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The Cardiologist’s Guide to the Cardiovascular Consequences of Smoking and the Benefits of Cessation

The Cardiologist’s Guide to the Cardiovascular Consequences of Smoking and the Benefits of Cessation. Overview. Coronary artery disease Peripheral vascular disease Abdominal aortic aneurysm Stroke Cardiovascular disease and environmental tobacco smoke

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The Cardiologist’s Guide to the Cardiovascular Consequences of Smoking and the Benefits of Cessation

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  1. The Cardiologist’s Guide to the Cardiovascular Consequences of Smoking and the Benefits of Cessation

  2. Overview • Coronary artery disease • Peripheral vascular disease • Abdominal aortic aneurysm • Stroke • Cardiovascular disease and environmental tobacco smoke • Cardiovascular benefits of smoking cessation

  3. Smoking and Coronary Artery Disease (CAD)

  4. Smoking: Role in the Pathogenesis of Cardiovascular Events • Endothelial dysfunction • Increased hematologic thrombogenicity • Enhanced inflammatory response • Oxidative modification Atherosclerotic Disease Right Coronary Artery Lavi et al. Circulation. 2007;115:2621-2627; http://www.texasheartinstitute.org/HIC/Topics/Diag/diangio.cfm. Accessed June 14, 2007.

  5. Tissue factor (TF) is highly expressed in atherosclerotic plaques and may play a role in thrombosis TF was assessed by adding factor Xa (FXa) Current smokers have significantly higher levels of circulating TF activity than nonsmokers Smoking: Increased Thrombogenicity P=.003 Factor Xa (FXa) pmol/L/min Sambola et al. Circulation. 2003;107:973-977.

  6. 60 50 40 30 20 10 0 –10 Smoking: Impaired Endothelial Vasodilator Function Angiographically normal nonsmokers • Flow-dependent dilation was significantly blunted in current smokers compared with nonsmokers Angiographically irregular nonsmokers Angiographically normal smokers Angiographically irregular smokers P<.01 P<.001 P<.01 P<.01 P<.01 Flow-Dependent Dilation (%) Nonsmokers Current Smokers Zeiher et al. Circulation. 1995;92:1094-1100.

  7. 60 P=.03 45 30 15 0 Nonsmokers Ex-smokers CurrentSmokers Smoking: Epicardial Endothelial Dysfunction • Current smokers are more likely to have epicardial endothelial dysfunction than nonsmokers 46% 35% 34% Endothelial Dysfunction (%) Lavi et al. Circulation. 2007;115:2621-2627.

  8. 8 6 4 2 0 Smoking: Elevated White Blood Cell Count • Elevated white blood cell (WBC) count has been associated with a greater risk of cardiovascular events • Current smokers have significantly increased WBC counts compared with nonsmokers P<.0001 Nonsmokers Ex-smokers Current Smokers P=.03 Cell Counts (109/L) P<.0001 P<.0001 WBC Neutrophils Lymphocytes Monocytes Lavi et al. Circulation. 2007;115:2621-2627; Stewart et al. Circulation. 2005;111:1756-1762

  9. Smoking: Increased Oxidative Modification 640 1000 560 900 480 800 400 700 Free F2-Isoprostanesa (pmol/L) Esterified F2-Isoprostanesa (pmol/L) 320 600 240 500 160 400 80 300 Nonsmokers Current Smokers Current Smokers Nonsmokers aF2-isoprostane level is an index of lipid peroxidation in vivo. The dots representing subjects who smoked are each connected to a dot representing a nonsmoker matched to the subject for age and sex. Adapted from Morrow et al. N Engl J Med. 1995;332(18):1198-1203.

  10. Smoking: Reduced Nitric Oxide (NO) Biosynthesis 5000 P<.0001 4000 3613 3000 NO Concentration (nmol/L) 2000 1266 1000 0 Nonsmokers Current Smokers Barua et al. Circulation. 2001;104:1905-1910.

  11. Smoking: Multiplicative Risk Factor for Coronary Artery Disease Rates per 1000a No RiskFactors Smoking, Elevated Cholesterol, or Hypertension Alone Smoking PlusElevated Cholesterolor Hypertension ElevatedCholesterol Plus Hypertension All 3 Risk Factors Present Risk Factor Status at Entry Into the Study a All rates were age-adjusted by 10-year age groups to the US white male population in 1980. Hypercholesterolemia defined as cholesterol 250 mg/dL. Hypertension defined as a diastolic blood pressure 90 mm Hg. Burns. Prog Cardiovasc Dis. 2003;46(1): 11-29; Source: Pooling Project Research Group, 1978.

