Smoking and vascular risk: are all forms of smoking harmful to all types of vascular disease?

A Retrospective Cohort Study That Examined the Impact of Cannabis Consumption on Long-Term Kidney Outcomes

Background: Cannabis consumption for recreational and medical use is increasing worldwide. However, the long-term effects on kidney health and disease are largely unknown. Materials and Methods: Post hoc analysis of cannabis use as a risk factor for kidney disease was performed using data from the Assessment, Serial Evaluation, and Subsequent Sequelae of Acute Kidney Injury (ASSESS-AKI) study that enrolled hospitalized adults with and without acute kidney injury from four U.S. centers during 2009-2015. Associations between self-reported cannabis consumption and the categorical and continuous outcomes were determined using multivariable Cox regression and linear mixed models, respectively. Results: Over a mean follow-up of 4.5±1.8 years, 94 participants without chronic kidney disease (CKD) (estimated glomerular filtration rate [eGFR] >60 mL/min/1.73 m2) who consumed cannabis had similar rates of annual eGFR decline versus 889 nonconsumers (mean difference=-0.02 mL/min/1.73 m2/year, p=0.9) and incident CKD (≥25% reduction in eGFR compared with the 3-month post-hospitalization measured eGFR and achieving CKD stage 3 or higher) (adjusted hazard ratio [aHR]=1.2; 95% confidence interval [CI]=0.7-2.0). Nineteen participants with CKD (eGFR <60 mL/min/1.73 m2) who consumed cannabis had more rapid eGFR decline versus 597 nonconsumers (mean difference=-1.3 mL/min/1.73 m2/year; p=0.02) that was not independently associated with an increased risk of CKD progression (≥50% reduction in eGFR compared with the 3-month post-hospitalization eGFR, reaching CKD stage 5, or receiving kidney replacement therapy) (aHR=1.6; 95% CI=0.7-3.5). Cannabis consumption was not associated with the rate of change in urine albumin to creatinine ratio (UACR) over time among those with (p=0.7) or without CKD (p=0.4). Conclusions: Cannabis consumption did not adversely affect the kidney function of participants without CKD but was associated with a faster annual eGFR decline among participants with CKD. Cannabis consumption was not associated with changes in UACR over time, incident CKD, or progressive CKD regardless of baseline kidney function. Additional research is needed to investigate the kidney endocannabinoid system and the impact of cannabis use on kidney disease outcomes.

Perceived message effectiveness of cigar warning themes among adults in the United States

Most tobacco warnings focus on health harms to the consumer, but other message themes may be promising. We assessed perceived message effectiveness (PME) among adults who smoke cigars for 12 cigar warning statements to discourage smoking, and measured PME across four message themes: explicit health effects to the consumer, secondhand smoke effects, chemicals/constituents, and toxicity. Between April 23 and May 7, 2020, we conducted an online study with U.S. adults who used any cigar type in the past 30 days (n = 777). Participants were randomly assigned to view two out of 12 warnings and rate each one on PME. We analyzed PME mean ratings (range 1 [low] to 5 [high]). The warning statements for lung cancer (M = 3.91) and heart disease (M = 3.77) had the highest PME ratings; secondhand smoke (M = 3.50) and formaldehyde (M = 3.48) had the lowest PME ratings. Multilevel analyses showed that the explicit health effects theme was associated with higher PME ratings compared to other warning themes (ps < 0.05 for chemicals/constituents and secondhand smoke effects) except toxicity (p =.16). Higher awareness of consequences was associated with higher PME ratings (p <.001). Higher nicotine dependence was also associated with higher PME ratings (p = .004). Warning statements with information addressing the themes of health harms and toxicity could potentially inform those who smoke cigars about the broader harms of cigar use and should be considered in FDA labeling regulations for cigars.

Risk factors for hippocampal cavities in a marginally housed population

Cavities in the hippocampus are morphological variants of uncertain significance. Aberrant neurodevelopment along with vascular and inflammatory etiologies have been proposed. We sought to characterize these cavities and their potential risk factors in a marginally housed population, with high rates of viral infection, addiction, and mental illness. (1) The volume of hippocampal cavities (HCavs) is greater in this highly multimorbid population compared to the general population. (2) Conventional vascular risk factors such as greater age and systolic blood pressure are associated with higher HCav volume. (3) Nonprescribed substance-related risk factors such as stimulant use or dependence, and smoking are associated with increased HCav volume independent of vascular risk factors. This is a retrospective analysis of an ongoing prospective study. We analyzed baseline data, including medical history, physical exam, psychiatric diagnosis, and MRI from a total of 375 participants. Hippocampal cavities were defined as spaces isointense to CSF on T1 MRI sequences, bounded on all sides by hippocampal tissue, with a volume of at least 1 mm³ . Risk factors were evaluated using negative binomial multiple regression. Stimulant use was reported by 87.3% of participants, with stimulant dependence diagnosed in 83.3% of participants. Prevalence of cavities was 71.6%, with a mean total bilateral HCav volume of 13.89 mm³ . On average, a 1 mmHg greater systolic blood pressure was associated with a 2.17% greater total HCav volume (95% CI = [0.57%, 3.79%], p = .0076), while each cigarette smoked per day trended toward a 2.69% greater total HCav volume (95% CI = [-0.87%, 5.54%], p = .058). A diagnosis of stimulant dependence was associated with a 95.6% greater total HCav volume (95% CI = [5.39%, 263.19%], p = .0335). Hypertension and diagnosis of stimulant dependence were associated with a greater total volume of HCav.

Invited Discussion on: "The Effect of Smoking on Septoplasty and Septorhinoplasty Outcomes"

Drs. Erol and Koycu's manuscript entitled, "The Effect of Smoking on Septoplasty and Septorhinoplasty Outcomes" suggests that septoplasty and septorhinoplasty can be performed on patients who actively smoke with comparable results to non-smokers in terms of function, complications, and rates of revision. Still, many surgeons advise or require their patients to cease smoking before undergoing elective surgery. Smoking cessation's benefits center upon maintaining overall health and may indicate a patient's ability to follow postoperative instructions. Accordingly, it is uncertain if there will be an increase in surgeons offering these operations to active smokers.

