chronic kidney disease (CKD) patients. However, the epidemiological data is scarce. We aimed to determine the prevalence of left ventricular (LV) dysfunction and HF, and to explore the risk factors for HF among those patients.

Methods

This is a cross-sectional analysis of the China Hypertension Survey conducted between October 2012 and December 2015. A total of 5, 808 participants aged ≥ 65 years were included in the analysis. Self-reported history of HF and any other cardiovascular diseases was acquired. 2-D and Doppler echocardiography were used to assess LV dysfunction. CKD was defined as either estimated glomerular filtration rate (eGFR) < 60 mL/min per 1.73 m² or urinary albumin to creatinine ratio (ACR) ≥ 30 mg/g.

Results

Among CKD patients aged ≥ 65 years, the weighted prevalence of HF, heart failure with preserved ejection fraction (HFpEF), heart failure with mid-range ejection fraction (HFmrEF), and heart failure with reduced ejection fraction (HFrEF) was 4.8%, 2.5%, 0.8%, and 1.7%, respectively. The weighted prevalence of HF was 5.0% in patients with eGFR < 60 mL/min per 1.73 m², and was 5.9% in patients with ACR ≥ 30 mg/g. The prevalence of LV systolic dysfunction was 3.1%, and while it was 8.9% for moderate/severe diastolic dysfunction. Multivariate analysis showed that smoking was significantly associated with the risk of HF. Furthermore, age, smoking, and residents in rural areas were significantly associated with a risk of LV diastolic dysfunction.

Conclusions

The prevalence of HF and LV dysfunction was high in older patients with CKD, suggesting that particular strategies will be required.

An international survey: Tobacco smoking cessation strategies within left ventricular assist device centers

BACKGROUND

Tobacco smoking is a significant source of morbidity in patients with a durable left ventricular assist device. While various cessation strategies have been investigated, the ability of ventricular assist device centers to implement a successful tobacco cessation program remains uncertain. We explored various cessation strategies employed by ventricular assist device centers and assessed perspectives of their effectiveness, as well as institutional investment in these programs.

METHODS

A 37-question online self-report survey was created using Survey Monkey^® and distributed worldwide. We investigated (1) programmatic strategies utilized for smoking cessation, (2) the respondent's perspective on the effectiveness of these strategies, (3) the structure with which these therapies are administered, and (4) overall organizational support for these treatments.

RESULTS

A total of 47 centers worldwide completed the survey. The most common methods of tobacco cessation were pharmacologic and nicotine replacement therapy (78% and 66%). However, only about half (47% and 50%, respectively) of the centers indicated that these strategies were effective. When asked whether a respondent's center perceives that tobacco smoking should be a deciding factor in destination therapy evaluations, nearly a third (15, 32%) responded in the affirmative.

CONCLUSION

While significant overlap exists among centers regarding treatments used for smoking cessation with left ventricular assist device patients, the most common treatments are not thought to be effective. While the current recommendations require tobacco smoking cessation in only bridge-to-transplant patients and not destination therapy patients, a number of centers disagree with the national guidelines and believe smoking should be prohibited in both populations.

Time-to-Treatment and Its Association With Complications and Mortality Rate in Patients With Acute Myocardial Infarction: A Prospective Cohort Study

INTRODUCTION

Time-to-treatment is one of the most important factors affecting the complications and mortality rate in patients with acute myocardial infarction. The purpose of this study was to determine time-to-treatment and its association with complications and mortality rates in patients with acute myocardial infarction in selected hospitals in Zanjan, Iran.

METHODS

This prospective cohort study was performed with 200 patients suffering from acute myocardial infarction in selected educational hospitals of Zanjan from June 2016 to March 2017. Parameters including the interval between pain onset and treatment, myocardial infarction complications, in-hospital mortality, and 30-day mortality after the occurrence of myocardial infarction were collected through a special questionnaire and phone calls. The data were analyzed using descriptive statistics and logistic regression models.