  12. Smoking: Increased Coronary Artery Disease (CAD) Mortality Relative Risk (95% CI)a Nonsmokers 1-14/Day 15-24/Day 25/Day Cigarettes/DayCurrent Smokers Fatal CAD a The probability of an event (developing a disease) occurring in exposed people compared with the probability of the event in nonexposed people. Adjusted for age.Willett et al. N Engl J Med. 1987;317(21):1303-1309.

  13. Smoking: Effect on Coronary Artery Disease Progression of Existing Lesions Formation of New Lesions 57 P=.002 P=.007 37 36 Patients (%) Patients (%) 20 Nonsmokers Current Smokers Nonsmokers Current Smokers Waters et al. Circulation. 1996;94:614-621.

  14. Smoking: Increased Risk of Angina 2.6 Relative Risk (95% CI)a 2.0 1.6 1.0 Nonsmokers 1-14/Day 15-24/Day 25/Day Cigarettes/DayCurrent Smokers aThe probability of an event (developing a disease) occurring in exposed people compared with the probability of the event in nonexposed people. Adjusted for age.Willett et al. N Engl J Med. 1987;317(1):1303-1309.

  15. 10 9 8 7 6 5 Odds Ratio (95% CI)a 4 3 2 1 0 Age <40 y Age 40-49 y Age 50-59 y Age 60-69 y Age >70 y Nonsmokers Ex-smokers 1-19 20 Smoking: Increased Risk of Acute Nonfatal Myocardial Infarction • Current smoking was associated with a 3-fold increase in odds of a nonfatal acute myocardial infarction compared with nonsmokers aThe ratio of the odds of development of disease in exposed persons to the odds of development of disease in nonexposed persons.Teo. Lancet. 2006;368:647-658.

  16. Smoking: Increased Risk of Sudden Cardiac Death Relative Risk (95% CI)a aThe probability of an event (developing a disease) occurring in exposed people compared with the probability of the event in nonexposed people. Adjusted for age.Wannamethee et al. Circulation. 1995;91:1749-1756.

  17. Smoking: Increased Risk of Q-Wave MI After Percutaneous Coronary Revascularization 2.08 Relative Risk (95% CI)a 1.28 1.0 Q-wave Myocardial Infarction (MI) aThe probability of an event (developing a disease) occurring in exposed people compared with the probability of the event in nonexposed people. Adjusted for the baseline variables significantly associated with each end point. Hasdai et al. N Engl J Med. 1997;336:755-761.

  18. Summary: Smoking and Coronary Artery Disease (CAD) • Smoking plays a role in the development of CAD via: • Endothelial dysfunction • Increased thrombogenicity • Elevated WBC counts • Increased oxidative stress • Reduced NO biosynthesis • Smoking acts as a multiplicative risk factor for development of CAD • Smoking is associated with an increased • Rate of progression of CAD • Risk of angina • Risk of acute myocardial infarction • Risk of sudden cardiac death • Risk of Q-wave myocardial infarction after Percutaneous Coronary Revascularization

  19. Smoking and Peripheral Vascular Disease

  20. PVD affects approximately 20% of adults older than age 55 Approximately half of patients with PVD are asymptomatic 5% to 10% of asymptomatic patients will progress to symptomatic PVD over 5 years Patients with symptomatic PVD are at higher risk for other cardiovascular disease and mortality Peripheral Vascular Disease (PVD) Build-up of atherosclerotic plaque in arterial wall Hankey et al. JAMA. 2006;295:547-553; Hooi et al. Am J Epidemiol. 2001;153:666-672; Hooi et al. Br J Gen Pract. 1999;49:49-55; Hooi et al. Scand J Prim Health Care. 1998;16:177-182; http://healthguide.howstuffworks.com/peripheral-artery-disease-and-intermittent-claudication-in-depth.htm. Accessed October 8, 2007.

  21. Asymptomatic Peripheral Vascular Disease: Increased Risk Odds Ratio (95% CI)a Nonsmokers Ex-smokers Current Smokers aThe ratio of the odds of development of disease in exposed persons to the odds of development of disease in nonexposed persons. Adjusted for other cardiovascular risk factors. Hooi et al. Scand J Prim Health Care. 1998;16:177-182.

