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CARDIOVASCULAR

Risk Of Heart Attacks Is Double For Daily E-Cigarette Users

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Use of e-cigarettes every day can nearly double the odds of a heart attack, according to a new analysis of a survey of nearly 70,000 people, led by researchers at UC San Francisco.

The research also found that dual use of e-cigarettes and conventional cigarettes — the most common use pattern among e-cigarette users — appears to be more dangerous than using either product alone. The study found that the risks compound, so that daily use of both e-cigarettes and conventional cigarettes raises the heart attack risk five-fold when compared to people who don’t use either product.

This is the first study to examine the relationship between e-cigarette use and heart attacks, and begins to fill the understanding of the effects of e-cigarettes on long-term health. The study was published Aug. 22, 2018, in the American Journal of Preventive Medicine. The data were first presented in February in Baltimore at the 2018 annual meeting of the Society for Research on Nicotine and Tobacco.

“Most adults who use e-cigarettes continue to smoke cigarettes,” said senior author Stanton Glantz, PhD, a UCSF professor of medicine and director of the UCSF Center for Tobacco Control Research and Education.

“While people may think they are reducing their health risks, we found that the heart attack risk of e-cigarettes adds to the risk of smoking cigarettes,” Glantz said.

“Using both products at the same time is worse than using either one separately. Someone who continues to smoke daily while using e-cigarettes daily increases the odds of a heart attack by a factor of five.”

But the research also reported some good news if smokers quit:

“The risk of heart attack starts to drop immediately after you stop smoking,” said Glantz.

“Our results suggest the same is true when they stop using e-cigarettes.”

Electronic cigarettes typically deliver an aerosol of nicotine and other flavors by heating a liquid and are promoted as a safer alternative to conventional cigarettes, which generate the nicotine aerosol by burning tobacco.

While e-cigarettes deliver lower levels of carcinogens than conventional cigarettes, they deliver both ultrafine particles — which are 1/50 to 1/100 the size of a human hair — and other toxins that have been linked to increased cardiovascular and non-cancer lung disease risks.

The new analysis involved 69,452 people who were interviewed through National Health Interview Surveys in 2014 and 2016, a cross-sectional study in which in-person interviewers asked participants whether they had ever used e-cigarettes and/or cigarettes, and whether they had ever been told by a doctor or other health professional that they had had a heart attack.

Among the 9,352 current and former e-cigarette users, 333 (3.6 percent) had experienced a heart attack at some point, with the highest percentage (6.1 percent) among those who used e-cigarettes daily. In the analysis, a quarter of the 2,259 people who currently used e-cigarettes were former smokers of conventional cigarettes and about 66 percent of current e-cigarette users were also current cigarette smokers.

The researchers found that the total odds of having a heart attack were about the same for those who continued to smoke cigarettes daily as those who switched to daily e-cigarette use. For those who used both products daily, the odds of having had a heart attack were 4.6 times that of people who had never used either product.

The authors also said that that while there was a “lasting effect” associated with being a former smoker, there was not a significant increase in myocardial infarction risk for former or (sometimes) e-cigarette users. They proposed that the risks of e-cigarette use may dissipate rapidly when someone stops using them, that some people briefly experiment with e-cigarettes and stop using them before any lasting damage is done, or that e-cigarettes have not been available long enough to cause permanent damage to the cardiovascular system.

“The only way to substantially reduce the risk of a heart attack is to stop using tobacco,” Glantz said.

The authors noted that it was not known whether the heart attacks occurred relative to e-cigarette use, and that some of the heart attacks that subjects reported are likely to have occurred before e-cigarettes became available in the U.S. (around 2009), which would lead them to underestimate the effects of e-cigarettes on heart attack risk.

CARDIOVASCULAR

Heart Disease Common Among Firefighters Who Die Of Cardiac Arrest

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Firefighters who died from cardiac arrest were much more likely than those who died of other causes to show signs of both atherosclerotic and hypertensive heart disease at autopsy, according to new research in Journal of the American Heart Association, the Open Access Journal of the American Heart Association/American Stroke Association.