RESULTS

The longest time-to-treatment delay is related to prehospital time (mean, 330.68 [SD=411.55] minutes). Based on the results, the increase in the interval time between onset of pain and treatment (odds ratio: 1.001; 95% confidence interval, 1.000-1.002; P = 0.01), hypertension (odds ratio: 2.96; 95% confidence interval, 1.14-7.68; P = 0.02), and left coronary artery complete occlusion (odds ratio: 2.78; 95% confidence interval, 1.57-4.94; P < 0.001) were mortality predictor factors. Furthermore, the increase in the interval time between onset of pain and treatment (odds ratio: 1.001; 95% confidence interval, 1.000-1.002; P = 0.03), current smoking (odds ratio: 5.53; 95% confidence interval, 1.75-17.43; P = 0.004), and right coronary artery complete occlusion (odds ratio: 5.87; 95% confidence interval, 1.34-25.82; P = 0.02) were highly associated with the occurrence of heart failure.

DISCUSSION

Hypertension, smoking history, and delay in treatment time were highly associated with the occurrence of heart failure and mortality. Therefore, in Iranian society, education on primary and secondary prevention of myocardial infarction is recommended to reduce patient mortality.

Active Tobacco Smoking Impairs Cardiac Systolic Function

Tobacco smoking is a well-established risk factor for cardiovascular disease, but its direct effect on myocardial structure and function remains unclear. This study investigated the effects of smoking using a nested matched case-control study design. 5,668 participants of the UK Biobank study who underwent cardiovascular magnetic resonance imaging were screened for inclusion. 102 smokers (56 males) with a median age of 56 years were matched to non-smokers based on sex, age, and body surface area. Manual post-processing and feature tracking analyses were performed to determine left ventricular (LV) and right ventricular (RV) structure and function measures. Linear regression analyses were performed to determine the effect of tobacco smoking on imaging measures. Tobacco smoking was associated with increased LV and RV end-systolic volume (4.98 ± 2.08 mL, 5.19 ± 2.62 mL, P = 0.018, 0.049 respectively), reduced LV and RV ejection fraction (β: −2.21 ± 0.82%, −2.06 ± 0.87%, P = 0.007, 0.019 respectively), and reduced absolute measures of LV peak global longitudinal, radial, and circumferential strain (β: 0.86 ± 0.30%, −2.52 ± 0.99%, 1.05 ± 0.32%, P = 0.004, 0.011, 0.001 respectively). Effect sizes were larger in daily smokers compared to occasional smokers. In a general Caucasian population without known clinical cardiovascular disease, active tobacco smoking was dose dependently associated with impaired cardiac systolic function.

[Lifestyle intervention in the primary prevention of cardiovascular diseases]

Cardiovascular diseases are the leading cause of death worldwide. Adherence to a healthy lifestyle lifelong is capable of significantly reducing the cardiovascular risk by up to 70% and is therefore a key component in primary prevention of cardiovascular disease. According to the European and American guidelines lifestyle interventions include not smoking, daily physical activity of ≥150 min/week at moderate intensity or 75 min/week for higher intensity physical activity, a cardioprotective nutrition (high proportion of unsaturated fatty acids, low amounts of saturated fatty acids and low salt intake), normal body weight (body mass index 20-25 kg/m²), arterial blood pressure <140/90 mm Hg (optimum <130/80 mm Hg), low-density lipoprotein (LDL)-cholesterol target values depending on the cardiovascular risk and a normal glucose metabolism in type 2 diabetes mellitus with adjustment of a HbA1c to <7%. Lifestyle measures with weight reduction and intensification of physical activity can improve the cardiometabolic risk factors. In this way reduction of the systolic and diastolic blood pressures by approximately 10-15 mm Hg, reduction of HbA1c by approximately 1 % and reduction of triglycerides by ca. 30-40 % are possible. The LDL-cholesterol and lipoprotein(a) levels cannot be easily influenced. Beyond the recommendations for a cardioprotective lifestyle, additional pharmacological therapy may have to be added depending on the cardiovascular risk profile.

Hospitalizations for cardiovascular diseases attributable to tobacco smoking in France in 2015

AIMS

Tobacco smoking is a major risk factor for many cardiovascular diseases. In France, the daily smoking prevalence is among the highest in high-income European countries. This study estimated the number of hospitalizations for cardiovascular diseases attributable to smoking in France in 2015, and the number of stays that could have been avoided if there had been 10% less current smokers or if the prevalence of current smokers had been 20%.