  22. Rate of development of IC is approximately 4 times as great in current smokers than in nonsmokers (OR 4.1[2.3-7.9]) Risk tends to increase with the intensity of smoking The 5-year mortality for patients with IC who continue to smoke is 40% to 50% Intermittent Claudication (IC): Increased Risk Stenosis of the Left Iliac Artery Hooi et al. Scand J Prim Health Care. 1998;16:177-182; Kannel et al. Geriatrics. 1973;28:61-68; http://www.radiologyassistant.nl/en/42c2527422d06.

  23. For smokers, the risk of peripheral vascular disease (PVD) is greater than the risk of coronary artery disease (CAD) Risk of Peripheral Vascular Disease vs Coronary Artery Disease Relative Risk (95% CI)a Moderate Smokers Heavy Smokers aThe probability of an event (developing a disease) occurring in exposed people compared with the probability of the event in nonexposed people. Adjusted for age and sex. Price et al. Eur Heart J. 1999;20(5):344-353.

  24. Peripheral Vascular Disease: Progression • Smoking is the most important risk factor for the progression of peripheral vascular disease (PVD) • Symptoms of PVD occur approximately a decade earlier in smokers than nonsmokers • Smokers with PVD have twice the amputation rate of nonsmokers MyFootShop Peripheral VascularDisease. http://www.myfootshop.com/detail.asp?Condition=Peripheral%20Vascular%20Disease. Accessed October 19, 2007; Bendermacher et al. J Thromb Haem. 2005;3:1628-37; Dormandy et al. J Vasc Surg. 2000;31(1 pt 2):S1-296.

  25. Lower Extremity Bypass Grafts: Increased Risk of Graft Failure Peto ORa95% CI Weight% Peto ORa95% CI Prospective Patency Studies Wray 1.26 6.46 (1.42, 29.30) Greenhalgh 1.77 14.55 (4.06, 52.14) Herring 1.29 1.98 (0.44, 8.85) Provan 2.76 4.38 (1.58, 12.19) Rutherford 10.22 1.96 (1.15, 3.34) Ameli 3.79 3.89 (1.62, 9.30) Wiseman 5.57 2.90 (1.41, 5.95) Powell 2.95 2.36 (0.88, 6.35) Cheshire 1.86 5.18 (1.49, 17.95) Giswold 5.72 3.04 (1.50, 6.19) Subtotal (95% CI) 37.19 3.09 (2.34, 4.08) 0.2 0.5 1 2 5 10 Favors Treatment Favors Control aAn approximation to the exact OR that is used when doing a meta-analysis using the Peto method. Willigendael et al. J Vasc Surg. 2005;42:67-74.

  26. Smoking: Increased Mortality After Vascular Surgery • In order to provide very late survival data, Kazmers et al evaluated 310 patients undergoing elective vascular surgery • Follow-up was 6.644.62 years • Age, diabetes, smoking, and low ejection fraction were independently associated with overall mortality postoperatively Kazmers et al. J Surg Res. 2002;105:109-114.

  27. Summary: Smoking and Peripheral Vascular Disease (PVD) • Smoking is associated with an increased risk of • Asymptomatic PVD • Intermittent claudication • Progression of PVD • Amputation due to complications of PVD • Femoral-popliteal bypass graft failure • Mortality after vascular surgery • Symptoms of PVD occur approximately a decade earlier in smokers than in nonsmokers • Current smokers are at greater risk for developing PVD than coronary artery disease

  28. Smoking and Abdominal Aortic Aneurysm (AAA)

  29. AAA: Greater Risk in Smokers Than CAD or Cerebrovascular Disease • The association between smoking and aortic aneurysm is substantially stronger than the association between smoking and coronary or cerebrovascular disease P<.00001 Pooled Estimates of Ratio of Current Smokers’ RRa NeverSmokers Aortic Aneurysm to CAD Aortic Aneurysm to Cerebrovascular Disease AAA= Abdominal Aortic Aneurysm; CAD=Coronary Artery Disease aThe probability of an event (developing a disease) occurring in exposed people compared with the probability of the event in nonexposed people.Lederle et al. J Vasc Surg. 2003(2);38:329-334.

  30. Smoking and AAA: Increased Risk Odds Ratio(95% CI)a Nonsmokers 1 to 9 10 to 19 20 to 24 25 Cigarettes/Day Current Smokers AAA= Abdominal Aortic Aneurysm aThe ratio of the odds of development of disease in exposed persons to the odds of development of disease in nonexposed persons. Adjusted for age and sex. Vardulaki et al. Br J Surg. 2000;87(2):195-200.

