No Surprise: Smoking and Sudden Cardiac Death Closely Tied 3

Although cigarette smoking has long been linked to cardiovascular (CV) disease and sudden cardiac death (SCD),  the precise contribution of smoking, and the effect of smoking discontinuation, on SCD has not been clear. Now a new report from the Nurses’ Health Study published in Circulation: Arrhythmia & Electrophysiology provides new clarity about the relationship between smoking and SCD.

“Cigarette smoking is a known risk factor for sudden cardiac death, but until now, we didn’t know how the quantity and duration of smoking affected the risk among apparently healthy women, nor did we have long-term follow-up,” said lead investigator Roopinder Sandhu, in an AHA press release.

Dr. Sandhu and colleagues analyzed data from more than 100,000 women without known CV disease or cancer.  During 30 years of followup there were 351 incident SCDs. Compared to women who never smoked, the risk of SCD was significantly elevated in current smokers (relative risk 2.44) and former smokers (RR 1.40).

The number of cigarettes smoked each day was correlated with the increase in SCD risk, but even women who smoked only 1-14 cigarettes per day had a significant 1.84-fold increase in risk. Women who smoked more than 25 cigarettes a day had a 3.3-fold increase in risk. Smoking duration was also significant, resulting in an 8% increase in SCD risk for every 5 years of smoking.

Women who quit smoking reduced their SCD risk. After 15 years the reduction in risk achieved statistical significance, and by 20 years the risk was similar to women who had never smoked.

In an exploratory analysis, women smokers with coronary heart disease (CHD) had a much higher incidence of SCD than women without CHD. Women with CHD who quit smoking did not enjoy the same immediate reduction in SCD risk as observed in women without CHD.

“Sudden cardiac death is often the first sign of heart disease among women, so lifestyle changes that reduce that risk are particularly important,” said Dr. Sandhu. “Our study shows that cigarette smoking is an important modifiable risk factor for sudden cardiac death among all women. Quitting smoking before heart disease develops is critical.”
Click here to read the AHA press release…

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Half the News That’s Fit To Print: NY Times On ECG Screening For Student Athletes 6

There may be no more horrifying medical catastrophe than the sudden death of a young athlete on the playing field in front of a large crowd of friends, family, and community. But it’s also a dizzyingly complex subject with no easy solutions. Experts are divided. The American Heart Association recently reaffirmed that it does not recommend universal screening for potential cardiovascular disease in young athletes with electrocardiograms (ECGs). On the other hand, universal screening has been adopted, apparently successfully, in Italy.

According to Anahad O’Connor in the New York Times, however, the movement toward routine ECG screening for student athletes may be inexorable, as it is not just cost-effective but desirable from a medical and a societal perspective. The Times article states that sudden cardiac death (SCD) of young athletes “is far more prevalent… than previously believed.” About 2,000 children each year die from SCD, according to the American Academy of Pediatrics, as cited by the Times, but this includes all children, not just athletes. The Times quotes the mother of a young athlete who died: “this happens all the time.”

But the world’s leading expert on SCD, Barry Maron, of the Minneapolis Heart Institute, insists that there has been no noticeable change in prevalence, and that SCD in children– whether athletes or not– is a rare event.  “The peer reviewed data on this topic suggests that there are about 75 sudden cardiovascular deaths in competitive atheltes every year in the US,” he told me in an interview. (The Times article is similarly dizzy about the cost of an ECG test. Although medical costs are always a byzantine topic, the $1,400 cost cited in the article is preposterous. Move the decimal point one place: $140 is a lot closer to reality.)

O’Connor acknowledges that the AHA does not recommend universal screening, but argues that the position “pivots on old data.” He cites a 2010 study from Stanford published in Annals of Internal Medicine suggesting that ECG screening may be cost-effective, but doesn’t cite an accompanying article in the same issue that reached a much less positive conclusion. Also not mentioned is an editorial accompanying the articles, written by Maron himself, offering a number of reasons why widespread ECG  screening should not be widely adopted at this time. (Click here for my previous coverage of the Annals articles.)

Even the Stanford author tells the Times that “we are not advocating this as a mandatory test for all students or all athletes,” but the article moves on to quote another expert who thinks “the time has come for thorough heart screenings for all young athletes.” James Willerson, of the Texas Heart Institute, told O’Connor: “If we save even one life, it will be worth it.” But Willerson, who had a distinguished career as a cardiology thought leader, is not an expert in SCD, and has an important conflict of interest in this case. As mentioned in the Times article, Willerson has a $5 million private grant to screen 10,000 students in Houston middle schools.

In his interview with me Maron offered a far more balanced perspective. He acknowledged that “each of these deaths are greatly tragic, and it is never the intention to minimize it by citing numbers, however large and however small. Furthermore,” he continued, “no one would ever feel comfortable placing a monetary value on a young athlete’s life.”
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