METHODS

Age- and sex-specific attributable fractions were calculated by combining relative risks extracted from the literature with the prevalence of smoking estimated in the 2014 Health Barometer, a national representative survey. These fractions were applied to hospitalization stays with a primary diagnosis for a cardiovascular disease whose risk is known to increase with smoking.

RESULTS

In France in 2015, 250,813 hospital stays (95% uncertainty interval=234,869-269,807) related to a cardiovascular condition were estimated as attributable to smoking. This represented 21% of all stays for a cardiovascular condition. Ischemic heart disease accounted for the largest share of smoking-related stays (39%). If the number of current smokers had been 10% lower or if the prevalence of smoking in the population had dropped to below 20%, 5867 stays and 25,911 stays, respectively, would have been prevented.

CONCLUSIONS

In France, a large number of hospital stays for cardiovascular disease are attributable to tobacco smoking. A 10% reduction in smoking would avoid nearly 6000 hospital stays per year; more than 25,000 annual hospital stays if only 20% of the French population smoked.

Association of Smoking Cessation With Subsequent Risk of Cardiovascular Disease

IMPORTANCE

The time course of cardiovascular disease (CVD) risk after smoking cessation is unclear. Risk calculators consider former smokers to be at risk for only 5 years.

OBJECTIVE

To evaluate the association between years since quitting smoking and incident CVD.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective analysis of prospectively collected data from Framingham Heart Study participants without baseline CVD (original cohort: attending their fourth examination in 1954-1958; offspring cohort: attending their first examination in 1971-1975) who were followed up through December 2015.

EXPOSURES

Time-updated self-reported smoking status, years since quitting, and cumulative pack-years.

MAIN OUTCOMES AND MEASURES

Incident CVD (myocardial infarction, stroke, heart failure, or cardiovascular death). Primary analyses included both cohorts (pooled) and were restricted to heavy ever smokers (≥20 pack-years).

RESULTS

The study population included 8770 individuals (original cohort: n = 3805; offspring cohort: n = 4965) with a mean age of 42.2 (SD, 11.8) years and 45% male. There were 5308 ever smokers with a median 17.2 (interquartile range, 7-30) baseline pack-years, including 2371 heavy ever smokers (406 [17%] former and 1965 [83%] current). Over 26.4 median follow-up years, 2435 first CVD events occurred (original cohort: n = 1612 [n = 665 among heavy smokers]; offspring cohort: n = 823 [n = 430 among heavy smokers]). In the pooled cohort, compared with current smoking, quitting within 5 years was associated with significantly lower rates of incident CVD (incidence rates per 1000 person-years: current smoking, 11.56 [95% CI, 10.30-12.98]; quitting within 5 years, 6.94 [95% CI, 5.61-8.59]; difference, -4.51 [95% CI, -5.90 to -2.77]) and lower risk of incident CVD (hazard ratio, 0.61; 95% CI, 0.49-0.76). Compared with never smoking, quitting smoking ceased to be significantly associated with greater CVD risk between 10 and 15 years after cessation in the pooled cohort (incidence rates per 1000 person-years: never smoking, 5.09 [95% CI, 4.52-5.74]; quitting within 10 to <15 years, 6.31 [95% CI, 4.93-8.09]; difference, 1.27 [95% CI, -0.10 to 3.05]; hazard ratio, 1.25 [95% CI, 0.98-1.60]).

CONCLUSIONS AND RELEVANCE

Among heavy smokers, smoking cessation was associated with significantly lower risk of CVD within 5 years relative to current smokers. However, relative to never smokers, former smokers' CVD risk remained significantly elevated beyond 5 years after smoking cessation.

Saudi Heart Association (SHA) guidelines for the management of heart failure

Heart failure (HF) is the leading cause of morbidity and mortality worldwide and negatively impacts quality of life, healthcare costs, and longevity. Although data on HF in the Arab population are scarce, recently developed regional registries are a step forward to evaluating the quality of current patient care and providing an overview of the clinical picture. Despite the burden of HF in Saudi Arabia, there are currently no standardized protocols or guidelines for the management of patients with acute or chronic heart failure. Therefore, the Heart Failure Expert Committee, comprising 13 local specialists representing both public and private sectors, has developed guidelines to address the needs and challenges for the diagnosis and treatment of HF in Saudi Arabia. The ultimate aim of these guidelines is to assist healthcare professionals in delivering optimal care and standardized clinical practice across Saudi Arabia.

