Smoking and Cardiac Structure and Function in the Elderly: The ARIC Study (Atherosclerosis Risk in Communities)

Association Between Major Adverse Cardiovascular Events and Left Ventricular Mass Index in Patients Who Have Undergone Coronary Computed Tomography Angiography: From the FU-CCTA Registry

Background

Left ventricular mass (LVM) is a predictor of future cardiovascular risk. We determined the association between LVM measured by coronary computed tomography angiography (CCTA) and the prognosis in patients who have undergone CCTA for screening of coronary artery disease (CAD).

Methods

We performed a prospective cohort study. Five hundred twenty consecutive patients who underwent CCTA at Fukuoka University Hospital (FU-CCTA registry) were enrolled. They were clinically suspected of having CAD or had at least one cardiovascular risk factor, and were a follow-up of up to 5 years. Equal to more than 50% of coronary stenosis as assessed by CCTA was diagnosed as CAD. Using CCTA, LVM index (LVMI), LV ejection fraction (LVEF), LV end-diastolic volume (LVEDV) and LV end-systolic volume were measured. The primary endpoint was major adverse cardiovascular events (MACEs: including all causes of death, ischemic stroke, acute myocardial infarction and coronary revascularization). The patients were divided into non-MACEs and MACEs groups.

Results

The non-MACEs and MACEs groups consisted of 478 and 42 patients, respectively. Percent of CAD in the MACEs group was significantly higher than that in the non-MACEs group. The MACEs group showed significantly higher LVMI and tended to have a lower LVEF and LVEDV than the non-MACEs group. Although LVMI was not associated with MACEs in all patients, LVMI was independently associated with MACEs in males (odd ratio: 1.018, 95% confidence interval: 1.002 - 1.035, P = 0.030), but not females.

Conclusions

Evaluation of LVMI by CCTA may be useful for predicting MACEs in males.

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.

Preventing new-onset heart failure: Intervening at stage A

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

Tissue-specific mitochondrial toxicity of cigarette smoke concentrate: consequence to oxidative phosphorylation

Cigarette smoke exposure is a well-known risk factor for developing numerous chronic health conditions, including pulmonary disease and cardiometabolic disorders. However, the cellular mechanisms mediating the toxicity of cigarette smoke in extrapulmonary tissues are still poorly understood. Therefore, the purpose of this study was to characterize the acute dose-dependent toxicity of cigarette smoke on mitochondrial metabolism by determining the susceptibility and sensitivity of mitochondrial respiration from murine skeletal (gastrocnemius and soleus) and cardiac muscles, as well as the aorta to cigarette smoke concentrate (CSC). In all tissues, exposure to CSC inhibited tissue-specific respiration capacity, measured by high-resolution respirometry, according to a biphasic pattern. With a break point of 451 ± 235 μg/mL, the aorta was the least susceptible to CSC-induced mitochondrial respiration inhibition compared with the gastrocnemius (151 ± 109 μg/mL; P = 0.008, d = 2.3), soleus (211 ± 107 μg/mL; P = 0.112; d = 1.7), and heart (94 ± 51 μg/mL; P < 0.001; d = 2.6) suggesting an intrinsic resistance of the vascular smooth muscle mitochondria to cigarette smoke toxicity. In contrast, the cardiac muscle was the most susceptible and sensitive to the effects of CSC, demonstrating the greatest decline in tissue-specific respiration with increasing CSC concentration (P < 0.001, except the soleus). However, when normalized to citrate synthase activity to account for differences in mitochondrial content, cardiac fibers' sensitivity to cigarette smoke inhibition was no longer significantly different from both fast-twitch gastrocnemius and slow-twitch soleus muscle fibers, thus suggesting similar mitochondrial phenotypes. Collectively, these findings established the acute dose-dependent toxicity of cigarette smoke on oxidative phosphorylation in permeabilized tissues involved in the development of smoke-related cardiometabolic diseases.NEW & NOTEWORTHY Despite numerous investigations into the mechanisms underlying cigarette smoke-induced mitochondrial dysfunction, no studies have investigated the tissue-specific mitochondrial toxicity to cigarette smoke. We demonstrate that, while aorta is least sensitive and susceptible to cigarette smoke-induced toxicity, the degree of cigarette smoke-induced toxicity in striated muscle depends on the tissue-specific mitochondrial content. We conclude that while the mitochondrial content influences cigarette smoke-induced toxicity in striated muscles, aorta is intrinsically protected against cigarette smoke-induced mitochondrial toxicity.

Peak early diastolic strain rate improves prediction of adverse cardiovascular outcomes in patients with ST-elevation myocardial infarction

BACKGROUND

The prognostic role of diastolic dysfunction measured by the circumferential peak early diastolic strain rate (PEDSR) on ST-elevation myocardial infarction (STEMI) is not completely established.

OBJECTIVES

We aimed to investigate the prognostic value of diastolic function by measuring PEDSR within 1 week after STEMI.

METHODS

The cardiac magnetic resonance (CMR) pictures of 420 subjects from a clinical registry study (NCT03768453) were analyzed and the composite major adverse cardiac events (MACEs) were followed up.

RESULTS

The PEDSR of patients was significantly lower compared with that of control subjects (P < 0.001). Within the median follow-up period of 52 months, PEDSR of patients who experienced MACEs deceased more significantly than that of patients without MACEs (P < 0.001). After adjusting with clinical or CMR indexes, per 0.1/s reduction of PEDSR increased the risks of MACEs to 1.402 or 1.376 fold and the risk of left ventricular (LV) remodeling to 1.503 or 1.369 fold. When PEDSR divided by best cutoff point, significantly higher risk of MACEs (P < 0.001) and more remarkable LV remodeling (P < 0.001) occurred in patients with PEDSR ≤ 0.485/s. Moreover, when adding the PEDSR to the conventional prognostic factors such as LV ejection fraction and infarction size, better prognostic risk classification models were created. Finally, aging, tobacco use, remarkable LV remodeling, and a low LV ejection fraction were factors related with the reduction of PEDSR.

CONCLUSIONS

Diastolic dysfunction has an important prognostic effect on patients with STEMI. Measurement of the PEDSR in the acute phase could serve as an effective index to predict the long-term risk of MACEs and cardiac remodeling.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

An integral perspective of canonical cigarette and e-cigarette-related cardiovascular toxicity based on the adverse outcome pathway framework

BACKGROUND

Nowadays, cigarette smoking remains the leading cause of chronic disease and premature death, especially cardiovascular disease. As an emerging tobacco product, e-cigarettes have been advocated as alternatives to canonical cigarettes, and thus may be an aid to promote smoking cessation. However, recent studies indicated that e-cigarettes should not be completely harmless to the cardiovascular system.

AIM OF REVIEW

This review aimed to build up an integral perspective of cigarettes and e-cigarettes-related cardiovascular toxicity.

KEY SCIENTIFIC CONCEPTS OF REVIEW

This review adopted the adverse outcome pathway (AOP) framework as a pivotal tool and aimed to elucidate the association between the molecular initiating events (MIEs) induced by cigarette and e-cigarette exposure to the cardiovascular adverse outcome. Since the excessive generation of reactive oxygen species (ROS) has been widely approved to play a critical role in cigarette smoke-related CVD and may also be involved in e-cigarette-induced toxic effects, the ROS overproduction and subsequent oxidative stress are regarded as essential parts of this framework. As far as we know, this should be the first AOP framework focusing on cigarette and e-cigarette-related cardiovascular toxicity, and we hope our work to be a guide in exploring the biomarkers and novel therapies for cardiovascular injury.