Secondhand smoke exposure and dyslipidemia among non-smoking adults in the United States

Dyslipidemia is a major public health challenge worldwide and whether secondhand smoke exposure (SHSE) is associated with dyslipidemia is yet to be understood. This study evaluated the relationship between SHSE and odds of dyslipidemia among adults in the United States. We identified 3064 adults who had never smoked in the 2015-2016 National Health and Nutrition Examination Survey and estimated the odds ratio and 95% confidence interval for the relationship between SHSE and odds of dyslipidemia using a multivariable adjusted-logistic regression at a two-sided p < 0.05. Overall, the mean age of respondents was 46.4 ± 18.0 years, 59.6% had dyslipidemia and 36.2% had SHSE. The odds of dyslipidemia among individuals with SHSE were 1.148 (1.147, 1.149) in the overall sample, 1.214 (1.214, 1.215) among women and 1.165 (1.163, 1.167) among men. The odds trended similarly independent of age groups: 1.130 (1.129, 1.131) for young adults (<60 years) and 1.304 (1.300, 1.308) for old adults (≥60 years). SHSE was associated with higher odds of dyslipidemia with higher odds among women and old adults. Primary intervention(s) targeted at reducing SHSE may show benefits in reducing the odds of dyslipidemia, and longitudinal studies would be necessary to clarify the association between SHSE and dyslipidemia.

Reducing Nontraumatic Lower-Extremity Amputations by 20% by 2030: Time to Get to Our Feet: A Policy Statement From the American Heart Association

Nontraumatic lower-extremity amputation is a devastating complication of peripheral artery disease (PAD) with a high mortality and medical expenditure. There are ≈150 000 nontraumatic leg amputations every year in the United States, and most cases occur in patients with diabetes. Among patients with diabetes, after an ≈40% decline between 2000 and 2009, the amputation rate increased by 50% from 2009 to 2015. A number of evidence-based diagnostic and therapeutic approaches for PAD can reduce amputation risk. However, their implementation and adherence are suboptimal. Some racial/ethnic groups have an elevated risk of PAD but less access to high-quality vascular care, leading to increased rates of amputation. To stop, and indeed reverse, the increasing trends of amputation, actionable policies that will reduce the incidence of critical limb ischemia and enhance delivery of optimal care are needed. This statement describes the impact of amputation on patients and society, summarizes medical approaches to identify PAD and prevent its progression, and proposes policy solutions to prevent limb amputation. Among the actions recommended are improving public awareness of PAD and greater use of effective PAD management strategies (eg, smoking cessation, use of statins, and foot monitoring/care in patients with diabetes). To facilitate the implementation of these recommendations, we propose several regulatory/legislative and organizational/institutional policies such as adoption of quality measures for PAD care; affordable prevention, diagnosis, and management; regulation of tobacco products; clinical decision support for PAD care; professional education; and dedicated funding opportunities to support PAD research. If these recommendations and proposed policies are implemented, we should be able to achieve the goal of reducing the rate of nontraumatic lower-extremity amputations by 20% by 2030.

Nicotine exacerbates atherosclerosis through a macrophage-mediated endothelial injury pathway

Evidence suggests that nicotine intake promotes atherosclerosis. We enrolled 100 patients with coronary heart disease (CHD) and found that plaque burden, TXNIP expression, and inflammatory chemokine levels were higher in smokers than non-smokers. Additionally, patients with higher TXNIP expression in peripheral blood mononuclear cells (PBMCs) had a higher Gensini Scores and higher plasma IL-1β and IL-18 levels. Treating bone marrow-derived macrophages (BMDMs) with nicotine in vitro led to enhanced lipid phagocytosis, chemotaxis, and increased production of reactive oxygen species (ROS), which activated TXNIP/NLRP3 inflammasome signaling and promoted pyroptosis, as evidenced by caspase-1 cleavage and increased production of IL-1β, IL-18, and gasdermin D. Nicotine intake by ApoE(-/-) mice fed a high-fat diet recapitulated those phenotypes. The effects of nicotine on pyroptotic signaling were reversed by N-acetyl-cysteine, a ROS scavenger. Silencing TXNIP in vivo reversed the effects of nicotine on macrophage invasion and vascular injury. Nicotine also induced pyroptotic macrophages that contributed to the apoptotic death of endothelial cells. These findings suggest that nicotine accelerates atherosclerosis in part by promoting macrophage pyroptosis and endothelial damage. Therefore, targeting the TXNIP/NLRP3-mediated pyroptotic pathway in macrophages may ameliorate nicotine-induced endothelial damage.

Tobacco Smoking and Smokeless Tobacco Use among Domestic and International Medical Students in Hungary

Medical students as future physicians will have an important role in tobacco control; therefore, their tobacco use behavior is of particular interest. Consumption of combustible tobacco (cigarettes, waterpipes, cigars, and pipes) is prevalent throughout Europe, whereas smokeless tobacco use is common mainly in the Nordic countries. Objectives: Aim of our study is to assess tobacco use among medical students from different countries studying in Hungary with special focus on students from Norway where smokeless tobacco is widely used. A self-administered questionnaire survey was carried out to measure current tobacco use. Results: The survey included 1337 students from Hungary, Norway, Germany, and from other countries (Multinational group). The lowest prevalence of cigarette smoking was found among students from Norway (13.0%) when compared with students from Hungary (21.5%), Germany (34.2%), or with students in the Multinational group (29.5%). Conversely, prevalence of smokeless tobacco use was the highest among students from Norway (40.9%) when compared with students from Hungary (1.4%), Germany (2.6%), or with students in the Multinational group (6.2%). Waterpipes, cigars, and pipes were rarely used, mostly only 1-3 times a month in all groups. More than half of Norwegian students used some form of tobacco (smokeless and/or combustible tobacco). Conclusions: Considering the impending role of medical students in tobacco control, faculties of medicine should sensitize their students on the topic of possible health risks associated with combustible and smokeless tobacco products. Culturally tailored tobacco cessation programs need to be offered to medical students coming from different cultural backgrounds.