  31. Smoking: Increased Progression of Aortic Atherosclerosis Relative Risk (95% CI)a Never Smokers 1 to 9 10 to 19 20 Cigarettes/Day Current Smokers aThe probability of an event (developing a disease) occurring in exposed people compared with the probability of the event in nonexposed people. Adjusted for age, systolic blood pressure, serum total cholesterol, Quetelet index, diabetes mellitus, menopausal status, alcohol consumption, use of replacement estrogens, and duration of follow-up.Witteman et al. Circulation. 1993;88(part 1):2156-2162.

  32. Smoking: Effect on AAA Expansion P<.001 Average Linear Growth Rate (mm/year) Nonsmokers Current Smokers AAA= Abdominal Aortic Aneurysm Brady. Circulation. 2004;110:16-21.

  33. Summary: Smoking and Abdominal Aortic Aneurysm (AAA) • Current smokers have a higher risk of developing an AAA than either coronary artery disease or cerebrovascular disease • Smoking is associated with an increased risk of • Formation of AAA • Progression of aortic atherosclerosis • Expansion of AAA

  34. Smoking and Stroke

  35. Smoking contributes to 12% to 14% of all stroke deaths Smoking may potentiate the effects of other stroke risk factors Smoking increases stroke risk Acutely: effects on thrombus formation Chronically: increased burden of atherosclerotic disease Smoking and Stroke MRI of BrainWith an Acute Ischemic Stroke Goldstein et al. Stroke. 2006;37:1583-1633; http://www.ucihs.uci.edu/stroke/whatisastroke.shtml. Accessed October 19, 2007.

  36. Smoking: Increased Progression of Carotid Atherosclerosis • Both active smoking and environmental tobacco smoke exposure are associated with increased progression of carotid atherosclerosis. 43.0 38.8 31.6 Progression of Intima-Medial Thickness, µm/3 y (95% CI)a 32.8 25.9 NonsmokerswithoutExposureb NonsmokerswithExposureb Ex-smokers withoutExposureb Ex-smokers with Exposureb CurrentSmokers aAdjusted for demographic characteristics, cardiovascular risk factors, and lifestyle variables (risk factor model and Keys score, education, leisure activity, body mass index, and alcohol use). bTo environmental tobacco smoke.Howard et al. JAMA. 1998;279(2):119-124.

  37. Smoking: Increased Risk of Fatal and Nonfatal Stroke in Women Relative Risk (95% CI)a Nonsmokers 1-14 15-24 ≥25 Cigarettes/Day Current Smokers aThe probability of an event (developing a disease) occurring in exposed people compared with the probability of the event in nonexposed people. Adjusted for age, follow-up period, history of diabetes, hypertension, high cholesterol levels, and relative weight (in 5 categories).Colditz et al. N Engl J Med. 1988;318(15):937-941.

  38. Smoking: Increased Risk of Hemorrhagic Stroke Nonsmokers (n=20,339) <15 Cigarettes/day (n=1914) 15 Cigarettes/day (n=3265) Relative Risk (95% CI)a 2.06 4.04 1.74 3.43 2.39 2.89 Total Hemorrhagic Stroke Intracerebral Hemorrhage Subarachnoid Hemorrhage aThe probability of an event (developing a disease) occurring in exposed people compared with the probability of the event in nonexposed people.Adjusted for age, exercise, alcohol consumption, body mass index, history of hypertension, and history of diabetes. Kurth et al. Stroke. 2003;34:2792-2795.

  39. Smoking: Increased Stroke Mortality • Cigarette smoking increases the risk of mortality from stroke in men Mortality Ratea 1-15 15-24 ≥25 Cigarettes/Day Current Smokers aTwenty-year age-adjusted mortality per 10,000 person-years for men. P<.014 for trend. Hart et al. Stroke. 1999;30:1999-2007.