Influence of Smoking Status on Risk of Incident Heart Failure: A Systematic Review and Meta-Analysis of Prospective Cohort Studies

Smoking is a well-known risk factor for atherosclerotic cardiovascular disease. However, there are insufficient data regarding the predictive influence of smoking status on the risk of incident heart failure (HF). This study involved a systematic review and meta-analysis of prospective cohort studies to identify the association of smoking status with incident risk of HF. Peer-reviewed articles published in PubMed, Embase, Web of Science, Cochrane, and CINAHL up to May 2019 were identified. Seven studies, based on 42,759 participants and 4826 HF cases, were included. Pooled hazard ratios (HRs) and their 95% confidence intervals (CI) were estimated using the fixed effects model. Subgroup analyses were conducted to define possible sources of heterogeneity. Current smokers aged 18 years and over had a greater risk of HF incidence compared with non-smokers (never or former smokers) (HR = 1.609, 95% CI, 1.470–1.761). Additionally, former smokers had a greater risk of HF incidence compared with never smokers (HR = 1.209, 95% CI, 1.084–1.348). The present study highlighted that never smokers have more obvious cardiovascular benefits than current or former smokers. Therefore, health professionals should support cessation at the earliest among current smokers and encourage young people and non-smokers not to start smoking.

Soluble Neprilysin in the General Population: Clinical Determinants and Its Relationship to Cardiovascular Disease

Background

Neprilysin is a metalloprotease involved in proteolysis of numerous peptides, including natriuretic peptides, and is of prognostic and therapeutic importance in heart failure with reduced ejection fraction. No studies have investigated circulating neprilysin in the community, its clinical correlates, or its relationship to cardiovascular disease in the general population.

Methods and Results

Plasma neprilysin was measured in 1536 participants from Olmsted County, Minnesota, using a commercially available sandwich ELISA assay. Clinical and echocardiographic correlates and subsequent outcomes were determined. Soluble neprilysin is non‐normally distributed in the community (median: 3.9 ng/mL; interquartile range: 1.0–43.0 ng/mL). There was no relationship between plasma neprilysin and age (Spearman correlation: −0.04, P=0.16); body mass index (Spearman correlation: −0.04, P=0.16); glomerular filtration rate (Spearman correlation: −0.007, P=0.8); or A‐, B‐, or C‐type natriuretic peptides (Spearman correlation: 0.03, P=0.22; −0.001, P=0.96; 0.01, P=0.67, respectively). Among tertiles of neprilysin, the lowest tertile group had the highest prevalence of smokers (P<0.001), hypertension (P=0.04), dyslipidemia (P=0.03), and diastolic dysfunction (P=0.02). Soluble neprilysin was not prospectively associated with death or heart failure over a median of 10.7 years.

Conclusions

In a large community‐based cohort, for the first time, we described the distribution of circulating neprilysin in the general community. We observed that neprilysin does not correlate with natriuretic peptide levels and is not independently associated with adverse outcomes. The novel associations observed between low soluble neprilysin levels and an adverse cardiometabolic and smoking profile requires further investigation.

Relation Between Cigarette Smoking and Heart Failure (from the Multiethnic Study of Atherosclerosis)

We studied the association between cigarette smoking and incident heart failure (HF) in a racially diverse US cohort. We included 6,792 participants from the Multi-Ethnic Study of Atherosclerosis with information on cigarette smoking at baseline, characterized by status, intensity, burden, and time since quitting. Adjudicated outcomes included total incident HF cases and HF stratified by ejection fraction (EF) into HF with reduced EF (HFrEF; EF ≤ 40%) and preserved EF (HFpEF; EF ≥ 50%). We used Cox proportional hazards models adjusted for traditional cardiovascular risk factors and accounted for competing risk of each HF type. Mean age was 62 ± 10 years; 53% were women, 61% were nonwhite, and 13% were current smokers. A total of 279 incident HF cases occurred over a median follow-up of 12.2 years. The incidence rates of HFrEF and HFpEF were 2.2 and 1.9 cases per 1000 person-years, respectively. Current smoking was associated with higher risk of HF compared with never smoking (hazard ratio [HR], 2.05; 95% confidence interval [CI], 1.36 to 3.09); this was similar for HFrEF (HR, 2.58; 95% CI, 1.27 to 5.25) and HFpEF (HR, 2.51; 95% CI, 1.15 to 5.49). Former smoking was not significantly associated with HF (HR, 1.17; 95% CI, 0.88 to 1.56). Smoking intensity, burden, and time since quitting did not provide additional information for HF risk after accounting for smoking status.

