Cigarette Smoking, Cessation, and Risk of Heart Failure With Preserved and Reduced Ejection Fraction

Airway organoids: 3D toxicology evaluation models in vitro of heated tobacco products for health risk

Cigarette smoking poses significant health risks, particularly to the airway, which consists predominantly of basal, club, and ciliated cells that are highly susceptible to damage from exogenous stimuli. Traditional in vitro toxicology relies on 2D cell cultures, which lack the structural complexity and functional relevance of airway architecture. As a novel category of tobacco products, the health implications of heated tobacco products (HTPs) remain largely unknown. To address this, 3D airway organoids were developed as a more physiologically relevant in vitro model for evaluating the toxicity of HTPs. Airway organoids derived from mouse lungs were induced to differentiate into various airway cell types and exposed to HTP aerosols. The exposure impaired organoid growth, reduced cell viability, and altered the proportions of secretory, basal, and ciliated cells, effectively replicating the complex cellular damage observed in vivo. Additionally, typical adverse outcomes, such as oxidative stress, inflammation, and genetic toxicity, were induced, paralleling findings from conventional 2D models. These results established the airway organoids as a viable alternative to animal testing for toxicological studies and offer critical insights into the respiratory health risks associated with HTPs.

Underpinnings of Heart Failure With Preserved Ejection Fraction in Women - From Prevention to Improving Function. A Co-publication With the American Journal of Preventive Cardiology and the Journal of Cardiac Failure

Heart failure with preserved ejection fraction (HFpEF) represents a major clinical challenge with rising global prevalence. Women have a nearly double lifetime risk of developing HFpEF compared to heart failure with reduced ejection fraction (HFrEF). In HFpEF, sex differences emerge both in how traditional cardiovascular risk factors (such as hypertension, obesity, and diabetes) affect cardiac function and through distinct pathophysiological mechanisms triggered by sex-specific events like menopause and adverse pregnancy outcomes. These patterns influence not only disease development, but also therapeutic responses, necessitating sex-specific approaches to treatment. This review aims to synthesize existing knowledge regarding HFpEF in women including traditional and sex-specific risk factors, pathophysiology, presentation, and therapies, while outlining important knowledge gaps that warrant further investigation. The impact of HFpEF spans a woman's entire lifespan, requiring prevention and management strategies tailored to different life stages. While understanding of sex-based differences in HFpEF has improved, significant knowledge gaps persist. Through examination of current evidence and challenges, this review highlights promising opportunities for innovative research, therapeutic development, and clinical care approaches that could transform the management of HFpEF in women.

Accelerometer-based sedentary time and physical activity with incident and progressive tobacco smoking in 2503 children: A 13-year mediation and temporal longitudinal study

BACKGROUND

Long-term accelerometer-based studies examining whether engaging in physical activity (PA) reduces the risk of smoking in children are lacking, and whether directly measured adiposity increases smoking risk is uncertain.

METHODS

From the Avon Longitudinal Study of Parents and Children (ALSPAC), UK birth cohort, 2503 children aged 11 years with complete smoking and at least one valid time-point movement behaviour data were followed up until age 24 years. ActiGraph assessed sedentary time (ST), light PA (LPA), and moderate-to-vigorous PA (MVPA) at ages 11, 15, and 24-year clinic visits and smoking-based questionnaires were administered, whilst fat mass was measured with dual-energy x-ray absorptiometry scanner. Data were analysed with generalized linear-mixed effect models with logit-links and structural equation models.

RESULTS

Mean [SD] age at baseline was 11.71 [0.20] years and the prevalence of smoking at ages 13, 15, and 24 years were 1.5%, 13.5%, and 26.6%, respectively. Higher MVPA at age 11 years was significantly associated with lower odds of smoking at age 13 years (odds ratio, 0.991; [95% CI, 0.983-0.999], P = 0.035). Cumulative MVPA during ages 11-24 years was significantly associated with lower odds of progressive smoking during growth from ages 13-24 years (0.992; [95% CI, 0.989-0.996], P < 0.001). Cumulative ST and LPA had no significant associations with smoking. Higher fat mass suppressed (10% suppression) the inverse relationship between MVPA and smoking. In path analysis, higher MVPA at age 15 years temporally preceded reduced smoking at age 24 years.

CONCLUSION

In the present study, engaging in MVPA from age 11 years may prevent 9 in 1000 children from starting smoking at the age of 13 years when smoking prevalence was 15 in 1000 children, i.e potentially preventing 60% of children from initiating smoking. However, the MVPA preventive approach diminished as children grew into young adults.

Association of serum 25-hydroxyvitamin D3 levels with carotid artery intima-media thickness and carotid atherosclerotic plaques in smokers

OBJECTIVE

This study explores the association of serum 25-hydroxyvitamin D3 (25(OH)D3) levels with carotid artery intima-media thickness (CIMT), and the presence of carotid atherosclerotic plaques in individuals with a history of smoking.