Among firefighters, more job-related deaths stem from cardiac arrest than from any other cause. To understand which heart diseases affect firefighters who die of cardiac arrest, this study looked at autopsy reports for firefighters who had died in the line of duty. Results showed that the most common diseases were narrowed arteries, or coronary artery disease, and structural abnormalities. These abnormalities included an enlarged heart (cardiomegaly) and increased wall thickness (hypertrophy) of the heart’s primary chamber for pumping blood, or left ventricle.

“Firefighters face many dangers, but the greatest risk is from underlying cardiovascular disease in combination with the physiological strain that the work places on the firefighter,” said study lead author Denise L. Smith, Ph.D., Tisch Distinguished Professor and director of the First Responder Health and Safety Laboratory at Skidmore College in Saratoga Springs, New York.

“Medical screening is necessary to establish that a firefighter is healthy enough to do this strenuous work.”

In terms of specific risks, narrowing of the arteries, enlarged heart and prior heart attack all were all independently associated with a greatly increased likelihood of death from cardiac arrest than firefighters who died of other causes. Similarly, firefighters who had a prior heart attack were 6 times more likely to have a duty-related death. an enlarged heart or a prior heart attack.

The researchers looked at autopsy records for U.S. male firefighters who died on duty between 1999 and 2014. Of 627 total deaths, 276 resulted from cardiac arrest and 351 from trauma. At the time of death, the firefighters were between 18 and 65 years old.

In the United States, approximately 1 in 7 people will die of sudden cardiac arrest. The life-threatening condition occurs when the heart’s electrical system stops working properly. Symptoms include unresponsiveness and gasping for air or not breathing. Immediate medical treatment is critical, including CPR and calling 9-1-1.

Cardiac arrest differs from a heart attack, which occurs when a blockage prevents blood flow to the heart, although heart attack and other heart conditions can cause cardiac arrest. Since cardiac arrest often is the first sign of underlying heart disease, screening and treatment for common heart diseases are critical.

“Historically, screening has focused more on risk factors for coronary artery disease,” Smith said.

“While this screening remains essential, it is important that clinicians also consider testing to identify an enlarged heart and increased wall thickness.”

Several limitations could have affected the study’s results. Among these limitations were differences in autopsy descriptions of heart disease, the use of a cut-off weight for an enlarged heart, and lack of information about other risk factors such as smoking and high blood pressure.

To control risk factors, the American Heart Association recommends lifestyle changes known as Life’s Simple 7®: manage blood pressure, control cholesterol, reduce blood sugar, get active, eat better, lose weight and stop smoking.

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CARDIOVASCULAR

Targeted And Population-Based Strategies Both Necessary For Blood Pressure Control

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Hypertension, or high blood pressure, is the leading risk factor for heart disease, and improvements in both targeted and population-based strategies for blood pressure control can lead to better prevention and control of hypertension, according to a review paper published today in the Journal of the American College of Cardiology. This paper is part of an eight-part health promotion series where each paper will focus on a different risk factor for cardiovascular disease.

The prevalence of hypertension globally is high and continues to increase. High blood pressure is associated with an increased risk of stroke, ischemic heart disease, heart failure and noncardiac vascular disease, as well as other conditions.

“Hypertension is caused by a combination of genetic, environmental and social determinants,” said Robert M. Carey, MD, professor of medicine at the University of Virginia School of Medicine and lead author of the paper.

“While genetic predisposition is nonmodifiable and conveys lifelong cardiovascular risk, the risk for hypertension is modifiable and largely preventable due to a strong influence by key environmental and lifestyle factors.”

Modifiable lifestyle factors, which are gradually introduced in childhood and early adult life, include being overweight/obesity, unhealthy diet, high sodium and low potassium intake, insufficient physical activity and consumption of alcohol. Many adults do not change their lifestyle after being diagnosed with hypertension and sustaining any changes that are made can be difficult.

Social determinants such as race and socioeconomic status are also risk factors for hypertension. High blood pressure is more prevalent in black and Hispanic populations as well as poorer areas and certain geographical areas such as the southeastern U.S.

According to the authors, prevention and control of hypertension can be achieved through targeted and population-based strategies. The targeted approach is the traditional strategy used in health care practice and seeks to achieve a clinically important reduction in blood pressure for individual patients. The population-based strategy aims to achieve small reductions that are applied to the entire population, resulting in a small downward shift in the entire blood pressure distribution. Studies have shown that the population-based approach may be better at preventing cardiovascular disease compared with the targeted strategy.