Remote exposure to secondhand tobacco smoke is associated with lower exercise capacity through effects on oxygen pulse, a proxy of cardiac stroke volume

BACKGROUND

Past exposure to secondhand tobacco smoke (SHS) is associated with exercise limitation. Pulmonary factors including air trapping contribute to this limitation but the contribution of cardiovascular factors is unclear.

OBJECTIVE

To determine the contribution of cardiovascular mechanisms to SHS-associated exercise limitation.

METHODS

We examined the cardiovascular responses to maximum-effort exercise in 245 never-smokers with remote, prolonged occupational exposure to SHS and no known history of cardiovascular disease. We estimated the contribution of oxygen-pulse (proxy for cardiac stroke volume) and changes in systolic blood pressures (SBP), diastolic blood pressures and heart rate (HR) towards exercise capacity, and examined whether the association of SHS with exercise capacity was mediated through these variables.

RESULTS

At peak exercise (highest workload completed (WattsPeak)=156±46 watts (135±33 %predicted)), oxygen consumption and oxygen-pulse (O2-PulsePeak) were 1557±476 mL/min (100±24 %predicted) and 11.0±3.0 mL/beat (116±25 %predicted), respectively, with 29% and 3% participants not achieving their predicted normal range. Oxygen saturation at peak exercise was 98%±1% and remained >93% in all participants. Sixty-six per cent showed hypertensive response to exercise. In models adjusted for covariates, WattsPeak was associated directly with O2-PulsePeak, HRPeak and SBPPeak and inversely with SHS, air trapping (residual volume/total lung capacity) and rise of SBP over workload (all p<0.01). Moreover, SHS exposure association with WattsPeak was substantially (41%) mediated through its effect on O2-PulsePeak (p=0.038). Although not statistically significant, a considerable proportion (36%) of air trapping effect on WattsPeak seemed to be mediated through O2-PulsePeak (p=0.078). The likelihood of having baseline respiratory symptoms (modified Medical Research Council score ≥1) was associated with steeper rise in SBP over workload (p<0.01).

CONCLUSION

In a never-smoker population with remote exposure to SHS, abnormal escalation of blood pressure and an SHS-associated reduction in cardiac output contributed to lower exercise capacity.

Relation of Cigarette Smoking and Heart Failure in Adults ≥65 Years of Age (From the Cardiovascular Health Study)

Cigarette smoking is associated with adverse cardiac outcomes, including incident heart failure (HF). However, key components of potential pathways from smoking to HF have not been evaluated in older adults. In a community-based study, we studied cross-sectional associations of smoking with blood and imaging biomarkers reflecting mechanisms of cardiac disease. Serial nested, multivariable Cox models were used to determine associations of smoking with HF, and to assess the influence of biochemical and functional (cardiac strain) phenotypes on these associations. Compared with never smokers, smokers had higher levels of inflammation (C-reactive protein and interleukin-6), cardiomyocyte injury (cardiac troponin T [hscTnT]), myocardial "stress"/fibrosis (soluble suppression of tumorigenicity 2 [sST2], galectin 3), and worse left ventricle systolic and diastolic function. In models adjusting for age, gender, and race (DEMO) and for clinical factors potentially in the causal pathway (CLIN), smoking exposures were associated with C-reactive protein and interleukin-6, sST2, hscTnT, and with N-terminal pro-brain natriuretic protein (in Whites). In DEMO adjusted models, the cumulative burden of smoking was associated with worse left ventricle systolic strain. Current smoking and former smoking were associated with HF in DEMO models (hazard ratio 1.41, 95% confidence interval 1.22 to 1.64 and hazard ratio 1.14, 95% confidence interval 1.03 to 1.25, respectively), and with current smoking after CLIN adjustment. Adjustment for time-varying myocardial infarction, inflammation, cardiac strain, hscTnT, sST2, and galectin 3 did not materially alter the associations. Smoking was associated with HF with preserved and decreased ejection fraction. In conclusion, in older adults, smoking is associated with multiple blood and imaging biomarker measures of pathophysiology previously linked to HF, and to incident HF even after adjustment for clinical intermediates.

Lifestyle and Cardiovascular Risk Factors Associated With Heart Failure Subtypes in Postmenopausal Breast Cancer Survivors

Background

Breast cancer (BC) survivors experience an increased burden of long-term comorbidities, including heart failure (HF). However, there is limited understanding of the risk for the development of HF subtypes, such as HF with preserved ejection fraction (HFpEF), in BC survivors.

Objectives

This study sought to estimate the incidence of HFpEF and HF with reduced ejection fraction (HFrEF) in postmenopausal BC survivors and to identify lifestyle and cardiovascular risk factors associated with HF subtypes.

Methods

Within the Women’s Health Initiative, participants with an adjudicated diagnosis of invasive BC were followed to determine the incidence of hospitalized HF, for which adjudication procedures determined left ventricular ejection fraction. We calculated cumulative incidences of HF, HFpEF, and HFrEF. We estimated HRs for risk factors in relation to HF, HFpEF, and HFrEF using Cox proportional hazards survival models.

Results

In 2,272 BC survivors (28.6% Black and 64.9% White), the cumulative incidences of hospitalized HFpEF and HFrEF were 6.68% and 3.96%, respectively, over a median of 7.2 years (IQR: 3.6-12.3 years). For HFpEF, prior myocardial infarction (HR: 2.83; 95% CI: 1.28-6.28), greater waist circumference (HR: 1.99; 95% CI: 1.14-3.49), and smoking history (HR: 1.65; 95% CI: 1.01-2.67) were the strongest risk factors in multivariable models. With the exception of waist circumference, similar patterns were observed for HFrEF, although none were significant. In relation to those without HF, the risk of overall mortality in BC survivors with hospitalized HFpEF was 5.65 (95% CI: 4.11-7.76), and in those with hospitalized HFrEF, it was 3.77 (95% CI: 2.51-5.66).

Conclusions

In this population of older, racially diverse BC survivors, the incidence of HFpEF, as defined by HF hospitalizations, was higher than HFrEF. HF was also associated with an increased mortality risk. Risk factors for HF were largely similar to the general population with the exception of prior myocardial infarction for HFpEF. Notably, both waist circumference and smoking represent potentially modifiable factors.

Preventing heart failure: a position paper of the Heart Failure Association in collaboration with the European Association of Preventive Cardiology

The heart failure epidemic is growing and its prevention, in order to reduce associated hospital readmission rates and its clinical and economic burden, is a key issue in modern cardiovascular medicine. The present consensus document aims to provide practical evidence-based information to support the implementation of effective preventive measures. After reviewing the most common risk factors, an overview of the population attributable risks in different continents is presented, to identify potentially effective opportunities for prevention and to inform preventive strategies. Finally, potential interventions that have been proposed and have been shown to be effective in preventing HF are listed.

Preventing heart failure: a position paper of the Heart Failure Association in collaboration with the European Association of Preventive Cardiology

The heart failure epidemic is growing and its prevention, in order to reduce associated hospital readmission rates and its clinical and economic burden, is a key issue in modern cardiovascular medicine. The present position paper aims to provide practical evidence-based information to support the implementation of effective preventive measures. After reviewing the most common risk factors, an overview of the population attributable risks in different continents is presented, to identify potentially effective opportunities for prevention and to inform preventive strategies. Finally, potential interventions that have been proposed and have been shown to be effective in preventing heart failure are listed.