METHODS

A total of 469 patients suspected of having carotid atherosclerosis, aged 52 to 73 years with an average age of 65.26 ± 4.37 years, were recruited from the author's hospital from January 2023 to October 2023. All patients had a smoking history of nearly 5 years. Based on their serum 25(OH)D3 levels, they were divided into two groups: the normal group (serum level 30-50 ng/mL, n = 300) and the deficiency group (<30 ng/mL, n = 169). General details of the two patient groups were collected. Carotid artery ultrasound was employed to assess pulse wave velocity (PWV), carotid artery compliance coefficient (CC), and CIMT. Blood chemistry analysis measured serum lipid metabolism indicators including total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HD-LC). The relationship between CIMT and each variable was analyzed through Pearson correlation, and logistic regression was used to identify risk factors influencing carotid artery plaque development.

RESULTS

General patient information between the two groups showed no significant differences (P > 0.05). Patients in the 25(OH)D3 deficiency group exhibited elevated left and right PWV and CC compared to the 25(OH)D3 normal group (P < 0.05). The deficiency group exhibited larger CIMT and plaque area compared to the normal group (P < 0.05). Additionally, the deficiency group demonstrated higher levels of TC, LDL-C, and HD-LC compared to the normal group (P < 0.05). A moderate positive correlation was found between TC, LDL-C, and CIMT (P < 0.05), while a strong positive correlation existed between 25(OH)D3 and CIMT (P < 0.05). In smokers, the formation of carotid artery plaque was associated with factors such as patient age, CIMT, serum LDL-C, and 25(OH)D3 levels (P < 0.05). As age, CIMT, LDL-C levels increased, and 25(OH)D3 levels decreased, the risk of carotid plaques in smokers increased (P < 0.05).

CONCLUSIONS

Smokers with lower 25(OH)D3 levels exhibit higher CIMT and more prominent carotid atherosclerotic plaques, indicating increased arterial stiffness and elevated cardiovascular risk. These findings demonstrate crucial implications that insufficient levels of vitamin D may potentially contribute to a higher risk of atherosclerosis among smokers.

Network analysis of smoking-related sleep characteristics in Chinese adults

The associations between multiple sleep characteristics and smoking behavior are inconsistent, and it is unclear which sleep characteristics are most crucial for tobacco prevention. This study aimed to explore the associations between smoking status/intensity and multiple sleep characteristics and to identify the potential core domain of smoking-related sleep using network analysis. Data were obtained from a survey of cancer-related risk factors among Chinese adults. Logistic regression models were used to quantify the associations between sleep characteristics and smoking status/intensity. Network analyses were employed to identify the core sleep characteristics. A total of 5,228 participants with a median age of 44 years old were included in the study. Current smoking was significantly positively associated with long nap time, difficulty falling asleep, late bedtime, getting up after 7 am, and waking up earlier than expected. There was significant positive association between current smoking and short sleep duration in young adults under 45 years old. Late bedtime and getting up after 7 am were only associated with current heavy smoking, but not current light smoking. Network analyses showed that multiple smoking-related sleep characteristics were interconnected, with difficulty falling asleep and late bedtime as central characteristics in the network. The study found that the associations between sleep characteristics and smoking varied by age and smoking intensity and highlights the potential benefits of sleep health promotion in smoking cessation, with a particular focus on difficulty falling asleep and late bedtime.

Narrative Review of Heart Failure Related to Cocaine Consumption and Its Therapeutic Management

Background: Cocaine use can cause multiple cardiovascular complications, including heart failure. Aim: This general review of the literature delivers data on the relationship between cocaine consumption and the development of heart failure, as well as the elements of its diagnosis and management. Methods: A literature search was carried out using the PubMed, Web Of Science, and Google Scholar bibliographic databases over the period of 2007-2022 using the following keywords: "cocaine" AND "heart failure" NOT "acute heart disease". The exclusion criteria exempted studies carried out on animals, along with articles not written in English. Results and Discussion: A total of 27 articles (11 reviews, 10 clinical studies, 4 letters to the editor, and 2 clinical cases) were included. The prevalence of heart failure among cocaine users varies from one study to another (2.5%, 5.3%, 6.2%, or even 20%); however, when patients have a history of cocaine consumption, the prevalence of heart failure is higher than that ordinarily found in the young population (<0.1% to 0.5%). Cocaine consumption has a number of serious cardiotoxic effects that can lead to heart failure. According to the studies analysed, heart failure should be treated with beta-blockers, even in the event of long-term cocaine use, with a preference for carvedilol. Conclusions: Despite previous concerns about the use of beta-blockers in cocaine users, treatment with beta-blockers (particularly carvedilol) may actually result in measurable clinical improvement. Cocaine withdrawal remains essential for optimal treatment.

Up-to-date advance in the relationship between obstructive sleep apnea and heart failure: a narrative review

PURPOSE

Obstructive sleep apnea (OSA) is recognized as an independent and significant risk factor for various cardiovascular and cerebrovascular conditions, including heart failure (HF). In this review, we explore the impact of OSA on HF, examine shared contributing factors and underlying pathophysiological mechanisms, and assess the treatment options for OSA and their potential therapeutic value in HF patients.

METHODS

Pubmed/MEDLINE were searched through September 2024 to explore the relationship between OSA and HF. The relevant papers included OSA and HF, risk factors of OSA and HF, and the prognosis and treatment of HF patients with OSA.