  40. Summary: Smoking and Stroke • Smoking contributes to 12% to 14% of all stroke deaths • Increased risk of • Progression of carotid atherosclerosis • Stroke • Hemorrhagic stroke • Intracerebral hemorrhage • Subarachnoid hemorrhage • Increased stroke-related mortality

  41. Cardiovascular Disease (CVD) and Environmental Tobacco Smoke

  42. Effects of Environmental Tobacco Smoke on Cardiovascular Disease • Effects of environmental tobacco smoke •  risk of heart disease •  platelet and endothelial function •  arterial stiffness •  atherosclerosis •  oxidative stress •  inflammation • ↓ heart rate variability •  energy metabolism •  infarct size American Heart Association. Scientific Position, Risk Factors and Coronary Heart Disease, 2005. http://americanheart.org. Accessed February 2007; Barnoya et al. Circulation. 2005; 111:2684-2698; http://www.istockphoto.com/file_closeup/abuse/smoking/tobacco_products/3383715_cigarette_burning.php?id=3383715. Accessed October 11, 2007.

  43. 0.20 0.15 0.10 0.05 0 0 5 10 15 20 Environmental Tobacco Smoke: Prevalence of Heart Disease • Exposure to environmental tobacco smoke increases the risk of heart disease among nonsmokers by 30% Light activea Heavy passiveb Proportion With Major CAD Light passivec Years of Follow up Adjusted for age, systolic blood pressure, diastolic blood pressure, total cholesterol, HDL cholesterol, FEV, height, preexisting CAD, body mass index, triglycerides, white cell count, diabetes, physical activity, alcohol intake, and social class. aLight active refers to men smoking 1-9 cigarettes a day. bHeavy passive refers to upper three quarters of cotinine concentration combined (0.8 to 14.0 ng/mL). cLight passive refers to lowest quarter of cotinine concentration among nonsmokers (0-0.07 ng/mL). Whincup et al. BMJ. 2004;329:200-205.

  44. 5.6 36.8 5.2 34.8 4.8 32.8 4.4 30.8 4.0 28.8 3.6 26.8 3.2 24.8 2.5 22.8 1 2 3 4 5 12 1 2 3 4 5 12 Environmental Tobacco Smoke: Platelet Activation Nonsmokers Current Smokers 11-dehydro-thromboxane B2 Malondialdehyde ns ns ns ns ns ns ns ns ns ns ns ns Min/10° Plateletsa pg/mLa ns Day Day ns=not significant. a Unless marked as “ns,” differences for each value between groups were statistically significant at a level of P<.05. Schmid et al. Thromb Res. 1996;81:451-460.

  45. Environmental Tobacco Smoke: Vascular Endothelial Dysfunction • Acute exposure to environmental tobacco smoke significantly reduces mean coronary flow velocity reserve (CFVR) in nonsmokers P<.001 CFVR (Mean ±SD) Before Acute Exposure After Acute Exposure CFVR is a measure of endothelial function in the coronary circulation. Otsuka et al. JAMA. 2001;286:436-441.

  46. Environmental Tobacco Smoke: Risk of Acute Myocardial Infarction (MI) • Exposure to environmental tobacco smoke increased the risk of non-fatal acute MI in a graded manner 4 Nonsmokers 2 Odds Ratio (95% CI)a 1 Never 1-7 8-14 15-21 22 0.75 Environmental Tobacco Smoke Exposure (Hours per Week) aThe ratio of the odds of development of disease in exposed persons to the odds of development of disease in nonexposed persons. Adjusted for age, sex, region, physical activity, and consumption of fruits, vegetables, and alcohol. Adapted from Teo et al. Lancet. 2006;368:647-658.

  47. Summary: Cardiovascular Disease and Environmental Tobacco Smoke • Exposure to environmental tobacco smoke increases risk of • Heart disease, by 30% • Acute myocardial infarction (MI) • Environmental tobacco smoke affects multiple factors associated with the development of coronary artery disease, including • Platelet activation • Vascular endothelial dysfunction

  48. Cardiovascular Benefits of Smoking Cessation

  49. Cardiovascular Benefits of Cessation: Fibrinogen • After 2 weeks of cessation by formerly chronic smokers, both fibrinogen concentration and the rate of fibrinogen synthesis are reduced P<.001 P<.001 3.06 24.1 2.49 16.1 Plasma FibrinogenConcentration (g/L) Fibrinogen ASR mg/kg Smoking Abstentiona Smoking Abstentiona ASR=absolute rate of fibrinogen synthesis. aAbstention period of 2 weeks. Hunter et al. Clin Sci (Lond). 2001;100(4):459-465.

  50. Cardiovascular Benefits of Cessation: White Blood Cells P<.026 White Blood Cells (×109/l) Smoking Abstentiona aAbstention period of 17 weeks. Eliasson et al. Nicotine Tob Res. 2001;3(3):249-255.

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