Nicotine Use Disorder in Older Adults

Nicotine is one of the most abused substances worldwide. Just as in adolescence and adulthood, tobacco use is also problematic in the elderly. Older people are more vulnerable to smoking consequences because of the additive effects of smoke. Cardiovascular diseases are the most common health problems associated with smoking; however, other systems are also affected, including the respiratory, nervous, integumentary, and many other systems. Smoking cessation is a difficult task especially in the elderly; therefore, physicians should encourage older patients to quit with every patient-physician encounter by offering counseling and replacement therapy.

Association of smoking with indicators of the structure and function of left ventricle of the heart in middle-aged men

Aim. Evaluation of the association of smoking (status, intensity and duration) with indicators of the structure and function of the left ventricle of the heart in a sample of middle-aged men.

Material and methods. This study is part of a 32-year prospective cohort observation of men from childhood (11-12 years). 301 (30.0%) representatives of the original population sample aged 41-44 years were included in the study. The examination included a survey on intensity of smoking, anthropometry, measuring blood pressure, pulse rate, echocardiography, and blood lipid analysis.

Results. 301 men aged 41-44 included 92 (30.6%) men who had never smoked, 73 (24.3%) men smoked in the past and 136 (45.2%) men currently smoke. 75% of current smokers started smoking before age 19, of which 32.3% started smoking before age 15. The duration of smoking cessation among former smokers was 14.4 (12.5; 16.2) years. The average duration of smoking [average (95% confidence interval)] among former smokers was 14.4 (12.5; 16.2), for current smokers – 25.3 (24.6; 26.0) years. Current smoking was statistically significantly associated with higher mean values of the left ventricular myocardium mass (LVMM), the left ventricular myocardial mass index (LVMMI), the end-systolic and end-diastolic interventricular septum thickness (IVSTs/IVSTd), the end-systolic left ventricular posterior wall thickness (LVPWs), and the intensity and duration of current smoking were associated with higher values of the relative wall thickness of the left ventricle, the end-diastolic interventricular septum thickness, the end-systolic interventricular septum thickness, and with low values of the left ventricular stroke volume index (LV SVI). Multiple regression analysis showed that current smoking has an independent effect on the left ventricular myocardium mass, the left ventricular myocardial mass index and the end-diastolic interventricular septum thickness, and the duration and intensity of smoking has an effect on the index of the left ventricular stroke volume index.

Conclusion. Current smoking, duration and intensity in middle-aged men is associated with unfavorable changes in indicators of the structure and function of the left ventricle of the heart. Efforts for primary prevention of smoking should begin as early as childhood and continue into adolescence and young adulthood.

Adherence to Healthy Lifestyle and the Risk of Function Limitations in Late Life: The Atherosclerosis Risk in Communities Study

Background: Physiological function impairment is the main precursor of assisted living, movement disorder, and disability in the elderly. The relationship between a combination of healthy lifestyle factors and functional limitations is unclear. We investigated the association between healthy lifestyle scores and the risk of functional impairment in community residents.

Methods: A total of 10,602 participants (aged 40–64 years) of the Atherosclerosis Risk in Communities (ARIC) study with no history of cardiovascular events and tumors and who came for their fourth visit (1997–1999) were included in the final analysis. Primary outcomes were recorded during the fourth visit; these included impaired lower extremity function, activities of daily living, and instrumental activities of daily living. A logistic regression model was used to test the associations between healthy lifestyle scores and functional impairment. The lifestyle score comprised six factors: healthy diet, moderate alcohol consumption, coffee consumption, physical activity, normal body weight, and no smoking.

Results: Among the 10,602 participants with a median follow-up of 9 years, the prevalence rates of impaired lower extremity function, activities of daily living, and instrumental activities of daily living were 50.6%, 14.7%, and 21.6%, respectively. In the adjusted Cox regression model, participants with a healthy lifestyle score of 5 plus 6 had a significant lower risk of impaired lower extremity function (odds ratio = 0.252, 95% confidence interval: 0.184–0.344, P < 0.001), activities of daily living (odds ratio = 0.201, 95% confidence interval: 0.106–0.380, P < 0.001), and instrumental activities of daily living (odds ratio = 0.274, 95% confidence interval: 0.168–0.449, P < 0.001) than did participants with a score of 0. The association of healthy lifestyle scores with impaired activities of daily living and instrumental activities of daily living was stronger for individuals without diabetes than for those with it (P for interaction < 0.05). This can be partly explained by the fact that the lowest risk of functional impairment among the participants with diabetes was associated with being overweight.

Conclusion: Adherence to an overall healthy lifestyle was associated with a lower risk of physiological function limitation. This study highlights the importance of behavioral interventions in the prevention of disabilities.

Clinical Trial Registration: www.ClinicalTrials.gov; Unique identifier: NCT00005131.

Smoking Status, Intensity of Smoking, and Their Relation to Left Ventricular Hypertrophy in Working Aged Korean Men

INTRODUCTION

Smoking is an established risk factor for atherosclerotic cardiovascular disease. However, the effect of smoking on left ventricular (LV) structure has been less studied. This study was designed to assess the association of smoking status and smoking intensity with left ventricular hypertrophy (LVH).

METHODS

Study subjects were 53,666 working aged Korean men who received echocardiography as an item of health check up. They were grouped by smoking status (never, former, and current smokers), pack-year of smoking (never, <10, 10-19.9, and ≥20 pack-year), and urine cotinine excretion (<100, 100-999, ≥1000 ng/mL). Multivariate logistic regression analysis was used in calculating adjusted odds ratios (ORs) and 95% confidence interval for LVH (adjusted odds ratios [95% confidence interval]). The proportions of abnormal LV geometry patterns were compared among groups.

RESULTS

Former and current smokers had the higher levels in LV mass index, relative wall thickness, and the prevalence of LVH than never smoker. The association with LVH increased in order of never (reference), former (1.44 [1.01-2.04]), and current smokers (2.10 [1.44-3.05]). LVH showed the proportional relationship with pack-year of smoking (never smoker: reference, <10: 1.45 [1.01-2.08], 10-19.9: 1.73 [1.17-2.57], ≥20: 2.43 [1.58-3.74]) and urine cotinine excretion (never smoker: reference, 100-999: 1.70 [1.21-2.37], >1000: 1.97 [1.43-2.72]). The proportions of abnormal LV geometry patterns were higher in smoking groups than never smoking group.

CONCLUSION

Exposure to tobacco use and intensity of smoking was associated with LVH in working aged population.

IMPLICATIONS

In working aged Koreans with mean age of 39.9 ± 7.0 years, former and current smokers are more likely to have LVH than never smoker. Dose-dependent relationship was found between the smoking status (never, former, and current smokers), pack-year of smoking, urine cotinine excretion, and LVH. These findings indicate that smoking has an adverse influence on LV structure even in relatively young age group.

Clinical and demographic correlates of accelerometer-measured physical activity in participants enrolled in the OPTIMISE HFpEF study

AIMS

This study aimed to measure physical activity (PA) in participants with suspected heart failure with preserved ejection fraction (HFpEF) and assess associations between PA and participant characteristics.

