Cigarette smoking is associated with twice the risk of heart failure – in both subtypes – found a first-of-kind study from Johns Hopkins Bloomberg School of Public Health.
“This reinforces the view that smoking casts a long shadow over heart health,” the study’s senior author Dr Kunihiro Matsushita, associate professor in the Bloomberg School’s Department of Epidemiology.
The study, which is thought to be one of the first to assess smoking’s association with both heart failure subtypes – reduced ejection fraction and preserved ejection fraction – was based on a long-running study of nearly 9,500 individuals in four US communities. They found that people who had stopped smoking retained a significantly increased risk of either type of heart failure for decades after quitting.
The study was published in the Journal of the American College of Cardiology.
“These findings underline the importance of preventing smoking in the first place, especially among children and young adults,” Matsushita said.
“We hope our results will encourage current smokers to quit sooner rather than later, since the harm of smoking can last for as many as three decades.”
Heart failure is a progressive condition in which the heart loses its ability to pump enough blood to meet the body’s needs. It’s one of the most common causes of disability and death in developed countries, with more than 6m adults living with heart failure in America alone, according to the US Centers for Disease Control and Prevention’s (CDC) most recent data. Besides smoking, risk factors for heart failure include obesity, hypertension, diabetes, coronary artery disease, and advanced age.
There are two types of heart failure: reduced ejection fraction and preserved ejection fraction. In heart failure with reduced ejection fraction, the left ventricle – the principal cardiac pump – fails to contract sufficiently when pumping blood outward. Heart failure with reduced ejection fraction is more closely tied to coronary artery disease. Treatment includes several medications that improve prognosis.
In heart failure with preserved ejection fraction, the left ventricle fails to relax sufficiently after contracting. Treatment for heart failure with preserved ejection fraction is very limited, making its prevention critically important. At the same time, its risk factors are less clear. Some prior studies have linked smoking to higher risk of preserved ejection fraction, while others have not.
Matsushita and colleagues evaluated health records of participants in the Atherosclerosis Risk In Communities (ARIC) study. Launched in 1987, the ARIC study includes middle-aged and older adults across the US, with substantial representation of the black community. The new study’s analysis included data from four communities in Maryland, North Carolina, Minnesota and Mississippi, and focused on 9,345 ARIC participants, ages 61 to 81, who had sufficient records and no diagnosis of heart failure as of the start of 2005.
Over a median follow-up of 13 years, there were 1,215 cases of heart failure in the study, including 492 cases of reduced ejection fraction and 555 cases of preserved ejection fraction. The analysis showed that smokers in the group were diagnosed with the two heart failure subtypes at about the same elevated rates compared to never-smokers – 2.28 times higher for preserved ejection fraction, and 2.16 times higher for reduced ejection fraction.
The link with smoking also showed a “dose-response” relationship – more cigarettes per day and more years of smoking being associated with higher heart failure risk. Similarly, quitting smoking brought a drop in heart failure risk that increased over time. Overall, former smokers were 31% and 36% more likely to have preserved ejection fraction and reduced ejection fraction, respectively, compared with never-smokers.
When the researchers stratified former smokers by the number of years since quitting, they found that their overall heart failure risk remained significantly higher than never-smokers’ risk, except for the group that hadn’t smoked for 30 years or more.
Study details
Cigarette Smoking, Cessation, and Risk of Heart Failure With Preserved and Reduced Ejection Fraction.
Ning Ding, Amil M. Shah, Michael J. Blaha, Patricia P. Chang, Wayne D. Rosamond, Kunihiro Matsushita.
Published in the Journal of the American College of Cardiology on 14 June 2022.
Abstract
Background
Smoking is well-recognised as a risk factor for heart failure (HF). However, few studies have evaluated the prospective association of cigarette smoking and smoking cessation with heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF) as distinct phenotypes.
Objectives
The aim of this study was to quantify the association of cigarette smoking and smoking cessation with the incidence of HFpEF and HFrEF.
Methods
In 9,345 ARIC (Atherosclerosis Risk In Communities) study white and black participants without history of HF at baseline in 2005 (age range 61-81 years), we quantified the associations of several established cigarette smoking parameters (smoking status, pack-years, intensity, duration, and years since cessation) with physician-adjudicated incident acute decompensated HF using multivariable Cox models.
Results
Over a median follow-up of 13.0 years, there were 1,215 incident HF cases. Compared with never smokers, current cigarette smoking was similarly associated with HFpEF and HFrEF, with adjusted HRs ∼2. There was a dose-response relationship for pack-years of smoking and HF. A more extended period of smoking cessation was associated with a lower risk of HF, but significantly elevated risk persisted up to a few decades for HFpEF and HFrEF.
Conclusions
All cigarette smoking parameters consistently showed significant and similar associations with HFpEF and HFrEF. Smoking cessation significantly reduced the risk of HF, but excess HF risk persisted for a few decades. Our results strengthened the evidence that smoking is an important modifiable risk factor for HF and highlighted the importance of smoking prevention and cessation for the prevention of HF, including HFpEF.
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