RESULTS

The results showed that OSA increased the risk of HF. OSA can exacerbate or contribute to the onset of HF in several ways. The application of continuous positive airway pressure (CPAP) and other treatments may benefit HF patients with OSA. Drug therapy has shown promise for treating OSA, extensive multi-center studies remain essential, particularly in patients with both OSA and HF.

CONCLUSION

OSA can exacerbate or contribute to the onset and recurrence of HF in several ways. Further studies should be carried out to explore effective treatments in patients with HF and OSA.

The Impact of Metabolic Syndrome on Heart Failure in Young Korean Population: A Nationwide Study

Limited data are available regarding the effect of metabolic syndrome on heart failure (HF) development in young individuals. Utilizing data from the Korean National Health Insurance Service, we included a total of 1,958,284 subjects in their 40s who underwent health screening between January 2009 and December 2009 in Korea. Subjects were classified into three groups: normal, pre-metabolic syndrome (Pre-MetS), and metabolic syndrome (MetS). MetS was identified in 10.58% of males and 5.21% of females. The hazard ratio for HF in subjects with MetS was 1.968 (95% CI: 1.526-2.539) for males and 2.398 (95% CI: 1.466-3.923) for females. For those with Pre-MetS, the hazard ratio was 1.607 (95% CI: 1.293-1.997) in males and 1.893 (95% CI: 1.43-2.505) in females. Additionally, acute myocardial infarction and low hemoglobin levels were identified as significant risk factors for HF in both genders. MetS approximately doubled the risk of developing HF in individuals in their 40s. Pre-MetS was also a significant risk factor for HF in this population.

Risk factors for tachycardia-induced cardiomyopathy due to atrial fibrillation

BACKGROUND

Tachycardia-induced cardiomyopathy (TIC) is a reversible cardiomyopathy with ventricular dysfunction caused by tachyarrhythmias. Notably, atrial fibrillation (AF) is the most common causal arrhythmia leading to TIC. However, the risk factors for the development of TIC due to AF remain unclear. This study aimed to identify the associated factors of TIC due to AF.

METHODS

Persistent AF patients with heart rate (HR) ≥100 beats per minute who underwent initial catheter ablation were enrolled in this study. TIC was diagnosed as left ventricular ejection fraction (LVEF) < 50% during AF rhythm, which was recovered after the restoration of sinus rhythm. Non-TIC was defined as LVEF ≥ 50% despite AF rhythm. The patient backgrounds were compared between the TIC group and the non-TIC group to reveal the contributing factors of TIC.

RESULTS

The TIC group comprised 57 patients, while the non-TIC group consisted of 101 patients. The TIC group was younger than the non-TIC group (median 64 vs. 70, p = 0.006). Male sex was more frequent in the TIC group than the non-TIC group (82.5% vs. 58.4%, p = 0.003). HR was higher in the TIC group than in the non-TIC group (median 130 bpm vs. 111 bpm, p < 0.001). The number of smokers was significantly higher in the TIC group than in the non-TIC group (p < 0.001). Multivariable analysis demonstrated that higher HR (odds ratio [OR]: 1.74; 95% confidence interval [CI]: 1.37-2.21; p < 0.001) and current smokers (OR: 5.27; 95% CI: 1.60-17.4; p = 0.006) were the independent factors leading to TIC.

CONCLUSION

Higher HR and current smokers were independent risk factors for the development of TIC due to AF.

HFpEF and sex: understanding the role of sex differences

Heart failure is a complex clinical syndrome with many etiological factors and complex pathophysiology affecting millions worldwide. Males and females can have distinct clinical presentation and prognosis, and there is an emerging understanding of the factors that highlight the similarities and differences to synthesize and present available data for sex-specific differences in heart failure with preserved ejection fraction (HFpEF). While the majority of data demonstrate more similarities than differences between females and males in terms of heart failure, there are key differences. Data showed that females have a higher risk of developing HFpEF, but a lower risk of mortality and hospitalization. This can be conditioned by different profiles of comorbidities, postmenopausal changes in sex hormone levels, higher levels of inflammation and chronic microvascular dysfunction in females. These factors, combined with different left ventricular dimensions and function, which are more pronounced with age, lead to a higher prevalence of LV diastolic dysfunction at rest and exercise. As a result, females have lower exercise capacity and quality of life when compared to males. Females also have different activities of systems responsible for drug transformation, leading to different efficacy of drugs as well as higher risk of adverse drug reactions. These data prove the necessity for creating sex-specific risk stratification scales and treatment plans.