Factors preventing successful hypertension control include inaccurate blood pressure measurement and diagnosis of hypertension, lack of hypertension awareness and access to health care, and proper hypertension treatment and control. Low rates of medication adherence is also a common problem.

“Challenges to the prevention, detection, awareness and management of hypertension will require a multipronged approach directed not only to high-risk populations, but also to communities, schools, worksites and the food industry,” Carey said.

In the review, the authors discuss the Chronic Care Model, a framework for redesigning health care and addressing deficiencies in the care of chronic conditions such as hypertension, which may offer strategies for overcoming barriers at the health system, physician, patient and community levels. It is a collaborative partnership among the patient, provider and health system that incorporates a multilevel approach for control of hypertension. The model includes six domains — decision support, self-management support, delivery design, information systems, community resources and health care systems — which have been shown to lead to activated patients, responsive health care teams, improved health services and treatment outcomes, and cost-effectiveness. It also recognizes a collaborative partnership between the patient, provider and the care team. Community groups and organizations also play a significant role in providing health care information and support to various populations. Connected health, such as telemedicine and telephone and mobile health interventions can also help deliver improved care to a of greater number of patients with hypertension.

“Remarkable progress has been made in the understanding of blood pressure as a risk factor for heart disease and improving approaches to the prevention and treatment of hypertension,” said Carey.

“However, further research is still necessary to optimize care for these patients.”

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CARDIOVASCULAR

Clock Drawing Cognitive Test Should Be Done Routinely In Patients With High Blood Pressure

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A clock drawing test for detecting cognitive dysfunction should be conducted routinely in patients with high blood pressure, according to research presented today at ESC Congress 2018.

Patients with high blood pressure who have impaired cognitive function are at increased risk of developing dementia within five years. Despite this known link, cognitive function is not routinely measured in patients with high blood pressure.

“The ability to draw the numbers of a clock and a particular time is an easy way to find out if a patient with high blood pressure has cognitive impairment,” said study author Dr Augusto Vicario of the Heart and Brain Unit, Cardiovascular Institute of Buenos Aires, Argentina.

“Identifying these patients provides the opportunity to intervene before dementia develops.”

The Heart-Brain Study in Argentina evaluated the usefulness of the clock drawing test compared to the Mini-Mental State Examination (MMSE) to detect cognitive impairment in 1,414 adults with high blood pressure recruited from 18 cardiology centres in Argentina. The average blood pressure was 144/84 mmHg, average age was 60 years, and 62% were women.

For the clock drawing test, patients were given a piece of paper with a 10 cm diameter circle on it. They were asked to write the numbers of the clock in the correct position inside the circle and then draw hands on the clock indicating the time “twenty to four.” Patients were scored as having normal, moderate, or severe cognitive impairment. The MMSE has 11 questions and produces a score out of 30 indicating no (24-30), mild (18-23), or severe (0-17) cognitive impairment.

The researchers found a higher prevalence of cognitive impairment with the clock drawing test (36%) compared to the MMSE (21%). Three out ten patients who had a normal MMSE score had an abnormal clock drawing result. The disparity in results between the two tests was greatest in middle aged patients.

Dr Vicario said:

“Untreated high blood pressure silently and progressively damages the arteries in the subcortex of the brain and stops communication between the subcortex and frontal lobe. This disconnect leads to impaired ‘executive functions’ such as planning, visuospatial abilities, remembering details, and decision-making. The clock drawing test is known to evaluate executive functions. The MMSE evaluates several other cognitive abilities but is weakly correlated with executive functions.”

He continued:

“Our study suggests that the clock drawing test should be preferred over the MMSE for early detection of executive dysfunction in patients with high blood pressure, particularly in middle age. We think the score on the clock drawing test can be considered a surrogate measure of silent vascular damage in the brain and identifies patients at greater risk of developing dementia. In our study more than one-third of patients were at risk.”

Dr Vicario concluded:

“The clock drawing test should be adopted as a routine screening tool for cognitive decline in patients with high blood pressure. Further studies are needed to determine whether lowering blood pressure can prevent progression to dementia.”

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