Double Whammy for Older Smokers: Marginalized by Tobacco Control and Valued by the Tobacco Industry

In the last 20 years, the United States has made stunning progress reducing the rate of adult smoking. However, the smallest reduction is among older adults. Compared to younger smokers, older smokers are more likely to be lower socioeconomic status (SES), have several tobacco related comorbidities, and are less likely to be treated for tobacco addiction yet, in tobacco policy, they are not considered a marginalized group. The tobacco industry's interest in older smokers contrasts with the lack of interest shown by tobacco control. A double whammy is a set of two bad events or situations that have an effect at the same time. The purposes of this article are to use the health disparity paradigm to (a) discuss the "double whammy" of marginalization by tobacco control and valuation by the tobacco industry on the health of older smokers and (b) provide strategies to promote health equity for older smokers.

Cardiovascular injury induced by tobacco products: assessment of risk factors and biomarkers of harm. A Tobacco Centers of Regulatory Science compilation

Although substantial evidence shows that smoking is positively and robustly associated with cardiovascular disease (CVD), the CVD risk associated with the use of new and emerging tobacco products, such as electronic cigarettes, hookah, and heat-not-burn products, remains unclear. This uncertainty stems from lack of knowledge on how the use of these products affects cardiovascular health. Cardiovascular injury associated with the use of new tobacco products could be evaluated by measuring changes in biomarkers of cardiovascular harm that are sensitive to the use of combustible cigarettes. Such cardiovascular injury could be indexed at several levels. Preclinical changes contributing to the pathogenesis of disease could be monitored by measuring changes in systemic inflammation and oxidative stress, organ-specific dysfunctions could be gauged by measuring endothelial function (flow-mediated dilation), platelet aggregation, and arterial stiffness, and organ-specific injury could be evaluated by measuring endothelial microparticles and platelet-leukocyte aggregates. Classical risk factors, such as blood pressure, circulating lipoproteins, and insulin resistance, provide robust estimates of risk, and subclinical disease progression could be followed by measuring coronary artery Ca2+ and carotid intima-media thickness. Given that several of these biomarkers are well-established predictors of major cardiovascular events, the association of these biomarkers with the use of new and emerging tobacco products could be indicative of both individual and population-level CVD risk associated with the use of these products. Differential effects of tobacco products (conventional vs. new and emerging products) on different indexes of cardiovascular injury could also provide insights into mechanisms by which they induce cardiovascular harm.

Tobacco smoking and the risk of heart failure: A systematic review and meta-analysis of prospective studies

Background

We conducted a systematic review and meta-analysis to clarify the association between smoking and the risk of developing heart failure.

Methods

PubMed and Embase databases were searched up to 24 July 2018. Prospective studies were included if they reported adjusted relative risk (RR) estimates and 95% confidence intervals (CIs) of heart failure associated with smoking. Summary RRs and 95% CIs were estimated using a random effects model.

Results

Twenty-six studies were included. The summary RR was 1.75 (95% CI: 1.54–1.99, I2 = 81%, n = 10) for current smokers, 1.16 (95% CI: 1.08–1.24, I2 = 51%, n = 9) for former smokers, and 1.44 (1.34–1.55, I2 = 83%, n = 10) for ever smokers compared with never smokers. The summary RR was 1.41 (95% CI: 1.01–1.96, I2 = 82%, n = 2) per 10 cigarettes per day, 1.11 (95% CI: 1.04–1.18, I2 = 70%, n = 3) and 1.08 (95% CI: 1.02–1.14, I2 = 34%, n = 2) per 10 pack-years among ever smokers and former smokers, respectively, and 0.79 (95% CI: 0.63–1.00, I2 = 96%, n = 2) per 10 years since quitting smoking. The association between smoking cessation and heart failure reached significance at 15 years of smoking cessation, and at 30 years the summary RR was 0.72 (95% CI: 0.57–0.90), only slightly higher than the summary RR for never smokers (0.64 (95% CI: 0.57–0.72)) when compared with current smokers.