METHODS AND RESULTS

Adults with presumed HFpEF were recruited and received diagnostic evaluation and clinical assessment. Physical activity was objectively measured using accelerometers over 7 days. To examine predictors of PA, a best subset analysis was used, with the optimal model defined as that with the lowest Bayesian information criterion. One hundred and twenty-four participants with presumed HFpEF who had valid accelerometer data were included in this study. Seventy-six were confirmed by a cardiologist as meeting the European Society of Cardiology diagnosis criteria for HFpEF. The median age of all participants was 80.1 years, and 47.4% were female. Patients spent most of each 24-h period at low-intensity PA and few or no durations at high-intensity PA, with lower activity for those with HFpEF. Gait speed was the best univariate correlate of activity levels (adjusted R2 0.29). The optimal model using best subsets regression included six variables and improved adjusted R2 to 0.47. In the model, lower levels of PA were associated with slower gait speed, lower levels of anxiety, higher levels of depression, past smoking history, a confirmed HFpEF diagnosis, and higher body mass index.

CONCLUSION

Participants demonstrated very low PA levels. The study has identified important patient characteristics associated with PA, which may help to identify those most in need of interventions. Notably, participants with confirmed HFpEF were more inactive than participants with other heart failure phenotypes.

Impact of cardiovascular risk factors on myocardial work-insights from the STAAB cohort study

Myocardial work is a new echocardiography-based diagnostic tool, which allows to quantify left ventricular performance based on pressure–strain loops, and has been validated against invasively derived pressure–volume measurements. Myocardial work is described by its components (global constructive work [GCW], global wasted work [GWW]) and indices (global work index [GWI], global work efficiency [GWE]). Applying this innovative concept, we characterized the prevalence and severity of subclinical left ventricular compromise in the general population and estimated its association with cardiovascular (CV) risk factors. Within the Characteristics and Course of Heart Failure STAges A/B and Determinants of Progression (STAAB) cohort study we comprehensively phenotyped a representative sample of the population of Würzburg, Germany, aged 30–79 years. Indices of myocardial work were determined in 1929 individuals (49.3% female, mean age 54 ± 12 years). In multivariable analysis, hypertension was associated with a mild increase in GCW, but a profound increase in GWW, resulting in higher GWI and lower GWE. All other CV risk factors were associated with lower GCW and GWI, but not with GWW. The association of hypertension and obesity with GWI was stronger in women. We conclude that traditional CV risk factors impact selectively and gender-specifically on left ventricular myocardial performance, independent of systolic blood pressure. Quantifying active systolic and diastolic compromise by derivation of myocardial work advances our understanding of pathophysiological processes in health and cardiac disease.

Standardised computed tomographic assessment of left atrial morphology and tissue thickness in humans

AIMS

Left atrial (LA) remodelling is a common feature of many cardiovascular pathologies and is a sensitive marker of adverse cardiovascular outcomes. The aim of this study was to establish normal ranges for LA parameters derived from coronary computed tomographic angiography (CCTA) imaging using a standardised image processing pipeline to establish normal ranges in a previously described cohort.

METHODS

CCTA imaging from 193 subjects recruited to the Budapest GLOBAL twin study was analysed. Indexed LA cavity volume (LACVi), LA surface area (LASAi), wall thickness and LA tissue volume (LATVi) were calculated. Wall thickness maps were combined into an atlas. Indexed LA parameters were compared with clinical variables to identify early markers of pathological remodelling.

RESULTS

LACVi is similar between sexes (31 ml/m2 v 30 ml/m2) and increased in hypertension (33 ml/m2 v 29 ml/m2, p = 0.009). LASAi is greater in females than males (47.8 ml/m2 v 45.8 ml/m2 male, p = 0.031). Median LAWT was 1.45 mm. LAWT was lowest at the inferior portion of the posterior LA wall (1.14 mm) and greatest in the septum (median = 2.0 mm) (p < 0.001). Conditions known to predispose to the development of AF were not associated with differences in tissue thickness.

CONCLUSIONS

The reported LACVi, LASAi, LATVi and tissue thickness derived from CCTA may serve as reference values for this age group and clinical characteristics for future studies. Increased LASAi in females in the absence of differences in LACVi or LATVi may indicate differential LA shape changes between the sexes. AF predisposing conditions, other than sex, were not associated with detectable changes in LAWT.Clinical trial registration:http://www.ClinicalTrials.gov/NCT01738828.

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

Background

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

Methods and Results

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

Conclusions

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

Registration

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

The role of glucose metabolism and insulin resistance in cardiac remodelling induced by cigarette smoke exposure

The aim of this study is to evaluate whether the alterations in glucose metabolism and insulin resistance are mechanisms presented in cardiac remodelling induced by the toxicity of cigarette smoke. Male Wistar rats were assigned to the control group (C; n = 12) and the cigarette smoke-exposed group (exposed to cigarette smoke over 2 months) (CS; n = 12). Transthoracic echocardiography, blood pressure assessment, serum biochemical analyses for catecholamines and cotinine, energy metabolism enzymes activities assay; HOMA index (homeostatic model assessment); immunohistochemistry; and Western blot for proteins involved in energy metabolism were performed. The CS group presented concentric hypertrophy, systolic and diastolic dysfunction, and higher oxidative stress. It was observed changes in energy metabolism, characterized by a higher HOMA index, lower concentration of GLUT4 (glucose transporter 4) and lower 3-hydroxyl-CoA dehydrogenase activity, suggesting the presence of insulin resistance. Yet, the cardiac glycogen was depleted, phosphofructokinase (PFK) and lactate dehydrogenase (LDH) increased, with normal pyruvate dehydrogenase (PDH) activity. The activity of citrate synthase, mitochondrial complexes and ATP synthase (adenosine triphosphate synthase) decreased and the expression of Sirtuin 1 (SIRT1) increased. In conclusion, exposure to cigarette smoke induces cardiac remodelling and dysfunction. The mitochondrial dysfunction and heart damage induced by cigarette smoke exposure are associated with insulin resistance and glucose metabolism changes.

Radiomics Signatures of Cardiovascular Risk Factors in Cardiac MRI: Results From the UK Biobank

Cardiovascular magnetic resonance (CMR) radiomics is a novel technique for advanced cardiac image phenotyping by analyzing multiple quantifiers of shape and tissue texture. In this paper, we assess, in the largest sample published to date, the performance of CMR radiomics models for identifying changes in cardiac structure and tissue texture due to cardiovascular risk factors. We evaluated five risk factor groups from the first 5,065 UK Biobank participants: hypertension (n = 1,394), diabetes (n = 243), high cholesterol (n = 779), current smoker (n = 320), and previous smoker (n = 1,394). Each group was randomly matched with an equal number of healthy comparators (without known cardiovascular disease or risk factors). Radiomics analysis was applied to short axis images of the left and right ventricles at end-diastole and end-systole, yielding a total of 684 features per study. Sequential forward feature selection in combination with machine learning (ML) algorithms (support vector machine, random forest, and logistic regression) were used to build radiomics signatures for each specific risk group. We evaluated the degree of separation achieved by the identified radiomics signatures using area under curve (AUC), receiver operating characteristic (ROC), and statistical testing. Logistic regression with L1-regularization was the optimal ML model. Compared to conventional imaging indices, radiomics signatures improved the discrimination of risk factor vs. healthy subgroups as assessed by AUC [diabetes: 0.80 vs. 0.70, hypertension: 0.72 vs. 0.69, high cholesterol: 0.71 vs. 0.65, current smoker: 0.68 vs. 0.65, previous smoker: 0.63 vs. 0.60]. Furthermore, we considered clinical interpretation of risk-specific radiomics signatures. For hypertensive individuals and previous smokers, the surface area to volume ratio was smaller in the risk factor vs. healthy subjects; perhaps reflecting a pattern of global concentric hypertrophy in these conditions. In the diabetes subgroup, the most discriminatory radiomics feature was the median intensity of the myocardium at end-systole, which suggests a global alteration at the myocardial tissue level. This study confirms the feasibility and potential of CMR radiomics for deeper image phenotyping of cardiovascular health and disease. We demonstrate such analysis may have utility beyond conventional CMR metrics for improved detection and understanding of the early effects of cardiovascular risk factors on cardiac structure and tissue.