Cardiac diastolic dysfunction by cigarette smoking is associated with mitochondrial integrity in the heart

Cigarette smoking behaviors are harmful and cause one out of ten deaths due to cardiovascular disease. As population sizes grow and number of cigarette smokers increases, it is vital that we understand the mechanisms leading to heart failure in cigarette smokers. We have reported that metabolic regulation of a histone deacetylase, SIRT1, modulates cardiovascular and mitochondrial function under stress. Given this conclusion, we hypothesized that chronic cigarette smoking led to cardiovascular dysfunction via a reduction SIRT1. Mice were randomly organized into smoking or nonsmoking groups, and the smoking group received cigarette smoke exposure for 16 weeks. Following 16-week exposure, diastolic function of the heart was impaired in the smoking group as compared to sham, indicated by a significant increase in E/e'. The electrical function of the heart was also impaired in the smoking group compared to the sham group, indicated by increased PR interval and decreased QTc interval. This diastolic dysfunction was not accompanied by increased fibrosis in mouse hearts, although samples from human chronic smokers indicated increased fibrosis compared to their nonsmoker counterparts. As well as diastolic dysfunction, mitochondria from the 16-week smoking group showed significantly impaired function, evidenced by significant decreases in all parameters measured by the mitochondrial stress test. We further found biochemical evidence of a significantly decreased level of SIRT1 in left ventricles of both mouse and human smoking groups compared to nonsmoking counterparts. Data from this study indicate that decreased SIRT1 levels by cigarette smoking are associated with diastolic dysfunction caused by compromised mitochondrial integrity.

LDHA contributes to nicotine induced cardiac fibrosis through autophagy flux impairment

Cardiac fibrosis is a typical feature of cardiac pathological remodeling, which is associated with adverse clinical outcomes and has no effective therapy. Nicotine is an important risk factor for cardiac fibrosis, yet its underlying molecular mechanism remains poorly understood. This study aimed to identify its potential molecular mechanism in nicotine-induced cardiac fibrosis. Our results showed nicotine exposure led to the proliferation and transformation of cardiac fibroblasts (CFs) into myofibroblasts (MFs) by impairing autophagy flux. Through the use of drug affinity responsive target stability (DARTS) assay, cellular thermal shift assay (CETSA), and surface plasmon resonance (SPR) technology, it was discovered that nicotine directly increased the stability and protein levels of lactate dehydrogenase A (LDHA) by binding to it. Nicotine treatment impaired autophagy flux by regulating the AMPK/mTOR signaling pathway, impeding the nuclear translocation of transcription factor EB (TFEB), and reducing the activity of cathepsin B (CTSB). In vivo, nicotine treatment exacerbated cardiac fibrosis induced in spontaneously hypertensive rats (SHR) and worsened cardiac function. Interestingly, the absence of LDHA reversed these effects both in vitro and in vivo. Our study identified LDHA as a novel nicotine-binding protein that plays a crucial role in mediating cardiac fibrosis by blocking autophagy flux. The findings suggest that LDHA could potentially serve as a promising target for the treatment of cardiac fibrosis.

Highlighting the South Asian Heart Failure Epidemic

Heart failure (HF) remains a progressive syndrome with high morbidity and mortality, and accounts for many hospitalisations globally with a downstream impact of increasing healthcare costs. South Asian individuals account for most of the global burden of non-communicable diseases. In this systematic review, a literature search was performed for all studies focusing on South Asians and HF using PubMed as the primary research tool and citations were included from relevant MEDLINE-indexed journals. Upon identification of relevant studies, pertinent data points were extracted systematically from each eligible study. South Asians have an earlier age of onset of many non-communicable diseases compared to other ethnic groups worldwide, including cardiovascular disease (CVD). Given the large number of South Asians impacted by CVD and both traditional and non-traditional risk factors for CVD, HF has the potential to become an epidemic among South Asians across the world. Individuals of South Asian origin are at elevated risk for CVD compared to many other populations and should be followed closely for the potential development of HF. This review describes what is unique to South Asian individuals at risk for and with established HF, as well as management and prognostic considerations. Future directions and potential policy changes are highlighted that can reduce the HF burden among South Asians globally.

Assessing the predictive value of the controlling nutritional status score on all-cause mortality during hospitalization in patients with acute decompensated heart failure: a retrospective cohort study from Jiangxi, China

Objective

Nutritional status is closely associated with the prognosis of heart failure. This study aims to assess the relationship between the Controlling Nutritional Status (CONUT) score and in-hospital mortality among patients with acute decompensated heart failure (ADHF) in Jiangxi, China.

Methods

A retrospective cohort study was conducted. Multivariable Cox regression models and restricted cubic spline regression were employed to evaluate the relationship between the CONUT score and in-hospital mortality in ADHF patients from Jiangxi, China. The predictive value of the CONUT score for in-hospital mortality in ADHF patients was analyzed using receiver operating characteristic curves. Subgroup analyses were performed to identify risk dependencies of the CONUT score in specific populations.

Results

The study included 1,230 ADHF patients, among whom 44 (3.58%) mortality events were recorded. After adjusting for confounding factors, a positive correlation was found between the CONUT score and the risk of in-hospital mortality in ADHF patients. Restricted cubic spline regression analysis indicated a non-linear relationship between the CONUT score and the risk of in-hospital mortality in ADHF patients, estimating a rapid increase in mortality risk when the CONUT score exceeded 5. Receiver operating characteristic analysis demonstrated a good predictive value of the CONUT score for all-cause mortality events in ADHF patients [area under the curve = 0.7625, optimal threshold = 5.5]. Additionally, a relatively higher risk associated with the CONUT score was observed in male patients and those with concomitant cerebral infarction.