Cerebrovascular and cardiovascular diseases caused by drugs of abuse

Drugs such as stimulants, sedatives, sleeping pills, and narcotics are associated with drug abuse and are therefore regulated by law. Physical dependence on these drugs is sometimes difficult to control despite an awareness of the problems they cause in daily life and the harm they can cause to the body. Drug dependence is a social problem worldwide, and the physical implications are serious. Many of these drugs cause cerebrovascular and cardiovascular diseases, which often require emergency medical treatment. Differential diagnosis is essential because of the likelihood of life-threatening events, especially among young people who exhibit cerebrovascular and cardiovascular diseases without any of the typical risk factors. Drugs of abuse, especially stimulants, induce a hyperadrenergic state that evokes vasoconstriction and tachycardia, as well as subsequent ischemic and hemorrhagic stroke, acute coronary syndrome, arrhythmias, and aortic dissection. Chronic drug abuse can also cause cardiac hypertrophy and left ventricular dysfunction. As a treatment for these conditions, sedative drugs can be effective but the use of vasodilators may also be required. There are concerns that the use of both alpha- and beta-adrenergic receptor blockers may cause tachycardia and increased blood pressure. Therefore, careful differential diagnosis and selection of therapeutic agents is required.

Impact of cigarette smoking on nitric oxide-sensitive and nitric oxide-insensitive soluble guanylate cyclase-mediated vascular tone regulation

Cigarette smoking induces vascular endothelial dysfunction characterized by impaired nitric oxide (NO) bioavailability. There are two types of soluble guanylate cyclase (sGC), which is a cellular target of NO: NO-sensitive reduced form (the heme moiety with a ferrous iron) and NO-insensitive oxidized (the heme moiety with a ferric iron)/heme-free form. This study investigated the influence of cigarette smoking on NO-sensitive and NO-insensitive sGC-mediated vascular tone regulation in organ chamber experiments with isolated rat and human arteries. The rats were subcutaneously administered phosphate-buffered saline (PBS), nicotine-free cigarette smoke extract (N(-)-CSE) or nicotine-containing cigarette smoke extract (N(+)-CSE) for 4 weeks. Plasma thiobarbituric acid reactive substance (TBARS) levels were higher in the N(+)-CSE group than those in the N(-)-CSE group, and TBARS levels for these groups were higher than those for the PBS group. In the aorta and the pulmonary artery in rats administered N(-)-CSE or N(+)-CSE, acetylcholine-induced relaxation was significantly impaired compared with that in rats administered PBS; there was no significant difference in the relaxation between the N(-)-CSE and N(+)-CSE groups. However, sodium nitroprusside (NO-sensitive sGC stimulant)- and BAY 60-2770 (NO-insensitive sGC stimulant)-induced relaxations were not different among the three groups, regardless of the vessel type. In addition, in the human gastroepiploic artery, the relaxant responses to these sGC-targeting drugs were identical between nonsmokers and smokers. These findings suggest that NO-sensitive and NO-insensitive sGC-mediated vascular tone regulation functions normally even in blood vessels damaged by cigarette smoking.

Smoking cessation and risk of recurrent cardiovascular events and mortality after a first manifestation of arterial disease

AIMS

To quantify the relation between smoking cessation after a first cardiovascular (CV) event and risk of recurrent CV events and mortality.

METHODS

Data were available from 4,673 patients aged 61 ± 8.7 years, with a recent (≤1 year) first manifestation of arterial disease participating in the SMART-cohort. Cox models were used to quantify the relation between smoking status and risk of recurrent major atherosclerotic cardiovascular events (MACE including stroke, MI and vascular mortality) and mortality. In addition, survival according to smoking status was plotted, taking competing risk of non-vascular mortality into account.

RESULTS

A third of the smokers stopped after their first CV event. During a median of 7.4 (3.7-10.8) years of follow-up, 794 patients died and 692 MACE occurred. Compared to patients who continued to smoke, patients who quit had a lower risk of recurrent MACE (adjusted HR 0.66, 95% CI 0.49-0.88) and all-cause mortality (adjusted HR 0.63, 95% CI 0.48-0.82). Patients who reported smoking cessation on average lived 5 life years longer and recurrent MACE occurred 10 years later. In patients with a first CV event >70 years, cessation of smoking had improved survival which on average was comparable to former or never smokers.

CONCLUSIONS

Irrespective of age at first CV event, cessation of smoking after a first CV event is related to a substantial lower risk of recurrent vascular events and all-cause mortality. Since smoking cessation is more effective in reducing CV risk than any pharmaceutical treatment of major risk factors, it should be a key objective for patients with vascular disease.

Predictors of Severe or Moderate Coronary Artery Disease in Asymptomatic Individuals with Extremely Low Coronary Calcium Scores

PURPOSE

To evaluate predictors of severe or moderate coronary artery disease (CAD) in individuals with zero or very low (<10) coronary artery calcium (CAC) scores.

MATERIALS AND METHODS

The 1175 asymptomatic persons with zero or very low (<10) CAC scores were analyzed for CAD stenosis using coronary computed tomography angiography. Moderate and severe CADs were defined as having more than 50% and more than 70% stenosis in any of the major coronary arteries, respectively. Age, gender, body mass index, hypertension, type II diabetes, dyslipidemia, lipid profile, creatinine, and smoking status were evaluated as predictors for moderate and severe CAD.

RESULTS

In the study population, moderate and severe CADs were found in 7.5% and 3.3%, respectively. Among evaluated risk factors, age [odds ratio (OR) 1.04, 95% confidence interval (CI) 1.02-1.07, p<0.001], current smoking status (OR 3.12, 95% CI 1.82-5.34, p<0.001), and CAC 1-9 (OR 1.80, 95% CI 1.08-3.00, p=0.024) were significantly associated with moderate CAD. Meanwhile, age (OR 1.05, 95% CI 1.02-1.08, p=0.003), low high density lipoprotein (HDL) (OR 0.96, 95% CI 0.93-0.99, p=0.003), and current smoking status (OR 2.34, 95% CI 1.14-5.30, p=0.022) were found to be significantly associated with severe CAD. Improvement of discrimination power for predicting severe CAD was observed when smoking and HDL cholesterol were serially added into the age model.

CONCLUSION

Smoking showed significant correlations with moderate or severe CAD, and low HDL cholesterol also proved to be a predictor of severe CAD in asymptomatic individuals with extremely low CAC scores.

Uptake and Perceptions of E-cigarette use in Vascular Patients

Introduction: Smoking is one of the most important risk factors for cardiovascular disease (CVD). Electronic cigarettes (e-cigarettes) are becoming increasingly popular. However, little is known regarding their patterns of use in patients with established CVD.

Aims: We aimed to assess the perceptions and patterns of use of e-cigarettes in patients presenting to a vascular clinic.

Methods: We performed a qualitative study to identify perceptions and beliefs about e-cigarettes. Semi-structured interviews of consecutive patients consenting to participate were performed over five-months. Individuals were recruited from a vascular surgery outpatient clinic. Initial interviews were based on a questionnaire. Further structured interviews were conducted with patients currently using e-cigarettes, which were transcribed and analysed to assess perceptions and patterns of use.