Influence of cigarette smoking on biventricular systolic function independent of respiratory function: a cross-sectional study

Background

Cigarette smoking harms nearly every organ, including the heart and lungs. A comprehensive assessment of both cardiac and respiratory function is necessary for evaluating the direct effects of tobacco on the heart. However, few previous studies examining the effects of cigarette smoking on cardiac function included an assessment of lung function. This cross-sectional study investigated the influence of cigarette smoking on cardiac function, independent of respiratory function.

Methods

We retrospectively reviewed the medical records of 184 consecutive cases that underwent both spirometry and transthoracic echocardiography around the same time (within 1 month) in one hospital from April 2019 to March 2020. Participants were classified into three groups based on lifetime smoking exposure (pack-years): non-smoker (n = 49), low exposure (1–20 pack-years, n = 40), and high exposure (≥ 20 pack years, n = 95). Multiple linear regression analysis was used to assess the relationship among cigarette smoking, and cardiac and respiratory functions. The relationship between selected dependent variables and lifetime pack-years was assessed in two models with multiple linear regression analysis. Model 1 was adjusted for age and male sex; and Model 2 was adjusted for Model 1 plus forced expiratory volume percentage in 1 s and forced vital capacity percentage.

Results

Compared with the non-smokers, the participants with high smoking exposure had lower left ventricular (LV) systolic function and larger LV size. Multiple linear regression analysis revealed a negative association of cumulative lifetime pack-years with LV and right ventricular (RV) systolic functions, even after adjustment for age, sex, and spirometric parameters (forced expiratory volume percentage in 1 s and forced vital capacity percentage). Meanwhile, there was no significant association of smoking exposure with LV diastolic function (E/e′ and E/A) and RV diastolic function (e′t and e′t/a′t).

Conclusions

Cumulative smoking exposure was associated with a negative effect on biventricular systolic function in patients with relatively preserved cardiac function, independent of respiratory function.

A population-based phenome-wide association study of cardiac and aortic structure and function

Differences in cardiac and aortic structure and function are associated with cardiovascular diseases and a wide range of other types of disease. Here we analyzed cardiovascular magnetic resonance images from a population-based study, the UK Biobank, using an automated machine-learning-based analysis pipeline. We report a comprehensive range of structural and functional phenotypes for the heart and aorta across 26,893 participants, and explore how these phenotypes vary according to sex, age and major cardiovascular risk factors. We extended this analysis with a phenome-wide association study, in which we tested for correlations of a wide range of non-imaging phenotypes of the participants with imaging phenotypes. We further explored the associations of imaging phenotypes with early-life factors, mental health and cognitive function using both observational analysis and Mendelian randomization. Our study illustrates how population-based cardiac and aortic imaging phenotypes can be used to better define cardiovascular disease risks as well as heart-brain health interactions, highlighting new opportunities for studying disease mechanisms and developing image-based biomarkers.

Are there gender differences in the association between body mass index and left ventricular diastolic function? A clinical observational study in the Japanese general population

BACKGROUND

Increased body mass index (BMI) is a major risk factor for heart failure with preserved ejection fraction (HFpEF), and HFpEF is more prevalent in elderly females than males. We hypothesized that there may be gender differences in the association between BMI and echocardiographic left ventricular (LV) diastolic parameters.

METHODS

We enrolled 456 subjects (243 males) without overt cardiac diseases, all of whom underwent a health checkup. Early (E) and late (A) diastolic transmitral flow velocity, early diastolic mitral annular velocity (e'), and left atrial (LA) volume index were measured by echocardiography to assess LV diastolic function. To examine gender differences in the association between BMI and LV diastolic function, we analyzed the interaction effects of gender on the association between BMI and echocardiographic LV diastolic parameters.

RESULTS

Although there were significant gender differences in the association between BMI and E/A and e' in the crude model (interaction effect 0.037 and 0.173, respectively; P = .006 and .022, respectively), these differences were not statistically significant after adjustment for factors related to LV diastolic function. On the other hand, there were significant associations between BMI and LV diastolic parameters in each gender, even after adjustment.

CONCLUSIONS

Our findings suggest there is no gender difference in the association between BMI and echocardiographic LV diastolic parameters. However, the association between BMI and LV diastolic parameters was significant in both genders. Controlling body weight might be beneficial for both women and men to prevent progression of LV diastolic dysfunction and development of HFpEF.

Echocardiographic L-wave as a prognostic indicator in transcatheter aortic valve replacement

This study applies L-wave measurements of mid-diastolic trans-mitral flow. Although considered to be a marker of elevated filling pressure or delayed myocardial relaxation, its clinical and prognostic value is yet to be completely elucidated. It has been shown that transcatheter aortic valve replacement (TAVR) induces reverse remodeling and improves diastolic function and prognosis in patients with severe aortic stenosis (AS). Our purpose was to evaluate the prognostic value of L-wave following TAVR. We examined clinical and echocardiographic data of patients undergoing TAVR. L-Wave presence and velocity were recorded at baseline and at 1 month and 6 months following TAVR. The effect of the procedure on L-wave measurements and its impact on mortality and other clinical outcomes were analyzed. A total of 502 patients (mean age 82.58 ± 5.9) undergoing TAVR were included. Patients with baseline L-wave (n = 68, 12%) had a smaller stroke volume index by 5.7 ± 2.3 ml/m² (p = 0.01) as compared to patients without L-wave at baseline. L-waves disappeared In 35% and 70% of patients at 1 month and at 6 months respectively. Baseline L-wave velocity was 34.8 ± 11.5 (cm/s) and decreased significantly at follow-up examinations. Patients with persistent L-wave following TAVR had higher 3-year adjusted mortality rates (HR 5.7, 95% CI 3.7-8.9, p < 0.001). Multivariate analysis of survival was also statistically significant (p < 0.001). TAVR induces L-wave disappearance and a decrease in L-wave velocity in patients with severe AS. L-wave persistence following TAVR is an independent risk factor for mortality.

Active Tobacco Smoking Impairs Cardiac Systolic Function

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

The Effects of Electronic Nicotine Delivery Systems on Athletes

The rapid rise in popularity of Electronic Nicotine Delivery Systems (ENDS), or vaping, has not eluded the athletic population. Increasing use of youth sports participants, as well as collegiate and professionals, means sports medicine providers and coaches alike should be familiar with the effects of these devices. Current evidence demonstrates an impact on both the cardiovascular and pulmonary systems. These effects appear less significant than smoking tobacco cigarettes, but the extent and longevity of the consequences of ENDS use is unclear. Mechanisms for recovery, such as sleep and injury healing, also are affected. Lastly, the emergence of life-threatening pulmonary disease associated with ENDS use may have devastating effects on an athlete. This article will highlight the recent literature on the impact of ENDS on athletes and athletic performance, as well as the potentially life-threatening consequences of use.

Association of smoking and right ventricular function in middle age: CARDIA study

Objective

To evaluate the association of cigarette smoking and right ventricular (RV) systolic and diastolic functions in a population-based cohort of individuals at middle age.