Conclusion

This study reveals a positive correlation between the CONUT score and the risk of in-hospital mortality in ADHF patients. Based on the findings of this study, we recommend maintaining a CONUT score below 5 for patients with ADHF in Jiangxi, China, as it may significantly contribute to reducing the risk of in-hospital all-cause mortality.

Relationship between ω3 and ω6 polyunsaturated fatty acids and atrial fibrillation in acute ischemic stroke

BACKGROUND & AIMS

Some ω3 polyunsaturated fatty acids (PUFAs) are said to demonstrate a dose-related risk of atrial fibrillation (AF), conversely, some ω6 PUFAs might have AF protective potential. However, few investigated the relation among ischemic strokes. Primarily, we aimed to examine a relation between ω3 and ω6 PUFAs and the presence of AF in ischemic strokes. Further, since, some PUFAs are said to affect the cardiac load, we secondarily aimed to investigate the association between ω3 and ω6 PUFAs and brain natriuretic peptide (BNP) and the occurrence of cerebral large vessel occlusion (LVO) in ischemic strokes with AF.

METHODS

Consecutive patients with ischemic stroke admitted between 2012 and 2022 were retrospectively screened. Plasma levels of PUFAs, including eicosapentaenoic acid (EPA), docosahexaenoic acid, dihomo-γ-linolenic acid (DGLA) and arachidonic acid (AA), were assayed. Data were analyzed using a Poisson regression analysis with a robust variance estimator and a multiple linear regression analysis.

RESULTS

We screened 2112 consecutive ischemic strokes, including 1574 (1119 [71%] males, median age 69 years). Lower DGLA (prevalence ratio (PR) 0.885, 95% CI 0.811-0.966, p = 0.006), lower AA (PR 0.797, 95% CI 0.649-0.978, p = 0.030), and higher EPA/AA ratio (PR 1.353, 95% CI 1.036-1.767, p = 0.026) were associated with AF. Checking the linearity between AF and PUFAs, negative linear trends were observed between DGLA quartiles (Q1: PR 1.901, Q2: PR 1.550, Q3: PR 1.423, Q4: 1.000, p < 0.001 for trend) and AA quartiles (Q1: PR 1.499, Q2: PR 1.204, Q3: PR 1.125, Q4: 1.000, p = 0.004 for trend), with positive linear trends between EPA/AA ratio quartiles (Q1: 1.000, Q2: PR 1.555, Q3: PR 1.612, Q4: PR 1.797, p = 0.001 for trend). Among patients with AF, a negative association between AA and BNP (unstandardized coefficient -1.316, 95% CI -2.290∼-0.342, p = 0.008) was observed, and lower AA was associated with LVO (PR 0.707, 95% CI 0.527-0.950, p = 0.021).

CONCLUSION

Lower DGLA and AA and a higher EPA/AA ratio might be related to the development of AF in ischemic strokes. Further, AA might have a cardio-cerebrovascular protective role in ischemic strokes with AF.

Pulmonary Hypertension and Survival among Non-Small Cell Lung Cancer Patients: A Retrospective Cohort Study in the U.S. Military Health System

Background: Lung cancer is one of the most lethal cancers with survival being closely related to stage and influenced by comorbid illness. The survival implications of pulmonary hypertension (PH) on patients with non-small cell lung cancer (NSCLC) have only been evaluated in small cohorts, with limited long-term follow-up. Methods: We conducted a retrospective cohort study of 7946 patients with NSCLC diagnosed in the MHS. This study evaluated the survival impact of PH in patients diagnosed with NSCLC in the MHS. Patients were classified as having and not having PH. We stratified PH into those diagnosed before the diagnosis of NSCLC and those diagnosed after NSCLC diagnosis. Results: Relative to patients without PH, patients with PH diagnosed before NSCLC had an increased risk of death (HR = 1.15 [95% CI, 1.02-1.29]). The increased risk of death was more obvious for patients with PH diagnosed after NSCLC compared with those without PH (HR = 2.74 [95% CI, 2.51-2.99]). The results were similar when stratified by patient demographics. Conclusions: In the MHS, PH is associated with worsened NSCLC survival, regardless of when it is diagnosed. When PH is diagnosed after NSCLC, it is associated with a marked reduction in survival, and this finding may suggest a potential role for monitoring pulmonary pressures in NSCLC patients. Furthermore, as specific PH therapy exists, some NSCLC patients with PH may be candidates for therapy.

Degree of Risk Factor Control and Incident Cardiovascular Diseases in Patients With Hypertension

OBJECTIVE

To investigate whether joint risk factor control could reduce the excess risk of cardiovascular disease (CVD) in patients with hypertension.

PATIENTS AND METHODS

A total of 75,293 patients with diagnosed hypertension from the UK Biobank study were included, matched with 256,619 nonhypertensive controls, and followed up until May 31, 2021. Seven risk factors were measured to define joint risk factor control, including blood pressure, body mass index, low-density lipoprotein cholesterol, hemoglobin A1c, albuminuria, smoking, and physical activity.