Results/Findings: Four overarching themes emerged: attraction to e-cigarettes as a harm reduction/smoking cessation strategy; uncertainty regarding the risks of e-cigarettes; use of various types of smoking cessation strategies; dual use and often complete relapse to tobacco products.

Conclusions: Patients with established CVD view e-cigarettes as a means of smoking cessation; however, many relapse to tobacco products or use both simultaneously. Further research is necessary regarding the role of e-cigarettes in smoking cessation in this high-risk group.

Effects of Smoking Cessation with Nicotine Replacement Therapy on Vascular Endothelial Function, Arterial Stiffness, and Inflammation Response in Healthy Smokers

The effects of nicotine replacement therapy (NRT)-aided smoking cessation on vascular function are not fully clarified. We investigated 100 healthy smokers who were motivated to quit and received NRT for a 3-month period. Vascular endothelial function (measured by reactive hyperemia-peripheral arterial tonometry [RH-PAT]), arterial stiffness (measured by augmentation index [AI] and brachial-ankle pulse wave velocity [baPWV]), and systemic inflammation markers (including serum soluble intercellular adhesion molecule-1 [sICAM-1] and interleukin-1β [IL-1β]) were assessed at baseline and 3 and 12 months of follow-up. After 3 months of intervention, endothelial function, arterial stiffness, and inflammatory markers significantly improved (RH-PAT increased, AI and baPWV decreased, sICAM-1 and IL-1β decreased, all P < .05) for the participants who abstained from smoking completely, but for those who did not abstained completely, RH-PAT, AI, baPWV, and IL-1β remained unchanged. At 12 months follow-up, endothelial function (RH-PAT), arterial stiffness (AI and baPWV), and inflammatory markers (sICAM-1 and IL-1β) were further improved in participants who abstained from smoking (P < .001), while the above parameters deteriorated in continued smokers (P < .05). In conclusion, vascular dysfunction can be reversible after NRT-aided smoking cessation in healthy smokers and vascular function could be further damaged if they continue smoking.

Thoracic Aortic Dissection Associated with Marijuana Use

BACKGROUND

Acute aortic dissection (AD) is a life-threatening condition most frequently seen in men with an average age >60 years. Risk factors include family history, hypertension and cigarette smoking. AD has been associated with methamephatamine and cocaine use but has not previously been associated with the use of marijuana.

CASE REPORT

We report a case of an aortic dissection in a 56-year-old male that occurred while smoking marijuana. The patient had a family history significant for both aortic aneurysm and dissection. He developed crushing chest pain, shortness of breath, and diaphoresis shortly after smoking marijuana from a glass pipe called a "bubbler". His ECG was unremarkable as was his chest x-ray and initial labs. CT scan revealed an Aortic dissection from the aortic root to the internal iliac artery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The role of cannabis in cardiovascular disorders is complex and not completely understood. Acute chest pain associated with marijuana use typically raises concern for pneumothorax or pneumomediastinum. Marijuana has also been associated with hypertension and arrhythmias and has also been associated with an increased risk of myocardial infarction. However a link between marijuana and acute aortic dissection has not been previously reported. As more states legalize medical and recreational marijuana use this is a timely and important consideration for Emergency physicians evaluating chest pain. Our goal is to document the temporal relationship of cannabis use and acute aortic dissection in a recent ED patient.

Autophagy in Crotonaldehyde-Induced Endothelial Toxicity

Crotonaldehyde is an extremely toxic α,β-unsaturated aldehyde found in cigarette smoke, and it causes inflammation and vascular dysfunction. Autophagy has been reported to play a key role in the pathogenesis of vascular diseases. However, the precise mechanism underlying the role of acute exposure crotonaldehyde in vascular disease development remains unclear. In the present study, we aimed to investigate the effect of crotonaldehyde-induced autophagy in endothelial cells. Acute exposure to crotonaldehyde decreased cell viability and induced autophagy followed by cell death. In addition, inhibiting the autophagic flux markedly promoted the viability of endothelial cells exposed to high concentrations of crotonaldehyde. Crotonaldehyde activated the AMP-activated protein kinase (AMPK) and p38 mitogen-activated protein kinase (MAPK) pathways, and pretreatment with inhibitors specific to these kinases showed autophagy inhibition and partial improvement in cell viability. These data show that acute exposure to high concentrations of crotonaldehyde induces autophagy-mediated cell death. These results might be helpful to elucidate the mechanisms underlying crotonaldehyde toxicity in the vascular system and contribute to environmental risk assessment.

Active smoking among people with diabetes mellitus or hypertension in Africa: a systematic review and meta-analysis

The objective was to summarize existing data on the prevalence of active tobacco smoking among patients with hypertension or diabetes mellitus in Africa. We searched PubMed, EMBASE, and AJOL to include studies published from January 01, 2000 to August 23, 2017 reporting on the prevalence of active smoking in individuals aged ≥15 years with hypertension or diabetes mellitus residing inside Africa. We used a random-effects meta-analysis model to pool studies. The pooled prevalence of active smoking among patients with hypertension or diabetes was 12.9% (95%CI: 10.6–15.3; 50 studies; 16,980 patients) and 12.9% (95%CI: 9.6–16.6; 42 studies; 18,564 patients), respectively. For both conditions, the prevalence of active smoking was higher in males than in females (p < 0.001), and in Northern compared to sub-Saharan Africa (p < 0.001). There was no difference between urban and rural settings, and between community-based and hospital-based studies, except for patients with diabetes for whom the prevalence was higher in hospital-based studies (p = 0.032). The prevalence of active smoking is high among patients with hypertension or diabetes mellitus in Africa, with the heaviest burden in Northern Africa. Interventions for smoking prevention or cessation should be implemented in these high risk populations, targeting particularly the males.

Ideal cardiovascular health associated with fatty liver: Results from a multi-ethnic survey

BACKGROUND AND AIMS

Little is known about the role of liver enzymes as predictors of non-liver-related morbidity and mortality. The ideal cardiovascular health (CVH) score proposed by the American Heart Association (AHA) can be used to predict mortality and morbidity. We investigated the association of the CVH score with liver enzymes and the risk of non-alcoholic fatty liver disease (NAFLD) among US adults.

