Age and cigarette smoking modulate the relationship between pulmonary function and arterial stiffness in heart failure patients

Association between persistent smoking after a diagnosis of heart failure and adverse health outcomes: A systematic review and meta-analysis

INTRODUCTION

Heart failure (HF) is associated with increased mortality worldwide. Adverse health outcomes in HF are commonly attributed to poor adherence to self-care, including smoking cessation. Smoking is the major modifiable risk factor for HF. Patients have been observed to continue smoking even after diagnosis with HF. Despite the possible association between persistent smoking and adverse health outcomes among HF populations, no consensus has been reached. We aimed to review the literature to determine the association between smoking status after HF diagnosis and adverse health outcomes.

METHODS

A systematic literature search was performed in PubMed, PsycINFO, Web of Science, and Embase. Hand searching was also performed. In total, 9 articles (n=70461) were included in the review for meta-analysis, including seven cohort studies and two cross-sectional studies. Quality was assessed using the modified version of the Newcastle-Ottawa Scale.

RESULTS

Approximately 16% of HF patients continued smoking after HF diagnosis. Persistent smoking increased the hazard ratio (HR) of mortality by 38.4% (HR=1.384; 95% CI: 1.139-1.681) and readmission by 44.8% (HR=1.448; 95% CI: 1.086-1.930). Our review also found that persistent smoking was associated with poor health status, ventricular tachycardia, and arterial stiffness.

CONCLUSIONS

This review highlights the importance of assessment for any history of smoking before and after HF diagnosis. There is a need for smoking cessation programs to be established as crucial components of care for patients with HF. More studies are needed to investigate the possible mechanisms underlying relations among smoking patterns and health consequences.

Arterial Stiffness Assessed by Cardio-Ankle Vascular Index

Arterial stiffness is an age-related disorder. In the medial layer of arteries, mechanical fracture due to fatigue failure for the pulsatile wall strain causes medial degeneration vascular remodeling. The alteration of extracellular matrix composition and arterial geometry result in structural arterial stiffness. Calcium deposition and other factors such as advanced glycation end product-mediated collagen cross-linking aggravate the structural arterial stiffness. On the other hand, endothelial dysfunction is a cause of arterial stiffness. The biological molecular mechanisms relating to aging are known to involve the progression of arterial stiffness. Arterial stiffness further applies stress on large arteries and also microcirculation. Therefore, it is closely related to adverse outcomes in cardiovascular and cerebrovascular system. Cardio-ankle vascular index (CAVI) is a promising diagnostic tool for evaluating arterial stiffness. The principle is based on stiffness parameter β, which is an index intended to assess the distensibility of carotid artery. Stiffness parameter β is a two-dimensional technique obtained from changes of arterial diameter by pulse in one section. CAVI applied the stiffness parameter β to all of the arterial segments between heart and ankle using pulse wave velocity. CAVI has been commercially available for a decade and the clinical data of its effectiveness has accumulated. The characteristics of CAVI differ from other physiological tests of arterial stiffness due to the independency from blood pressure at the time of examination. This review describes the pathophysiology of arterial stiffness and CAVI. Molecular mechanisms will also be covered.