RESULTS

Among hypertensive patients, 14% to 24% lower risks of CVD outcomes were associated with each additional risk factor control. In the Cox proportional hazards models, adjusted hazard ratios for patients with 6 or more risk factor controls compared with patients having 2 or less risk factor controls were 0.49 (95% CI, 0.45 to 0.55) for CVD, 0.51 (95% CI, 0.45 to 0.57) for coronary heart disease, 0.48 (95% CI, 0.38 to 0.60) for stroke, and 0.34 (95% CI, 0.26 to 0.44) for CVD mortality. The excess risks of CVD outcomes in patients with hypertension were diminished to nonsignificant or even lower compared with controls if achieving 6 or more risk factor controls. Men experienced stronger protective associations of joint risk factor control on risks of CVD than women (P<.001 for interaction).

CONCLUSION

The joint risk factor control is associated with lower risks of CVD, and a high degree of risk factor control may considerably attenuate the excess risk of CVD among patients with hypertension.

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.

Prioritizing the primary prevention of heart failure: Measuring, modifying and monitoring risk

With the rising incidence of heart failure (HF) and increasing burden of morbidity, mortality, and healthcare expenditures, primary prevention of HF targeting individuals in at-risk HF (Stage A) and pre-HF (Stage B) Stages has become increasingly important with the goal to decrease progression to symptomatic (Stage C) HF. Identification of risk based on traditional risk factors (e.g., cardiovascular health which can be assessed with the American Heart Association's Life's Essential 8 framework), adverse social determinants of health, inherited risk of cardiomyopathies, and identification of risk-enhancing factors, such as patients with viral disease, exposure to cardiotoxic chemotherapy, and history of adverse pregnancy outcomes should be the first step in evaluation for HF risk. Next, use of guideline-endorsed risk prediction tools such as Pooled Cohort Equations to Prevent Heart Failure provide quantification of absolute risk of HF based in traditional risk factors. Risk reduction through counseling on traditional risk factors is a core focus of implementation of prevention and may include the use of novel therapeutics that target specific pathways to reduce risk of HF, such as mineralocorticoid receptor agonists (e.g., fineronone), angiotensin-receptor/neprolysin inhibitors, and sodium glucose co-transporter-2 inhibitors. These interventions may be limited in at-risk populations who experience adverse social determinants and/or individuals who reside in rural areas. Thus, strategies like telemedicine may improve access to preventive care. Gaps in the current knowledge base for risk-based prevention of HF are highlighted to outline future research that may target approaches for risk assessment and risk-based prevention with the use of artificial intelligence, genomics-enhanced strategies, and pragmatic trials to develop a guideline-directed medical therapy approach to reduce risk among individuals with Stage A and Stage B HF.

Lung cancer diagnosis and mortality beyond 15 years since quit in individuals with a 20+ pack-year history: A systematic review

Current US lung cancer screening recommendations limit eligibility to adults with a pack-year (PY) history of ≥20 years and the first 15 years since quit (YSQ). The authors conducted a systematic review to better understand lung cancer incidence, risk and mortality among otherwise eligible individuals in this population beyond 15 YSQ. The PubMed and Scopus databases were searched through February 14, 2023, and relevant articles were searched by hand. Included studies examined the relationship between adults with both a ≥20-PY history and ≥15 YSQ and lung cancer diagnosis, mortality, and screening ineligibility. One investigator abstracted data and a second confirmed. Two investigators independently assessed study quality and certainty of evidence (COE) and resolved discordance through consensus. From 2636 titles, 22 studies in 26 articles were included. Three studies provided low COE of elevated lung cancer incidence beyond 15 YSQ, as compared with people who never smoked, and six studies provided moderate COE that the risk of a lung cancer diagnosis after 15 YSQ declines gradually, but with no clinically significant difference just before and after 15 YSQ. Studies examining lung cancer-related disparities suggest that outcomes after 15 YSQ were similar between African American/Black and White participants; increasing YSQ would expand eligibility for African American/Black individuals, but for a significantly larger proportion of White individuals. The authors observed that the risk of lung cancer not only persists beyond 15 YSQ but that, compared with individuals who never smoked, the risk may remain significantly elevated for 2 or 3 decades. Future research of nationally representative samples with consistent reporting across studies is needed, as are better data from which to examine the effects on health disparities across different populations.

Comparative effect of varenicline and nicotine patches on preventing repeat cardiovascular events

OBJECTIVE

To determine the comparative effectiveness of postdischarge use of varenicline versus prescription nicotine replacement therapy (NRT) patches for the prevention of recurrent cardiovascular events and mortality and whether this association differs by sex.

METHODS

Our cohort study used routinely collected hospital, pharmaceutical dispensing and mortality data for residents of New South Wales, Australia. We included patients hospitalised for a major cardiovascular event or procedure 2011-2017, who were dispensed varenicline or prescription NRT patches within 90day postdischarge. Exposure was defined using an approach analogous to intention to treat. Using inverse probability of treatment weighting with propensity scores to account for confounding, we estimated adjusted HRs for major cardiovascular events (MACEs), overall and by sex. We fitted an additional model with a sex-treatment interaction term to determine if treatment effects differed between males and females.