METHODS

By using the National Health and Nutrition Examination Survey database (cross-sectional), the CVH score was calculated as meeting ideal levels of the following components: 4 behaviors (smoking, body mass index, physical activity and diet adherence) and 3 factors (total cholesterol, blood pressure and fasting glucose).

RESULTS

Individuals with a higher CVH score ("better CVH") had a more favorable profile of liver biomarkers. Adjusted (for age, gender, race, poverty to income ratio, education, marital status and alcohol intake) linear regression indicated significant and negative associations between liver biomarkers and CVH score: (β = -0.069, p < 0.001) for alanine aminotransferase, (β = -0.095, p < 0.001), aspartate aminotransferase, (β = -0.067, p < 0.001), alkaline phosphatase and (β = -0.125, p < 0.001) and fatty liver index. In the logistic regression, with the same confounders, individuals with a higher CVH score had 12% less likelihood of NAFLD compared with those with a lower score. Furthermore, each CVH metric separately was inversely linked to the risk of NAFLD.

CONCLUSIONS

For the first time among US adults, our findings shed light on the role CVH on liver biomarkers.

Relationships Among Chewing Tobacco, Cigarette Smoking, and Chronic Health Conditions in Males 18-44 Years of Age

As more public places are designated "non-smoking," chewing tobacco could be an alternative choice for tobacco use; however, controversy exists over the long-term health effects associated with it. This study assessed the relationship between chewing tobacco, cigarette smoking, and chronic health conditions in a representative sample of males 18-44 years of age, while controlling for other variables known to be related to tobacco use. This cross sectional analysis used 2013 data from the Behavioral Risk Factor Surveillance System (BRFSS). The results indicated that about 41% of males reported one or more chronic health conditions, and that about 15% used chewing tobacco only, 21% smoked cigarettes only, and 6% did both. From adjusted analyses, those who chewed tobacco only were 49% more likely to report one or more health conditions; those who smoked cigarettes only were 34% more likely to report one or more health conditions; and those who did both were 95% more likely to report at least one health condition. Overall, any combination of tobacco use was significantly and similarly related to the increased prevalence of chronic health conditions in males aged 18-44 years. Although chewing tobacco use may not be as prevalent in the general population as cigarette smoking, clinicians should be aware of the similar health risks associated with all tobacco use at ages younger than may be expected, and encourage cessation of any tobacco use.

Sex differences in relationships between metabolic syndrome components and factors associated with health-related quality of life in middle-aged adults living in the community: a cross-sectional study in Taiwan

Background

Metabolic syndrome (MetS) is a widespread condition with important effects on public health, in general. There is a lack of relevant research on possible sex differences in the relationship between MetS and health-related quality of life (HRQoL) and also the sex differences in factors associated with HRQoL. The aims of this study were to identify: 1) whether women exhibit greater negative impacts on physical domain HRQoL from MetS compared with men; 2) whether women exhibit greater mental domain impacts compared with men; and 3) whether factors associated with HRQoL scores are different for men and women.

Methods

This cross-sectional study was conducted in Taipei, Taiwan. Using random sampling, a total of 906 participants aged 35–55 years were recruited. MetS was defined according to the MetS criteria for the Taiwanese population, and HRQoL were assessed using physical component summary (PCS) and mental component summary (MCS) scores of the Short Form Health Survey (SF-36), Taiwan version. Demographics, physical activity, medical history, and blood tests as covariates were recorded and checked. The associations were assessed by multiple linear regression.

Results

After adjusting for covariates, women but not men with more components of MetS had significantly lower PCS scores (β = − 0.542, p = 0.036). The number of components of MetS was not a significant factor in MCS score differences between the sexes. Furthermore, there were sex differences regarding age, education level, physical activity, and smoking status in association with PCS scores. For MCS scores, sex differences were found in education level, marital status, and habits of smoking and alcohol consumption.

Conclusions

There were sex differences in the relationships between metabolic syndrome components and factors associated with HRQoL among middle-aged adults living in the community in Taiwan. Further research should be conducted to investigate mechanisms of these sex differences.

Dyslipidaemia in the elderly: to treat or not to treat?

INTRODUCTION

The elderly population (i.e. aged ≥ 65 years) is increasing worldwide. Ageing is associated with a higher incidence and prevalence of cardiovascular disease (CVD). Areas covered: The prevalence of CVD risk factors including type 2 diabetes mellitus, hypertension and dyslipidaemia also increases with advancing age, contributing to the higher absolute CVD risk observed in the elderly. The present narrative review comments on the associations of dyslipidaemia with CVD as well as the effects of lifestyle measures and lipid-lowering drugs on lipids and CVD risk with a special focus on the elderly population. Individual treatment goals and therapeutic options according to current guidelines are also reviewed. Finally, we discuss special characteristics of the elderly that may influence the efficacy and safety of drug therapy and should be considered before selection of hypolipidaemic pharmacotherapy. Expert commentary: There may be a greater CVD benefit in older patients following drug therapy compared with younger ones. Treatment goals and therapeutic options should be individualized according to current guidelines. Specific characteristics that may influence the efficacy and safety of drug therapy in the elderly should be considered in relation to dyslipidaemia treatment.

Circulating TNF Receptors 1 and 2 Predict Mortality in Patients with End-stage Renal Disease Undergoing Dialysis

Relatively high circulating levels of soluble tumor necrosis factor (TNF) receptors (TNFRs: TNFR1, TNFR2) have been associated with not only progression to end-stage renal disease but also mortality in patients with diabetes. It remains unknown whether elevated TNFR levels in haemodialysis patients are associated with mortality. We studied 319 patients receiving maintenance haemodialysis who were followed for a median of 53 months. Circulating markers of TNF pathway (TNFα and TNFRs) were measured with immunoassay. Strong positive correlations between TNFR1 and TNFR2 were observed (r = 0.81, P < 0.0001). During follow-up, 88 (27.6%) patients died of any cause (40 [45.5%] died of cardiovascular disease). In the Cox multivariate model, either TNFR but not TNFα remained a significant independent predictor of all-cause mortality (TNFR1: hazard ratio [HR] 2.34, 95% confidence interval [CI], 1.50–3.64; TNFR2: HR 2.13, 95% CI 1.38–3.29) after adjustment for age, prior cardiovascular disease, predialysis systolic blood pressure, and large systolic blood pressure decline during dialysis session. For cardiovascular mortality, significance was only observed in TNFR1 (TNFR1: HR 2.15, 95% CI 1.13–4.10). Elevated TNFRs levels were associated with the risk of cardiovascular and/or all-cause mortality independent of all relevant covariates in patients undergoing haemodialysis.