Methods

This cross-sectional study included participants who answered the smoking questionnaire and underwent echocardiography at the Coronary Artery Risk Development in Young Adulthood year 25 examination. RV systolic function was assessed by echocardiographic-derived tricuspid annular plane systolic excursion (TAPSE) and by right ventricular peak systolic velocity (RVS'), while RV diastolic function was evaluated by early right ventricular tissue velocity (RVE'). Multivariable linear regression models assessed the relationship of smoking with RV function, adjusting for age, sex, race, body mass index, systolic blood pressure, total cholesterol, high-density lipoprotein (HDL) cholesterol, diabetes mellitus, alcohol consumption, pulmonary function, left ventricular systolic and diastolic function and coronary artery calcium score.

Results

A total of 3424 participants were included. The mean age was 50±4 years; 57% were female; and 53% were black. There were 2106 (61%) never smokers, 750 (22%) former smokers and 589 (17%) current smokers. In the multivariable analysis, current smokers had significantly lower TAPSE (β=-0.082, SE=0.031, p=0.008), RVS' (β=-0.343, SE=0.156, p=0.028) and RVE' (β=-0.715, SE=0.195, p<0.001) compared with never smokers. Former smokers had a significantly lower RVE' compared with never smokers (β=-0.414, SE=0.162, p=0.011), whereas no significant difference in RV systolic function was found between former smokers and never smokers.

Conclusions

In a large multicenter community-based biracial cohort of middle-aged individuals, smoking was independently related to both worse RV systolic and diastolic functions.

Comparison of morphometry and ventricular function of healthy and smoking young people

Background

Tobacco smoke is one of the most significant risk factors for cardiovascular diseases and damages in the myocardial tissue directly. Cardiac magnetic resonance (CMR) has been used and is a promising tool to evaluate morphometry and cardiac function in humans. The objective of this study was to evaluate associations of smoking with morphometry and cardiac function by CMR technique in young adult smokers.

Methods

Altogether, 49 volunteers (22 smokers and 27 non-smokers) were included in the study. The comparisons between groups were performed by multiple linear regression adjusting for body mass index and gender.

Results

In the morphometric and functional evaluation of the left ventricle, we observed statistical significant lower values of end-diastolic volume (EDV) (p = 0.02), ejection volume (EV) (p = 0.001) and indexed ejection volume (IEV) (p = 0.007) in smokers when compared to no-smoker group. Right ventricle showed statistical significant lower values of EDV (p = < 0.001), end-systolic volume (p = 0.01), EV (p = < 0.001), IEV (p = 0.001), indexed end-diastolic volume (p = 0.001) and major axis (p = 0.01) in smokers when compared to non-smokers group.

Conclusions

There is a strongly association of smoking in young adult and cardiac function decline, even adjusted by cofounders, which compromises the proper functioning of the heart. Evidence confirms that smoking can directly influence the cardiac function, even without atherosclerosis or other chronic comorbidities, associated with increased risk of cardiovascular diseases.

A 6-month systems toxicology inhalation study in ApoE-/- mice demonstrates reduced cardiovascular effects of E-vapor aerosols compared with cigarette smoke

Smoking cigarettes is harmful to the cardiovascular system. Considerable attention has been paid to the reduced harm potential of alternative nicotine-containing inhalable products such as e-cigarettes. We investigated the effects of E-vapor aerosols or cigarette smoke (CS) on atherosclerosis progression, cardiovascular function, and molecular changes in the heart and aorta of female apolipoprotein E-deficient (ApoE^-/-) mice. The mice were exposed to aerosols from three different E-vapor formulations: 1) carrier (propylene glycol and vegetable glycerol), 2) base (carrier and nicotine), or 3) test (base and flavor) or to CS from 3R4F reference cigarettes for up to 6 mo. Concentrations of CS and base or test aerosols were matched at 35 µg nicotine/L. Exposure to CS, compared with sham-exposed fresh air controls, accelerated atherosclerotic plaque formation, whereas no such effect was seen for any of the three E-vapor aerosols. Molecular changes indicated disease mechanisms related to oxidative stress and inflammation in general, plus changes in calcium regulation, and altered cytoskeletal organization and microtubule dynamics in the left ventricle. While ejection fraction, fractional shortening, cardiac output, and isovolumic contraction time remained unchanged following E-vapor aerosols exposure, the nicotine-containing base and test aerosols caused an increase in isovolumic relaxation time similar to CS. A nicotine-related increase in pulse wave velocity and arterial stiffness was also observed, but it was significantly lower for base and test aerosols than for CS. These results demonstrate that in comparison with CS, E-vapor aerosols induce substantially lower biological responses associated with smoking-related cardiovascular diseases.NEW & NOTEWORTHY Analysis of key urinary oxidative stress markers and proinflammatory cytokines showed an absence of oxidative stress and inflammation in the animals exposed to E-vapor aerosols. Conversely, animals exposed to conventional cigarette smoke had high urinary levels of these markers. When compared with conventional cigarette smoke, E-vapor aerosols induced smaller atherosclerotic plaque surface area and volume. Systolic and diastolic cardiac function, as well as endothelial function, were further significantly less affected by electronic cigarette aerosols than conventional cigarette smoke. Molecular analysis demonstrated that E-vapor aerosols induce significantly smaller transcriptomic dysregulation in the heart and aorta compared with conventional cigarette smoke.

Effects of chronic cigarette smoking on myocardial deformation parameters by two-dimensional speckle tracking echocardiography

BACKGROUND

Cigarette smoking causes myocardial damage with several mechanisms such as sympathetic nervous system activation, oxidative stress, and endothelial dysfunction. Chronic smokers have an increased risk of morbidity and mortality associated with cardiac events. We aimed to compare the myocardial deformation parameters between chronic smokers and nonsmoker healthy population.

METHOD

Forty-two healthy participants (mean age 33.48 ± 10.00 years) without smoking history, 40 participants (mean age 33.98 ± 9.27 years) who had been smoking were prospectively included. In addition to conventional echocardiographic measurements, global longitudinal strain (GLS) of left ventricle (LV), GLS of right ventricle (RV), left atrial strain, and strain rate were analyzed.

RESULTS

Smokers had lower peak early diastolic velocity (E) and E/a (early diastolic velocity/late diastolic velocity) ratio in mitral inflow (70.0 ± 13.9 cm/sec vs 77.1 ± 13.3 cm/sec, P = .023; 1.4 ± 0.4 vs 1.7 ± 0.4, P = .011; respectively). Peak early diastolic velocity of mitral valve septal annulus (Em) and Em/Am ratio (peak early diastolic velocity of mitral valve/late diastolic velocity of mitral valve) (11.0 ± 2.1 cm/sec vs 12.1 ± 2.4 cm/sec, P = .023; 1.2 ± 0.3 vs 1.4 ± 0.4, P = .039; respectively) were lower in smokers. LV GLS and RV GLS were significantly lower in smokers (-17.6% ± 3.01 vs -19.2% ± 2.5; P = .013, -18.9% ± 4.4 vs -21.0% ± 4.5; P = .039; respectively).

CONCLUSION

Impaired LV and RV deformation were found in chronic smokers in our study. Although there was no statistically significant difference with left ventricular ejection fraction, LV GLS which is the early indicator of LV systolic dysfunction was lower in chronic smokers. The assessment of early harmful effects of smoking on left and right ventricle might be evaluated with speckle tracking echocardiography.