RESULTS

Our cohort of 844 varenicline users (72% male, 75% <65 years) and 2446 prescription NRT patch users (67% male, 65% <65 years) were followed for a median of 2.93 years and 2.34 years, respectively. After weighting, there was no difference in risk of MACE for varenicline relative to prescription NRT patches (aHR 0.99, 95% CI 0.82 to 1.19). We found no difference (interaction p=0.098) between males (aHR 0.92, 95% CI 0.73 to 1.16) and females (aHR 1.30, 95% CI 0.92 to 1.84), although the effect among females deviated from the null.

CONCLUSION

We found no difference between varenicline and prescription NRT patches in the risk of recurrent MACE. These results should be considered when determining the most appropriate choice of smoking cessation pharmacotherapy.

Opportunities and Challenges of Kava in Lung Cancer Prevention

Lung cancer is the leading cause of cancer-related deaths due to its high incidence, late diagnosis, and limited success in clinical treatment. Prevention therefore is critical to help improve lung cancer management. Although tobacco control and tobacco cessation are effective strategies for lung cancer prevention, the numbers of current and former smokers in the USA and globally are not expected to decrease significantly in the near future. Chemoprevention and interception are needed to help high-risk individuals reduce their lung cancer risk or delay lung cancer development. This article will review the epidemiological data, pre-clinical animal data, and limited clinical data that support the potential of kava in reducing human lung cancer risk via its holistic polypharmacological effects. To facilitate its future clinical translation, advanced knowledge is needed with respect to its mechanisms of action and the development of mechanism-based non-invasive biomarkers in addition to safety and efficacy in more clinically relevant animal models.

Editor-in-Chief's Top Picks From 2022

Each week, I record audio summaries for every paper in JACC, as well as an issue summary. This process has become a true labor of love due to the time they require, but I am motivated by the sheer number of listeners (16 million plus), and it has allowed me to familiarize myself with every paper that we publish. Thus, I have selected the top 100 papers (both Original Investigations and Review Articles) from distinct specialties each year. In addition to my personal choices, I have included papers that have been the most accessed or downloaded on our websites, as well as those selected by the JACC Editorial Board members. In order to present the full breadth of this important research in a consumable fashion, we will present these abstracts in this issue of JACC, as well as their Central Illustrations and podcasts. The highlights comprise the following sections: Basic & Translational Research, Cardiac Failure & Myocarditis, Cardiomyopathies & Genetics, Cardio-Oncology, Congenital Heart Disease, Coronary Disease & Interventions, Coronavirus, Hypertension, Imaging, Metabolic & Lipid Disorders, Neurovascular Disease & Dementia, Promoting Health & Prevention, Rhythm Disorders & Thromboembolism, and Valvular Heart Disease.^1-100.

Interaction of HSP70-2 gene polymorphism with body mass index and alcohol consumption on the prognosis of Uyghur patients with ischemic heart failure

OBJECTIVES

To investigate the interaction of HSP70-2 gene polymorphism with body mass index (BMI) and alcohol consumption on the prognosis of Uyghur patients with ischemic heart failure (IHF).

METHODS

A total of 205 Uyghur patients with IHF admitted in Urumqi Friendship Hospital from June 2014 to June 2017 were enrolled; 200 age and sex-matched healthy Uyghur physical examiners in the hospital were enrolled as healthy controls. The HSP70-2 gene +1267 polymorphism was detected by PCR. Multivariate unconditional logistic regression was used to analyze the risk factors associated with prognosis in patients with IHF, and the relative excess risk of interaction (RERI) was calculated by crossover analysis to determine the interaction of HSP70-2 gene polymorphism with BMI and alcohol consumption.

RESULTS

Patients were followed up for 3 years, there were 56 cases with poor prognosis (27.32%) and 149 cases with good prognosis (72.68%). Compared with the healthy control group and the good prognosis group, the poor prognosis group had a significantly higher proportion of subjects with alcohol consumption, abnormal alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels as well as lower BMI and left ventricular ejection fraction (all P<0.05). There were significant differences in distributions of HSP70-2 genotype AA/AG/GG and A/G allele between the good prognosis group and the poor prognosis group (both P<0.05). There were significant differences in the distribution of HSP70-2 genotype (χ2=45.42, P<0.01) and A/G allele among IHF patients with different NYHA cardiac function class; the frequency of A allele of HSP70-2 gene increased, and G allele decreased with the increase of cardiac function class (χ2=19.14, P<0.01). Multivariate logistic regression analysis showed that alcohol consumption as well as abnormal ALT and AST were risk factors for poor prognosis in patients with IHF, while BMI and GG type of HSP70-2 gene (compared with AA type) were protective factors (all P<0.05). Crossover analysis showed a significant additive interaction between BMI and HSP70-2 gene polymorphism (RERI=1.15, 95%CI: 0.54-1.76, P<0.01), and for patients carrying HSP70-2 gene type AA/AG, BMI<26.5 kg/m2 increased the risk of poor prognosis (OR=7.47, 95%CI: 2.51-22.22, P<0.01); there was no significant additive interaction between alcohol consumption and HSP70-2 gene polymorphism (RERI=0.56, 95%CI: －6.07-7.20, P>0.05).

CONCLUSIONS

The HSP70-2 gene polymorphism interacts with BMI in Uyghur IHF patients, and BMI<26.5 kg/m2 increases the risk of poor prognosis in IHF patients carrying the HSP70-2 AA/AG genotype.