Neighborhood conditions, religious coping, and uncontrolled hypertension

The purpose of this study is to see whether God-mediated control beliefs moderate the relationship between living in rundown neighborhoods and uncontrolled hypertension. God-mediated control refers to the belief that God will help people handle the stressors that arise in life. Data are provided by a nationwide survey of adults (N = 1919). Three ways of assessing uncontrolled hypertension are examined: a binary format contrasting people with and without uncontrolled hypertension, systolic and diastolic blood pressure scored continuously, and a four ordinal category scheme recommended by the American Heart Association. The data suggest that stronger God-mediated control beliefs moderate the relationship between neighborhood conditions and uncontrolled blood pressure when blood pressure is scored continuously and when the American Heart Association scheme are used as outcomes.

Comorbidity: Reconsidering the Unit of Analysis

In this short essay, I wish to briefly discuss smoking, polypharmacy, the human biome and multispecies relations, and biomedicalization as a means of stretching the common ways we think about comorbidity. My intent is to expand our thinking about comorbidity and multimorbidity beyond the individual as a unit of analysis, to reframe comorbidity in relation to trajectories of risk, and to address comorbid states of our own making when the treatment of one health problem results in the experience of additional health problems. I do so as a corrective to what I see as an overly narrow focus on comorbidity as co-occurring illnesses within a single individual, and as a complement to critical medical anthropological assessments of synergistic comorbid conditions (syndemics) occurring in structurally vulnerable populations living in environments of risk exposed to macro and micro pathogenic agents.

Non-cigarette tobacco and poly-tobacco use among persons living with HIV drawn from a nationally representative sample

INTRODUCTION

Smoking is more prevalent among persons living with HIV (PLWH) than the general population. Little is known about the prevalence of non-cigarette tobacco and poly-tobacco use (PTU; using multiple tobacco products) among this population, which, in the general population is associated with poor health and cessation outcomes. We aimed to characterize the prevalence of cigarette and non-cigarette tobacco use, PTU, and correlates of tobacco use status among a nationally-representative sample of PLWH.

METHODS

Data came from 472 HIV-positive adults from the 2005-2013 National Survey on Drug Use and Health (NSDUH).

RESULTS

The prevalence of PTU overall was 8.7% (95% CI=5.6-13.2), and 16.6% (95% CI=10.2-25.7) among past-year tobacco users. In multinomial logistic regression analyses, participants with a high school education or greater (aRRR=2.03, 95% CI=1.03-4.00) were more likely to be non-tobacco users than single product users. Past year drug users (aRRR=0.35, 95% CI=0.19-0.66) and past month binge drinkers (aRRR=0.24, 95% CI=0.12-0.50) were less likely to be non-tobacco users than single product users. Compared to 18-25 year olds, individuals age 26-34 (aRRR=0.13, 95% CI=0.03-0.65) and 35+ (aRRR=0.24, 95% CI=0.09-0.63), and with lifetime anxiety disorder(s) (aRRR=0.18, 95% CI=0.06-0.57) were less likely to be PTUs as compared to single product users. Individuals who reported liking to test themselves by doing risky things were more likely to be PTUs than single product users (aRRR=2.95, 95% CI=1.27-6.84).

CONCLUSIONS

PTU was slightly higher than in the general population, and should be taken into account when developing cessation interventions tailored to tobacco users living with HIV.

Job Burnout, Work Engagement and Self-reported Treatment for Health Conditions in South Africa

The purpose of the study being reported here was to investigate the relationship of job burnout and work engagement with self-reported received treatment for health conditions (cardiovascular condition, high cholesterol, depression, diabetes, hypertension and irritable bowel syndrome), while controlling for age, gender, smoking and alcohol use. The sample comprised 7895 employees from a broad range of economic sectors in the South African working population. A cross-sectional survey design was used for the study. Structural equation modelling methods were implemented with a weighted least squares approach. The results showed that job burnout had a positive relationship with self-reported received treatment for depression, diabetes, hypertension and irritable bowel syndrome. Work engagement did not have any significant negative or positive relationships with the treatment for these health conditions. The results of this study make stakeholders aware of the relationship between job burnout, work engagement and self-reported treatment for health conditions. Evidence for increased reporting of treatment for ill-health conditions due to burnout was found. Therefore, attempts should be made to manage job burnout to prevent ill-health outcomes.

Smoking cessation and the incidence of pre-diabetes and type 2 diabetes: a cohort study

AIMS

Smoking cessation has been suggested to increase the short-term risk of type 2 diabetes mellitus (T2DM). This study aimed at assessing the association between smoking cessation and incidence of T2DM and impaired fasting glucose (IFG).

METHODS

Data from participants in the CoLaus study, Switzerland, aged 35-75 at baseline and followed for 5.5years were used. Participants were classified as smokers, recent (≤5years), long-term (>5years) quitters, and non-smokers at baseline. Outcomes were IFG (fasting serum glucose (FSG) 5.6-6.99mmol/l) and T2DM (FSG ≥7.0mmol/l and/or treatment) at follow up.

RESULTS

3,166 participants (63% women) had normal baseline FSG, of whom 26.7% were smokers, 6.5% recent quitters, and 23.5% long-term quitters. During follow-up 1,311 participants (41.4%) developed IFG (33.6% women, 54.7% men) and 47 (1.5%) developed T2DM (1.1% women, 2.1% men). Former smokers did not have statistically significant increased odds of IFG compared with smokers after adjustment for age, education, physical activity, hypercholesterolemia, hypertension and alcohol intake, with OR of 1.29 [95% confidence interval 0.94-1.76] for recent quitters and 1.03 [0.84-1.27] for long-term quitters. Former smokers did not have significant increased odds of T2DM compared with smokers with multivariable-adjusted OR of 1.53 [0.58-4.00] for recent quitters and 0.64 [0.27-1.48] for long-term quitters. Adjustment for body-mass index and waist circumference attenuated the association between recent quitting and IFG (OR 1.07 [0.78-1.48]) and T2DM (OR 1.28 [0.48-3.40].

CONCLUSION

In this middle-aged population, smoking cessation was not associated with an increased risk of IFG or T2DM.