Conclusion

Smoking is associated with increased risk of heart failure, but the risk decreases with increasing duration since smoking cessation. Any further studies should investigate the association between number of cigarettes per day, duration, pack-years and time since quitting smoking and risk of heart failure.

Effects of smoking on disease risk among South Korean adults

INTRODUCTION

Tobacco smoking is currently considered to be the main preventable cause of death and disability worldwide. We examined the magnitude of cigarette smoking effects on major smoking-related diseases, such as chronic obstructive pulmonary disease (COPD), hypertension (HTN) and cardiovascular disease (CVD), among South Korean adults using nationwide and representative survey data.

METHODS

We used data from the Korea National Health and Nutrition Examination Survey, which was conducted over a 9-year period from 2007 to 2015 by the Korea Centers for Disease Control and Prevention. Multiple logistic regression analyses were performed to assess the associations between smoking status and all outcomes of interest. A total of 24072 participants ≥40 years of age were sampled in the current study.

RESULTS

The study results were as follows: 1) Current and former smoking is associated with lower socioeconomic status; 2) The prevalence of major smoking-related diseases was significantly higher in former and current smokers compared to non-smokers; 3) The odd ratios of developing COPD were 3.49 [95% confidence interval (CI): 2.44-5.00], 2.41 (95% CI: 1.68-3.45) and 3.45 (95% CI: 2.20-5.40) among male current smokers, male ex-smokers and female current smokers, respectively. The odd ratio of developing CVD was 2.01 (95% CI: 1.05-3.86) in male ex-smokers. Otherwise, no significant associations between smoking and other diseases were observed after controlling the sociodemographic and clinical factors; and 4) The risk for COPD tends to be related to the smoking amount and weaning after quitting smoking.

CONCLUSIONS

Our study showed that COPD had the strongest association with current and former smoking in both male and female smokers after controlling for all potential confounding factors among major smoking-related diseases.

Tobacco smoking and the risk of atrial fibrillation: A systematic review and meta-analysis of prospective studies

Background

Epidemiological studies on smoking and atrial fibrillation have been inconsistent, with some studies showing a positive association while others have found no association. It is also unclear whether there is a dose–response relationship between the number of cigarettes smoked or pack-years and the risk of atrial fibrillation. We conducted a systematic review and meta-analysis to clarify the association.

Design

Systematic review and meta-analysis.

Methods

We searched the PubMed and Embase databases for studies of smoking and atrial fibrillation up to 20 July 2017. Prospective studies and nested case–control studies within cohort studies reporting adjusted relative risk estimates and 95% confidence intervals (CIs) of atrial fibrillation associated with smoking were included. Summary relative risks (95% CIs) were estimated using a random effects model.

Results

Twenty nine prospective studies (22 publications) were included. The summary relative risk was 1.32 (95% CI 1.12–1.56, I2 = 84%, n = 11 studies) for current smokers, 1.09 (95% CI 1.00–1.18, I2 = 33%, n = 9) for former smokers and 1.21 (95% CI 1.12–1.31, I2 = 80%, n = 14) for ever smokers compared to never smokers. Comparing current versus non-current smokers the summary relative risk was 1.33 (95% CI 1.14–1.56, I2 = 78%, n = 10). The summary relative risk was 1.14 (95% CI 1.10–1.20, I2 = 0%, n = 3) per 10 cigarettes per day and 1.16 (95% CI 1.09–1.25, I2 = 49%, n = 2) per 10 pack-years and there was no evidence of a non-linear association for cigarettes per day, Pnon-linearity = 0.17.

Conclusions

The current meta-analysis suggests that smoking is associated with an increased risk of atrial fibrillation in a dose-dependent matter, but the association is weaker among former smokers compared to current smokers.

Cigarette Smoking and Incident Heart Failure: Insights From the Jackson Heart Study

BACKGROUND

Cigarette smoking has been linked with several factors associated with cardiac dysfunction. We hypothesized that cigarette smoking is associated with left ventricular (LV) structure and function, and incident heart failure (HF) hospitalization.

