Heart Failure Risks of Smoking Can Linger for Decades

Cigarette smoking is associated with a risk of heart failure, both when ejection fraction is reduced and when it’s preserved, according to an analysis from the community-based Atherosclerosis Risk In Communities (ARIC) study.

The analysis could serve as a reminder to smokers and their physicians that the deleterious cardiovascular effects of smoking are considerable and long-lasting, investigators say.

“There have been some conflicting results regarding whether smoking is associated with heart failure with preserved ejection fraction, . . . so I think our finding that smoking may be a risk factor for it is important because it has limited treatment options,” senior study author Kunihiro Matsushita, MD, PhD (Johns Hopkins Bloomberg School of Public Health, Baltimore, MD), told TCTMD. “I would hope our data encourage young people at risk to [refrain from] smoking and encourage those who are currently smoking to quit smoking as soon as possible.”

Compared with those who never smoked, people who smoked cigarettes for 25 to 39 pack-years (the number of packs smoked per day multiplied by the number of years of active smoking) had nearly a twofold increased risk of heart failure with preserved ejection fraction (HFpEF; adjusted HR 1.88; 95% CI 1.42-2.47) and heart failure with reduced ejection fraction (HFrEF; adjusted HR 1.94; 95% CI 1.46-2.58).

The findings suggest that the excess risk of HF incurred by an individuals’ smoking history may linger for decades, something Matsushita said smokers and former smokers shouldn’t necessarily dwell on since those in the study who quit smoking did see lower risks of both HFrEF and HFpEF, although the benefits were greatest among those who had been smoke-free the longest. Among those who hadn’t smoked in 30 years or more, there was a 50% reduction in the risk of HFrEF and HFpEF compared with current smokers, placing them in a similar risk category as never smokers.

In an accompanying editorial, Giuseppe Biondi-Zoccai, MD (Sapienza University of Rome, Latina, Italy), and colleagues agree that the new data may well serve as motivation for both current and former smokers.

“I think that most people are aware that smoking (especially combustion cigarettes), is very detrimental for dozens of reasons,” he told TCTMD in an email. Adding the concept that smoking leads to heart failure helps highlight the limited quality of life that goes along with continuing to smoke, he added.

“Furthermore, I believe it can be leveraged to motivate those people at high risk of developing heart failure, . . .  such as those with hypertension or diabetes,” said Biondi-Zoccai.

The study was published June 6, 2022, in the Journal of the American College of Cardiology.

ARIC Substudy

Matsushita and colleagues, led by Ning Ding, MD (Johns Hopkins Bloomberg School of Public Health, Baltimore, MD), examined data on 9,345 white and Black participants who were 45 to 64 years of age when they enrolled in the ARIC study in the late 1980s. Researchers chose 2005 as the baseline then followed patients with no prior history of HF for subsequent episodes of acute decompensation until death, date of last contact, or December 31, 2019, whichever came first. Smoking history, which was limited to cigarettes only, was analyzed by smoking status, pack-years, intensity (< 1 or ≥ 1 pack per day), duration (< 20 or ≥ 20 years), and years since smoking cessation (< 10 years, 10 to < 20 years, 20 to < 30 years; or ≥ 30 years).

Median follow-up was 13 years, by which time 1,215 incident HF cases occurred (HFpEF = 555, HFrEF =  492, unknown LVEF =  168). After adjustment for age, sex, and race, HF incidence per 1,000 person-years was 9.7 in never smokers, 13.5 in former smokers, and 20.1 in current smokers. For incident HF overall, the HR was 2.36 (95% CI 1.92-2.90) in current smokers and 1.36 (95% CI 1.19-1.55) in former smokers.

The elevated risk of any HF persisted from 20 to 30 years after individuals had quit smoking (HR 1.34; 95% CI 1.07-1.67) and was consistent for both HFpEF and HFrEF. For those who had been smoke-free for < 10 years, the risk of HF was reduced compared with current smokers for HFpEF (HR 0.85; 95% CI 0.56-1.27) and HFrEF (HR 0.63; 95% CI 0.42-0.95).

To TCTMD, Matsushita said the ARIC data appear to refute a long-held belief promoted by a 2004 US Surgeon General report, which asserted that by 15 years of smoking cessation, the risk of HF for most former smokers returns to that of never smokers. “I think that 15-year number may be underestimating the impact of smoking if we comprehensively consider its impact on the cardiovascular system, including heart failure,” he added.

Biondi-Zoccai and colleagues note that the study has some limitations, including reliance on self-reported smoking history, inclusion of subjects with a history of CAD (5% of never smokers and 10% of current and former smokers), absence of systolic function data in several individuals, lack of data on other types of exposure such as electronic cigarettes, and exclusion from multivariable models of pathophysiologically relevant biomarkers such as C-reactive protein, troponin, and natriuretic peptides.

However, they point out that assuming the results are accurate, 20 cases of incident HF could be anticipated for every 100 current smokers followed for 10 years, with even more events among the heaviest and longest smokers, versus half that number in never smokers. In addition to encouraging smoking cessation and abstinence among former smokers, they say “this work reinforces indirectly our efforts at minimizing exposure to other types of smoking (eg, cannabis, cigar, pipe, heat-not-burn devices, vaping), as well as smokeless tobacco, in order to minimize heart failure risk, even if these types of exposure were not appraised by Ding et al and may possibly be less detrimental.”