Variations in the Prevalence of Risk Factors for Coronary Artery Disease in Rio Grande do Sul-Brazil: A Comparative Analysis between 2002 and 2014

BACKGROUND

Due to the importance of coronary artery disease (CAD), continuous investigation of the risk factors (RFs) is needed.

OBJECTIVE

To evaluate the prevalence of RFs for CAD in cities in Rio Grande do Sul State, and compare it with that reported in a similar study conducted in the same cities in 2002.

METHODS

Cross-sectional study on 1,056 healthy adults, investigating the prevalence and absolute and relative frequencies of the following RFs for CAD: obesity, systemic arterial hypertension (SAH), dyslipidemias, smoking, sedentary lifestyle, diabetes mellitus, and family history, as well as age and sex. Data was collected in 19 cities, host of the Offices of the Regional Coordinators of Health, as in the 2002 study.

RESULTS

Twenty-six percent of the sample consisted of older adults and 57% were women. The prevalence of sedentary lifestyle was 44%, history family 50%, smoking 23%, overweight/obesity 68%, dyslipidemia (high cholesterol levels) 43%, SAH 40%, and diabetes 11%. When compared to the 2002 study, the prevalence of active smoking and sedentary behavior decreased, whereas the prevalence of hypertension, dyslipidemia and obesity increased. Obesity is the most prevalent RF in women, and SAH the most prevalent in men.

CONCLUSIONS

The prevalence of RFs for CAD in Rio Grande do Sul State remains high. Hypertension, obesity and dyslipidemia are still prevalent and require major prevention programs. Smoking and physical inactivity have decreased in the state, suggesting the efficacy of related campaigns.

Dietary patterns and lifestyle of patients with myocardial infarction

Civilization diseases, including cardiovascular, are major health problems in current modern society. Numerous studies provided sufficient evidence that variety of risk factors are involved in cardiovascular diseases formation. Of the most important is the lifestyle that largely contributes to our health, up to 50 - 60%. Lifestyle includes all modifiable risk factors that together affect the development of these diseases. In our study we searched and evaluated the nutritional parameters and lifestyle of patients hospitalized in Cardiocentre Nitra. In order to obtain the necessary information we chose the questionnaire method. In our survey 194 patients were included, of which 155 were men (79.89%) and 39 (20.11%) women. These patients were hospitalized with acute myocardial infarction diagnosis. The vast majority of patients had overweight and obesity caused by improper eating habits. The high prevalence of overweight, BMI in the range 25 - 30 kg/m2, was also confirmed as statistically significant, p <0.05 (P=0.02). BMI over 25 kg/m2 was present in 85% of men and 80% of women. The consumption of selected food commodities with evidence of a positive or negative impact on the emergence of acute myocardial infarction was not statistically significant (p >0.05) when evaluating dietary habits. But we can confirm too frequent consumption of chicken at the expense of other types of meat and relatively frequent consumption of fish (once a week). We recorded the preference of semi-skimmed dairy products, but also high and inappropriate consumption of full-fat dairy products in men and women (37% and 17.8%, respectively). Daily intake of fruits and vegetables was in 85.9% of women and 64.7% of men. Everyday intake of bread and pastries was confirmed by 100% of respondents. Lifestyle was evaluated according to the presence of smoking, excessive alcohol consumption, and physical activity. Up to 60.5% of men and 26.4% of women admitted smoking, while 34.6% of men and 7.5% women ended up with the habit after myocardial infarction. The excessive alcohol consumption was not detected in the study group. Approximately 67% of men and 56% of women carry out an easier walking and moderate physical activity while taking into account their health status.

Pharmacology in peripheral arterial disease: what the interventional radiologist needs to know

Peripheral arterial disease (PAD) is a progressive disease with significant morbidity and mortality. Risk factor control, using diet and lifestyle modification, exercise, and pharmacological methods, improves symptoms and reduces associated cardiovascular events in these patients. Antiplatelet agents and anticoagulants may be used to reduce the incidence of acute events related to thrombosis. The armamentarium available for symptom relief and disease modification is discussed. Novel treatments such as therapeutic angiogenesis are in their evolutionary phase with promising preclinical data.

Atherogenic risk factors and hearing thresholds

The objective of this study was to evaluate the influence of atherogenic risk factors on hearing thresholds. In a cross-sectional study we analyzed data from a Danish survey in 2009-2010 on physical and psychological working conditions. The study included 576 white- and blue-collar workers from children's day care units, financial services and 10 manufacturing trades. Associations between atherogenic risk factors (blood lipids, glycosylated hemoglobin, smoking habits, body mass index (BMI), and ambulatory blood pressure) and hearing thresholds were analyzed using multiple linear regression models. Adjusted results suggested associations between smoking, high BMI and triglyceride level and low high-density lipoprotein level and increased low-frequency hearing thresholds (average of pure-tone hearing thresholds at 0.25, 0.5 and 1 kHz). Furthermore, an increasing load of atherogenic risk factors seemed associated with increased low-frequency hearing thresholds, but only at a borderline level of statistical significance. Associations were generally strongest with hearing levels of the worst hearing ear. We found no statistically significant associations between atherogenic risk factors and high-frequency hearing thresholds (average of pure-tone hearing thresholds at 4, 6 and 8 kHz).

Multicenter cross-sectional study of asymptomatic peripheral arterial disease among patients with a single previous coronary or cerebrovascular event in the Arabian Gulf

OBJECTIVE

To evaluate the epidemiology and predictors of asymptomatic peripheral artery disease (PAD) in patients with a single previous coronary or cerebrovascular event in the Arabian Gulf.

METHODS

This was a cross-sectional, multicenter, observational survey in consecutive patients (≥18 years) with documented previous coronary and/or cerebrovascular atherothrombotic event in the United Arab Emirates (UAE), Kuwait and Qatar (64 centers), from October 2008 to December 2010. PAD was defined as an ankle brachial index <0.9 in at least one leg.

RESULTS

The overall mean age of the cohort (n = 2110) was 54 ± 11 years with only 14% being female (n = 303). The prevalence of asymptomatic PAD was 13.7%, with the highest prevalence seen in Kuwait (16.3%) and the UAE (14.7%) and the lowest in Qatar (5.3%). There were significant differences in the prevalence of asymptomatic PAD among the ethnic groups (p < 0.001): it was highest among the local Arabs and Caucasians at 19% and lowest among South East Asians (6%). The multivariate logistic model demonstrated that the most significant predictors of PAD were old age (adjusted odds ratio [OR], 1.04; 95% CI: 1.02-1.05; p < 0.001), female gender (OR, 1.56; 95% CI: 1.06-2.29; p = 0.024), ethnicity (OR, 0.39; 95% CI: 0.19-0.79; p = 0.009), smoking (OR, 1.70; 95% CI: 1.22-2.37: p = 0.002) and diabetes mellitus (OR, 1.49; 95% CI: 1.14-1.94; p = 0.004).