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

Background

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

Methods and Results

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

Conclusions

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

Cardiopulmonary and Muscular Interactions: Potential Implications for Exercise (In)tolerance in Symptomatic Smokers Without Chronic Obstructive Pulmonary Disease

Smoking and physical inactivity are important preventable causes of disability and early death worldwide. Reduced exercise tolerance has been described in smokers, even in those who do not fulfill the extant physiological criteria for chronic obstructive pulmonary disease (COPD) and are not particularly sedentary. In this context, it is widely accepted that exercise capacity depends on complex cardio-pulmonary interactions which support oxygen (O₂) delivery to muscle mitochondria. Although peripheral muscular factors, O₂ transport disturbances (including the effects of increased carboxyhemoglobin) and autonomic nervous system unbalance have been emphasized, other derangements have been more recently described, including early microscopic emphysema, pulmonary microvascular disease, ventilatory and gas exchange inefficiency, and left ventricular diastolic dysfunction. Using an integrative physiological approach, the present review summarizes the recent advances in knowledge on the effects of smoking on the lung-heart-muscle axis under the stress of exercise. Special attention is given to the mechanisms connecting physiological abnormalities such as early cardio-pulmonary derangements, inadequate oxygen delivery and utilization, and generalized bioenergetic disturbances at the muscular level with the negative sensations (sense of heightened muscle effort and breathlessness) that may decrease the tolerance of smokers to physical exercise. A deeper understanding of the systemic effects of smoking in subjects who did not (yet) show evidences of COPD and ischemic heart disease - two devastating smoking related diseases - might prove instrumental to fight their ever-growing burden.

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

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

Determinants of left ventricular diastolic function-The Cardiovascular Risk in Young Finns Study

Decreased left ventricular (LV) diastolic function is associated with increased all-cause mortality and risk for a heart failure. The determinants of LV diastolic function have been mainly studied in elderly populations; however, the origin of LV heart failure may relate to the lifestyle factors acquired during the life course. Therefore, we examined biochemical, physiological, and lifestyle determinants of LV diastolic function in 34-49-year-old participants of the Cardiovascular Risk in Young Finns Study (Young Finns Study). In 2011, clinical examination and echocardiography were performed for 1928 participants (880 men and 1048 women; aged 34-49 years). LV diastolic function was primarily defined using E/é-ratio (population mean 4.8, range 2.1-9.0). In a multivariate model, systolic blood pressure (P < 0.005), female sex (P < 0.005), age (P < 0.005), waist circumference (P = 0.024), smoking (P = 0.028), serum alanine aminotransferase (P = 0.032) were directly associated with E/é-ratio, while an inverse association was found for height (P < 0.005). Additionally, a higher E/é-ratio was found in participants with concentric hypertrophy compared to normal cardiac geometry (P < 0.005). Other indicators of the LV diastolic function including E/A-ratio and left atrial volume index showed similarly strong associations with systolic blood pressure and age. In conclusion, we identified systolic blood pressure, waist circumference and smoking as modifiable determinants of the LV diastolic function in the 34-49-year-old participants of the Young Finns Study.

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

Background

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

Methods

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

Results

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

Conclusion

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

Effect of Cigarette Smoking on Risk for Adverse Events in Patients With Heart Failure and Preserved Ejection Fraction

Smoking is an important risk factor in the development of heart failure with preserved ejection (HFpEF), and previous reports have identified smoking as a significant predictor of death in this population. However, the relation between smoking and heart failure-specific outcomes has not been examined in patients with HFpEF. This analysis included 1,717 patients (mean age = 71 ± 10 years; 50% men; 78% white) with HFpEF enrolled in the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist Trial from the Americas. Smoking was ascertained by self-reported history and categorized as never, former, or current. Multivariable Cox regression was used to examine the risk of hospitalization for heart failure, death, and cardiovascular death across smoking categories. There were 116 current smokers (7%), 871 former smokers (51%), and 729 never smokers (42%) in this analysis. Current smoking was associated with an increased risk of hospitalization for heart failure (never: hazard ratio [HR] 1.0; former: HR 1.25, 95% confidence interval [CI] 0.99 to 1.57; current: HR 1.68, 95% CI 1.08 to 2.61), death (never: HR 1.0; former: HR 1.02, 95% CI 0.81 to 1.29; current: HR 1.82, 95% CI 1.19 to 2.78), and cardiovascular death (never: HR 1.0; former: HR 1.00, 95% CI 0.74 to 1.35; current: HR 1.85, 95% CI 1.09 to 3.24) compared with former or never smokers in a multivariable model adjusted for cardiovascular risk factors. A similar increased risk of hospitalization for heart failure (former: HR 1.0; current: HR 1.54, 95% CI 1.01, 2.36), death (former: HR 1.0; current: HR 1.81, 95% CI 1.19, 2.75), and cardiovascular death (former: HR 1.0; current: HR 1.76, 95% CI 1.04, 2.98) was observed for current smokers when we limited the analysis to those with a history of smoking. In conclusion, current smoking is associated with an increased risk for adverse outcomes in HFpEF, including hospitalization for heart failure. Smoking cessation strategies possibly have a role to reduce the risk for adverse cardiovascular outcomes in patients with HFpEF.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Spondias mombin supplementation attenuated cardiac remodelling process induced by tobacco smoke

The objective of this study was to investigate the influence of Spondias mombin (SM) supplementation on the cardiac remodelling process induced by exposure to tobacco smoke (ETS) in rats. Male Wistar rats were divided into 4 groups: group C (control, n = 20) comprised animals not exposed to cigarette smoke and received standard chow; group ETS (n = 20) comprised animals exposed to cigarette smoke and received standard chow; group ETS100 (n = 20) received standard chow supplemented with 100 mg/kg body weight/d of SM; and group ETS250 (n = 20) received standard chow supplemented with 250 mg/kg body weight/d of SM. The observation period was 2 months. The ETS animals had higher values of left cardiac chamber diameters and of left ventricular mass index. SM supplementation attenuated these changes. In addition, the myocyte cross‐sectional area (CSA) was lower in group C compared with the ETS groups; however, the ETS250 group had lower values of CSA compared with the ETS group. The ETS group also showed higher cardiac levels of lipid hydroperoxide (LH) compared with group C; and, groups ETS100 and ETS250 had lower concentrations of LH compared with the ETS group. Regarding energy metabolism, SM supplementation decreased glycolysis and increased the β‐oxidation and the oxidative phosphorylation. There were no differences in the expression of Nrf‐2, SIRT‐1, NF‐κB, interferon‐gamma and interleukin 10. In conclusion, our results suggest that ETS induced the cardiac remodelling process. In addition, SM supplementation attenuated this process, along with oxidative stress reduction and energy metabolism modulation.

Global ECG Measures and Cardiac Structure and Function: The ARIC Study (Atherosclerosis Risk in Communities)

BACKGROUND

Electric excitation initiates myocardial mechanical contraction and coordinates myocardial pumping. We hypothesized that ECG global electric heterogeneity (GEH) and its longitudinal changes are associated with cardiac structure and function.

