By Austin Ulrich, PharmD, BCACP
Consultant Pharmacist, Greensboro, NC
SYNOPSIS: A cohort study of patients with atrial fibrillation (AF) in South Korea revealed patients who stopped smoking after AF diagnosis were at lower risk for developing dementia than those who continued smoking.
SOURCE: Lee HJ, Lee SR, Choi EK, et al. Risk of dementia after smoking cessation in patients with newly diagnosed atrial fibrillation. JAMA Netw Open 2022;5:e2217132.
Atrial fibrillation (AF) is considered the most common cardiac arrhythmia, causing significant
morbidity, mortality, and healthcare costs.1,2 AF is more common in older patients, who already are at higher risk of cognitive decline.3 Furthermore, AF is thought to be an independent risk factor for incident dementia or cognitive impairment.4
In addition to stroke prevention and rhythm/rate control techniques, lifestyle modifications (e.g., smoking cessation) are recommended for patients with AF.5 Oral anticoagulation and drug therapy for rhythm control are known to lower the dementia risk for patients with AF.6 Smoking cessation is a key intervention for patients with or at risk for AF because smoking is the most common risk factor for AF, stroke, and dementia, among other widely known health benefits of smoke avoidance.7
To determine the effects of smoking cessation on lowering the incidence of dementia in patients with AF, Lee et al conducted a retrospective study using the South Korean National Health Information Database. Patients who received a new diagnosis of AF between 2010 and 2016 were included if they had undergone a health examination within two years before the diagnosis and had not been diagnosed with dementia. Patients were stratified into groups based on smoking status: current smokers, quit smokers (smoked at time of first health exam but stopped smoking after AF diagnosis), ex-smokers, and never smokers.
Overall, 126,252 patients were included (average age = 62.6 years; average CHA2DS2-VASc score = 2.7). About 62% of patients were men, and 38% were women. By smoking status, 13.5% were current smokers, 7% were quit smokers, 27.5% were ex-smokers, and 52% were never smokers. Compared with never smokers, ex-smokers, quit smokers, and current smokers were younger and recorded a lower CHA2DS2-VASc score.
A total of 5,925 patients in the study were diagnosed with dementia during an average follow-up time of 3.1 years. Current smokers demonstrated the highest risk of dementia vs. never smokers (HR, 1.41; 95% CI, 1.27-1.56), followed by quit smokers (HR, 1.16; 95% CI, 1.03-1.32). Ex-smokers did not demonstrate a statistically significant risk compared with never smokers. Quit smokers recorded a 17% lower risk of dementia compared to current smokers (HR, 0.83; 95% CI, 0.72-0.95). The authors concluded patients who smoke cigarettes at the time of AF diagnosis are more likely to develop dementia than those who do not smoke at diagnosis. Additionally, smoking cessation after a diagnosis of AF reduces the risk of developing dementia.
COMMENTARY
This study adds another compelling reason for healthcare practitioners to emphasize smoking cessation during patient interactions. For patients at risk for AF, quitting smoking may reduce the risk of dementia if they were to receive a diagnosis of AF. For patients who are smoking when they receive an AF diagnosis, cessation may result in a lower risk of dementia.
Limitations to the study include its observational design, inability to detect amount of smoking (other than years of use), and patterns of substance use that could affect dementia risk. Further, use of anticoagulation was only present in 28% of the population, and it is unknown how anticoagulation affects smoking-related cognitive decline.
Regardless, this study does highlight an opportunity to improve outcomes for patients with AF. Clinicians should seek to identify smoking status at the time of AF diagnosis, educate and advocate for cessation, and explain the potential benefits of cessation in preventing brain injury.
REFERENCES
1. Vermond RA, Geelhoed B, Verweij N, et al. Incidence of atrial fibrillation and relationship with cardiovascular events, heart failure, and mortality. A community-based study from the Netherlands. J Am Coll Cardiol 2015;66:1000-1007.
2. Burdett P, Lip GYH. Atrial fibrillation in the UK: Predicting costs of an emerging epidemic recognizing and forecasting the cost drivers of atrial fibrillation-related costs. Eur Heart J Qual Care Clin Outcomes 2022;8:187-194.
3. Zathar Z, Karunatilleke A, Fawzy AM, Lip GYH. Atrial fibrillation in older people: Concepts and controversies. Front Med (Lausanne) 2019;6:175.
4. Kim D, Yang PS, Yu HT, et al. Risk of dementia in stroke-free patients diagnosed with atrial fibrillation: Data from a population-based cohort. Eur Heart J 2019;40:2313-2323.
5. Lip GYH. The ABC pathway: An integrated approach to improve AF management. Nat Rev Cardiol 2017;14:627-628.
6. Yang PS, Sung JH, Jang E, et al. The effect of integrated care management on dementia in atrial fibrillation. J Clin Med 2020;9:1696.
7. Cataldo JK, Glantz SA. Smoking cessation and Alzheimer’s disease: Facts, fallacies and promise. Expert Rev Neurother 2010;10:629-631.
A cohort study of patients with atrial fibrillation (AF) in South Korea revealed patients who stopped smoking after AF diagnosis were at lower risk for developing dementia than those who continued smoking.
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