Degree of Joint Risk Factor Control and Incident Heart Failure in Hypertensive Patients

BACKGROUND

Heart failure (HF) is a major complication in patients with hypertension.

OBJECTIVES

This study aimed to investigate the extent to which joint risk factor control could attenuate hypertension-related excess risk of HF.

METHODS

The study included a total of 75,293 participants with diagnosed hypertension from the UK Biobank and matched with 256,619 nonhypertensive control subjects, followed up until May 31, 2021. The degree of joint risk factor control was assessed on the basis of the major cardiovascular risk factors, including blood pressure, body mass index, low-density lipoprotein cholesterol, hemoglobin A1c, albuminuria, smoking, and physical activity. The Cox proportional hazards models were used to estimate associations between the degree of risk factor control and risk of HF.

RESULTS

Among hypertensive patients, joint risk factor control showed an association with a stepwise reduction of incident HF risk. Each additional risk factor control was related to a 20% lower risk, and the optimal risk factor control (controlling ≥6 risk factors) was associated with a 62% lower risk (HR: 0.38; 95% CI: 0.31-0.45). In addition, the study found that the hypertension-related excess risk of HF among participants jointly controlling ≥6 risk factors were even lower than in nonhypertensive control subjects (HR: 0.79; 95% CI: 0.67-0.94). The protective associations of joint risk factor control and risk of incident HF were broadly stronger among men than women and among medication users than nonusers (P for interaction < 0.05).

CONCLUSIONS

The joint risk factor control is associated with a lower risk of incident HF in an accumulative and sex-specific manner. Optimal risk factor control may eliminate hypertension-related excess risk of HF.

Uptake of prescription smoking cessation pharmacotherapies after hospitalization for major cardiovascular disease

AIMS

We determined the prevalence of prescription smoking cessation pharmacotherapy (SCP) use after hospitalization for major cardiovascular disease (MCD) among people who smoke and whether this varies by sex.

METHODS AND RESULTS

We conducted a population-based cohort study including all people hospitalized in New South Wales, Australia, between July 2013 and December 2018 (2017 for private hospitals) with an MCD diagnosis. For patients who also had a diagnosis of current tobacco use, we used linked pharmaceutical dispensing records to identify prescription SCP dispensings within 90 days post-discharge. We determined the proportion who were dispensed an SCP within 90 days, overall and by type of SCP. We used logistic regression to estimate the odds of females being dispensed an SCP relative to males. Of the 150 758 patients hospitalized for an MCD, 20 162 (13.4%) had a current tobacco use diagnosis, 31% of whom were female. Of these, 11.3% (12.4% of females, 10.9% of males) received prescription SCP within 90 days post-discharge; 3.0% were dispensed varenicline, and 8.3% were dispensed nicotine replacement therapy patches. Females were more likely than males to be dispensed a prescription SCP [odds ratio (OR) 1.16, 95% confidence interval (CI) 1.06-1.27)]; however, this was not maintained after adjusting for potential confounders (adjusted OR 1.04, 95% CI 0.94-1.15).

CONCLUSION

Very few females and males who smoke use prescription SCPs after hospitalization for an MCD. The use of varenicline, the SCP with the highest efficacy, was particularly low. This represents a missed opportunity to increase smoking cessation in this high-risk population, thereby reducing their risk of recurrent cardiovascular events.

Nicotine and novel tobacco products drive adverse cardiac remodeling and dysfunction in preclinical studies

Background

The heart undergoes structural and functional changes in response to injury and hemodynamic stress known as cardiac remodeling. Cardiac remodeling often decompensates causing dysfunction and heart failure (HF). Cardiac remodeling and dysfunction are significantly associated with cigarette smoking. Although cigarette smoking has declined, the roles of nicotine and novel tobacco products (including electronic cigarettes and heat-not-burn tobacco) in cardiac remodeling are unclear. In this perspective, we present evidence demonstrating maladaptive cardiac remodeling in nicotine-exposed mice undergoing hemodynamic stress with angiotensin (Ang)-II infusion and review preclinical literature linking nicotine and novel tobacco products with cardiac remodeling and dysfunction.

Methods

Adult, male C57BL/6J mice were exposed to room air or chronic, inhaled nicotine for 8 weeks. A subset of mice was infused with Ang-II via subcutaneous osmotic mini-pumps during the final 4 weeks of exposure. Left ventricular structure and function were assessed with echocardiography.

Results

Chronic, inhaled nicotine abrogated Ang-II-induced thickening of the left ventricular posterior wall, leading to reduced relative wall thickness. Ang-II infusion was associated with increased left ventricular mass index in both air- and nicotine-exposed mice.

Conclusions

These changes suggest a phenotypic shift from concentric hypertrophy to eccentric hypertrophy in nicotine-exposed, hemodynamically-stressed mice which could drive HF pathogenesis. These findings join a growing body of animal studies demonstrating cardiac remodeling and dysfunction following nicotine and electronic cigarette exposure. Further exploration is necessary; however, clinicians and researchers should not overlook these emerging products as potential risk factors in the pathogenesis of cardiac remodeling and associated diseases including HF.