METHODS

We investigated 4129 (never smoker n=2884, current smoker n=503, and former smoker n=742) black participants (mean age, 54 years; 63% women) without a history of HF or coronary heart disease at baseline in the Jackson Heart Study. We examined the relationships between cigarette smoking and LV structure and function by using cardiac magnetic resonance imaging among 1092 participants, cigarette smoking and brain natriuretic peptide levels among 3325 participants, and incident HF hospitalization among 3633 participants with complete data.

RESULTS

After adjustment for confounding factors, current smoking was associated with higher mean LV mass index and lower mean LV circumferential strain (P<0.05, for both) in comparison with never smoking. Smoking status, intensity, and burden were associated with higher mean brain natriuretic peptide levels (all P<0.05). Over 8.0 years (7.7-8.0) median follow-up, there were 147 incident HF hospitalizations. After adjustment for traditional risk factors and incident coronary heart disease, current smoking (hazard ratio, 2.82; 95% confidence interval, 1.71-4.64), smoking intensity among current smokers (≥20 cigarettes/d: hazard ratio, 3.48; 95% confidence interval, 1.65-7.32), and smoking burden among ever smokers (≥15 pack-years: hazard ratio, 2.06; 95% confidence interval, 1.29-3.3) were significantly associated with incident HF hospitalization in comparison with never smoking.

CONCLUSIONS

In blacks, cigarette smoking is an important risk factor for LV hypertrophy, systolic dysfunction, and incident HF hospitalization even after adjusting for effects on coronary heart disease.

Qualitative coronary artery calcium assessment on CT lung screening exam helps predict first cardiac events

Results

A total of 1,513 individuals underwent CTLS. Downstream data, pre-test cardiac risk factors and CAC scores were available for 88.3% (1,336/1,513). The average length of follow-up was 2.64 (SD ±0.72) years. There were a total of 43 events, occurring in 1.55% (6/386) of patients with mild CAC, 3.24% (11/339) of patients with moderate CAC, and 8.90% (26/292) of patients with marked CAC. There were no events among patients with no reported CAC (0/319). Using multivariable logistic modeling, the increased odds of an initial cardiac event was 2.56 (95% CI, 1.76-3.92, P<0.001) for mild CAC, 6.57 (95% CI, 3.10-15.4, P<0.001) for moderate CAC, and 16.8 (95% CI, 5.46-60.3, P<0.001) for marked CAC, as compared to individuals with no CAC. Time to event analysis showed distinct differences among the four CAC categories (P<0.001).

Conclusions

Qualitative coronary artery calcification scoring of CTLS exams may provide a novel method to help select individuals at elevated risk for an initial cardiac event.

Low apolipoprotein A-I levels in Friedreich's ataxia and in frataxin-deficient cells: Implications for therapy

Friedreich's ataxia (FA) is an autosomal recessive neurodegenerative disorder, which results primarily from reduced expression of the mitochondrial protein frataxin. FA has an estimated prevalence of one in 50,000 in the population, making it the most common hereditary ataxia. Paradoxically, mortality arises most frequently from cardiomyopathy and cardiac failure rather than from neurological effects. Decreased high-density lipoprotein (HDL) and apolipoprotein A-I (ApoA-l) levels in the general population are associated with an increased risk of mortality from cardiomyopathy and heart failure. However, the pathophysiology of heart disease in FA is non-vascular and there are conflicting data on HDL-cholesterol in FA. Two studies have shown a decrease in HDL-cholesterol compared with controls and two have shown there was no difference between FA and controls. One also showed that there was no difference in serum Apo-A-I levels in FA when compared with controls. Using a highly specific stable isotope dilution mass spectrometry-based assay, we demonstrated a 21.6% decrease in serum ApoA-I in FA patients (134.8 mg/dL, n = 95) compared with non-affected controls (172.1 mg/dL, n = 95). This is similar to the difference in serum ApoA-I levels between non-smokers and tobacco smokers. Knockdown of frataxin by > 70% in human hepatoma HepG2 cells caused a 20% reduction in secreted ApoA-I. Simvastatin, a 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitor caused a 200% increase in HMG-CoA in the control HepG2 cells with a similar increase in the frataxin knockdown HepG2 cells, back to levels found in the control cells. There was a concomitant 20% increase in secreted ApoA-I to levels found in the control cells that were treated with simvastatin. This study provides compelling evidence that ApoA-I levels are reduced in FA patients compared with controls and suggest that statin treatment would normalize the ApoA-I levels.