CONCLUSIONS

PAD is prevalent in the Arabian Gulf and is more likely to be associated with old age, females, ethnicity, smokers and those with diabetes mellitus.

Antiplatelet Treatment and Prothrombotic Diathesis Following Endovascular Abdominal Aortic Aneurysm Repair

Prothrombotic diathesis expressed by elevated levels of coagulation-specific biomarkers has been reported in patients with abdominal aortic aneurysm (AAA) and after AAA endovascular repair (EVAR). This study investigates the effect of antiplatelet agents (APLs) on the prothrombotic diathesis in the post-EVAR period. Forty elective EVAR patients had thrombin–antithrombin complex, d-dimer, fibrinopeptide A, and high-sensitivity C-reactive protein measured before, at 24 hours, 1 month, and 6 months after EVAR. Patients receiving APLs postoperatively were compared with those not receiving APLs. All biomarkers were above the normal limits preoperatively and increased significantly 24 hours postoperatively followed by a drop at 1 and 6 months. No statistically significant changes were noted among patients receiving APLs in comparison with those not receiving APLs. The preoperative and postoperative prothrombotic diathesis of AAA following EVAR was confirmed in line with other reports. There was however no significant alteration of the examined biomarkers in patients receiving APLs.

Effect of tobacco smoking and smoking cessation on plasma lipoproteins and associated major cardiovascular risk factors: a narrative review

Cigarette smoking, active or passive, kills about 6 million people each year worldwide. Cardiovascular disease (CVD) is responsible for 40% of all smoking-related deaths, lung cancer accounts for 20% of all smoking-related deaths, and chronic obstructive pulmonary disease is related to another 20% of deaths. In this narrative review we consider the relationship between cigarette smoking and CVD. We discuss disease states and/or CVD risk factors related to smoking, such as dyslipidaemia, vascular inflammation, endothelial dysfunction, arterial stiffness, insulin resistance, type 2 diabetes mellitus (T2DM), chronic kidney disease (CKD), and non-alcoholic fatty liver disease (NAFLD) as well as their complex interrelations. Smoking cessation can correct abnormalities related to smoking; however, success rates are relatively low. In cases of inability to quit, measures to minimize the adverse effects of smoking specifically related to CVD should be taken. Smokers should receive best practice treatment, according to guidelines, as for non-smokers.

Is there evidence of early vascular disease in patients with obstructive sleep apnoea without known comorbidities? Preliminary findings

We evaluated early atherosclerotic lesions in 20 non-smokers with newly diagnosed Obstructive Sleep Apnoea (OSA) and without known comorbidities by measuring common carotid artery intima media thickness (CCA-IMT), transcranial Doppler ultrasound (TCD), and ankle brachial index (ABI). These were compared with 20 healthy age- and BMI-matched controls. In OSA patients, CCA-IMT was not significantly higher vs. controls (0.74±0.17 vs. 0.66±0.12 mm, p=0.201) and it was positively correlated with neck circumference (r=0.466, p=0.039), arousal index (r=0.663, p=0.001), gamma-glutamyl transpeptidase activity (r=0.474, p=0.035) while it was negatively correlated with Forced Expiratory Volume in 1 sec (r=-0.055, p=0.012). No difference was noted between patients and controls in terms of vascular stenosis on TCD examination, while asymptomatic peripheral artery disease was found in one patient with OSA. In conclusion, OSA patients without known comorbidities exhibit a non-significant increase in CCA-IMT without further evidence of vascular disease, but additional experience in a larger patient series is needed.

Poly-tobacco use among HIV-positive smokers: implications for smoking cessation efforts

INTRODUCTION

Poly-tobacco use is defined as cigarette and other tobacco consumption with either product used daily or nondaily. While concurrent use of different types of tobacco has been documented within the general population, less is known about poly-tobacco use among HIV-positive smokers and its impact on smoking cessation efforts.

OBJECTIVE

To characterize the profile of poly-tobacco users (PTU) in a sample of HIV-positive smokers participating in a cessation program.

METHODS

The study sample consisted of 474 HIV-positive smokers enrolled in a 2-group randomized controlled trial of cigarette smoking cessation comparing a cell phone-based intervention to usual care. Prevalence was determined, and risk factors for poly-tobacco use were evaluated using logistic regression.

RESULTS

In this cohort of HIV-positive cigarette smokers, 21.6% of participants were PTU, with cigars (73.4%) the most common tobacco product consumed. Among PTU, 73.5% used other form(s) of tobacco some days, and 26.5% use them every day. Perceived discrimination and unemployment were significantly associated with poly-tobacco use after adjusting for other demographic, behavioral, and psychosocial factors. Analysis showed that participants in the cell phone group (vs. usual care) were more likely to report 24-hr abstinence, both among monocigarette users (16.6% vs. 6.3%, p < .001) and PTU (18.5% vs. 0%, p < .001).

CONCLUSION

Poly-tobacco use prevalence among adult HIV-positive smokers was considerably higher than in the general population. Special attention must be placed on concurrent use of cigarettes and cigars among HIV-positive smokers. Because PTU are a unique population less likely to succeed in brief smoking cessation interventions, effective cessation programs are needed.

Additional Issues on Screening, Prevention, and Treatment of Abdominal Aortic Aneurysms

The prevalence of abdominal aortic aneurysms (AAAs) and AAA-related deaths are steadily declining in some countries as a result of the reduction in smoking rates. It was thus suggested that screening programs that do not target high-risk populations are likely to have very low AAA detection rates. However, this may not apply to other countries that do not exhibit similar reductions in smoking rates. It was assumed that by using the U.S. Preventive Services Task Force screening criteria (men 65-75 years with smoking history) less than 30% of AAAs would be captured. A more extensive scoring system that includes additional risk factors such as the presence of carotid artery or peripheral arterial disease, obesity, hypertension, and so on, may identify almost 90% of AAAs. This article discusses this and other issues on screening, prevention, and treatment of AAAs.