METHODS AND RESULTS

Participants from the ARIC study (Atherosclerosis Risk in Communities) (N=5114; 58% female; 22% blacks) with resting 12-lead ECGs (visits 1-5) and echocardiographic assessment of left ventricular (LV) ejection fraction, LV global longitudinal strain, LV mass index, LV end-diastolic volume index, and LV end-systolic volume index at visit 5 were included. Longitudinal analysis included ARIC participants (N=14 609) with measured GEH at visits 1 to 4. GEH was quantified by spatial ventricular gradient, QRS-T angle, and sum absolute QRS-T integral. Cross-sectional and longitudinal regressions were adjusted for manifest and subclinical cardiovascular disease. Having 4 abnormal GEH parameters was associated with a 6.4% (95% confidence interval, 5.5-7.3) LV ejection fraction decline, a 24.2 g/m2 (95% confidence interval, 21.5-26.9) increase in LV mass index, a 10.3 mL/m2 (95% confidence interval, 8.9-11.7) increase in LV end-diastolic volume index, and a 7.8 mL/m2 (95% confidence interval, 6.9-8.6) increase in LV end-systolic volume index. Altogether, clinical and ECG parameters accounted for approximately one third of LV volume and 20% of systolic function variability. The associations were significantly stronger in cardiovascular disease. Sum absolute QRS-T integral increased by 20 mV*ms for each 3-year period in participants who demonstrated LV dilatation at visit 5. Sudden cardiac death victims demonstrated rapid GEH worsening, whereas those with LV dysfunction demonstrated slow GEH worsening. Healthy aging was associated with a distinct pattern of spatial ventricular gradient azimuth decrement.

CONCLUSIONS

GEH is a marker of subclinical abnormalities in cardiac structure and function.

Smoking intensity and duration is associated with cardiac structure and function: the ECHOcardiographic Study of Hispanics/Latinos

Objective

Cardiovascular disease is the leading cause of death in smokers and this relationship is complicated by the multiplicity of cardiovascular effects of smoking. However, the relationship between intensity and duration of cigarette smoking and echocardiographic measures of right and left ventricular structure and function has been poorly studied.

Methods

We examined ECHO-SOL (Echocardiographic Study of Hispanics/Latinos) participants, a subset of the Hispanic Community Health Study/Study of Latinos. Participants were administered a detailed tobacco exposure questionnaire and a comprehensive echocardiography exam. Multivariable linear regression models (adjusted for age, sex, obesity, hypertension and diabetes statuses) were performed using sampling weights. Statistical significance was defined at p<0.01.

Results

There were 1818 ECHO-SOL participants (57.4% women, mean age 56.4 years). Among current smokers (n=304), increased duration of smoking, as measured by a younger age of smoking initiation, was significantly associated with higher mean left ventricular mass (LVM) and lower right ventricular (RV) function (lower right ventricular stroke volumes). More cigarettes smoked per day was significantly associated with higher mean LVM, worse diastolic function (higher E/e′ ratio), worse LV geometry (increased relative wall thickness) and worse RV function (decreasing right ventricular stroke volume). Among current smokers, higher mean lifetime pack-years (a combined measure of smoking intensity and duration) was associated with higher LVM, worse LV geometry, worse diastolic function, greater RV dilatation and worse RV function.

Conclusions

There is a dose–response relationship between intensity and duration of cigarette tobacco smoking with unfavourable changes of multiple measures of right-sided and left-sided cardiac structure and function.

Prevalence of valvular heart diseases and associated risk factors in Han, Uygur and Kazak population in Xinjiang, China

Background

Valvular heart diseases (VHD) is very common in clinical practice and has became the subject of growing attention in the field of cardiovascular medicine. Our aim was to assess the prevalence and correlates of VHD in the general population in Xinjiang, China.

Methods

Using a 4-stage stratified cluster random sampling method, a total of 14618 participants were recruited in the Cardiovascular Risk Survey (CRS) study. The participants’ personal information, medical history were assessed by questionnaire. VHD was diagnosed by transthoracic echocardiography. We carried out the statistical analysis utilizing SPSS Statistics version 19.0.

Results

In the total study group, VHD was observed in 1397 (9.65%) individuals. The prevalence rates of VHD in Han, Uygur and Kazak group are 13.51%, 2.71% and 12.29% respectively. The prevalence rates of VHD increased strikingly with age (all P < 0.001). The results of multinomial regression analysis indicated that VHD were related to age in Han group, to age smoking and hypertension in Uygur group, to age and hypertension in Kazak group.

Conclusion

Our research provides a unique prevalence rate of VHD in Xinjiang natural population. The result suggests that VHD are notably common in this population (9.65%) and increase with age. There exists significant difference of prevalence rate between ethnics. The main risk factors of VHD are age, hypertension and smoking. Valvular heart diseases should be regarded as a serious and growing public-health problem.

Cardiovascular effects of electronic cigarettes

Cardiovascular safety is an important consideration in the debate on the benefits versus the risks of electronic cigarette (EC) use. EC emissions that might have adverse effects on cardiovascular health include nicotine, oxidants, aldehydes, particulates, and flavourants. To date, most of the cardiovascular effects of ECs demonstrated in humans are consistent with the known effects of nicotine. Pharmacological and toxicological studies support the biological plausibility that nicotine contributes to acute cardiovascular events and accelerated atherogenesis. However, epidemiological studies assessing Swedish smokeless tobacco, which exposes users to nicotine without combustion products, generally have not found an increased risk of myocardial infarction or stroke among users, but suggest that nicotine might contribute to acute cardiovascular events, especially in those with underlying coronary heart disease. The effects of aldehydes, particulates, and flavourants derived from ECs on cardiovascular health have not been determined. Although ECs might pose some cardiovascular risk to users, particularly those with existing cardiovascular disease, the risk is thought to be less than that of cigarette smoking based on qualitative and quantitative comparisons of EC aerosol versus cigarette smoke constituents. The adoption of ECs rather than cigarette smoking might, therefore, result in an overall benefit for public health.

Race-Related Differences in Left Ventricular Structural and Functional Remodeling in Response to Increased Afterload: The ARIC Study

OBJECTIVES

The aim of this study was to evaluate racial differences in arterial elastance (Ea), which reflects the arterial afterload faced by the left ventricle, and its associations with cardiac structure and function. The hypothesis under study was that the left ventricle in blacks displays heightened afterload sensitivity compared with whites.

BACKGROUND

Chronic increasing in arterial afterload may be an important trigger for left ventricular (LV) remodeling and dysfunction that lead to heart failure. Racial differences in the predisposition to heart failure are well described, but the underlying mechanisms remain unclear.

METHODS

In total, 5,727 community-based, older ARIC (Atherosclerosis Risk In Community) study participants (22% black) who underwent echocardiography between 2011 and 2013 were studied.

RESULTS

Blacks were younger (mean age 75 ± 5 years vs. 76 ± 5 years), were more frequently female (66% vs. 57%), and had higher prevalence rates of obesity (46% vs. 31%), hypertension (94% vs. 80%), and diabetes mellitus (47% vs. 34%) than whites. Adjusting for these baseline differences, Ea was higher among blacks (1.96 ± 0.01 mm Hg/ml vs. 1.80 ± 0.01 mm Hg/ml). In blacks, Ea was associated with greater LV remodeling (LV mass index, β = 3.21 ± 0.55 g/m2, p < 0.001) and higher LV filling pressures (E/e' ratio, β = 0.42 ± 0.11, p < 0.001). These relationships were not observed in whites (LV mass, β = 0.16 ± 0.32 g/m2, p = 0.61, p for interaction <0.001; E/e' ratio, β = -0.32 ± 0.06, p < 0.001, p for interaction <0.001).

CONCLUSIONS

These community-based data suggest that black Americans display heightened afterload sensitivity as a stimulus for LV structural and functional remodeling, which may contribute to their greater risk for heart failure compared with white Americans.