Smoking, smoking cessation and aortic arch calcification in older Chinese: The Guangzhou Biobank Cohort Study

doi:10.1016/j.atherosclerosis.2008.03.004

Atherosclerosis

Volume 202, Issue 2, February 2009, Pages 529-534

https://doi.org/10.1016/j.atherosclerosis.2008.03.004 Get rights and content

Abstract

Objective

To study the association between smoking, smoking cessation and aortic arc calcification (AAC) in an older Chinese population.

Methods

A total of 3022 men and 7279 women aged 50–85 years were recruited and received a medical check-up including measurement of fasting plasma vascular risk factors. Two radiologists reviewed the posterior–anterior plain chest X-ray radiographs and assessed AAC together. Information on smoking status, socioeconomic and lifestyle factors was collected.

Results

The crude prevalence of AAC in men (38.58%) was lower than that in women (41.37%). The adjusted odds ratios of AAC increased significantly across never, ex- and current smokers in both genders. Dose–response relationships were observed among current smokers for smoking amount (cigarettes/day), smoking duration (years) and cigarette pack-years in both genders (all p < 0.01). The odds ratios decreased significantly (p = 0.018) with longer duration of quitting in light ex-smoking men (<23.5 pack-years) but showed no beneficial effect (p = 0.72) for heavy ex-smokers (≥23.5 pack-years).

Conclusion

Smoking increased the risk of AAC in Chinese, while smoking cessation decreased the risk only in male light ex-smokers. Chest X-ray is a cheap and simple method to detect AAC, which should be an important warning signal for immediate smoking cessation.

Introduction

Calcium deposits in the coronary and extra-coronary arterial beds may indicate the extent of atherosclerotic lesions [1], [2], and previous studies showed that aortic arch calcification (AAC) was an important predictor of cerebral, cardiovascular and peripheral embolism [3], [4], [5]. Chest radiography is a common, non-invasive and inexpensive screening method for routine health examination and can reliably assess AAC [5], [6].

Cigarette smoking is the most important preventable risk factor for cardiovascular disease [7], [8]. Smoking cessation can significantly attenuate the risk of coronary heart disease and stroke [9], [10], [11]. Among the numerous studies describing smoking and cardiovascular events, there are little data linking smoking with AAC. We therefore studied the association between smoking, smoking cessation and AAC in an older Chinese population.

Section snippets

Methods

The Guangzhou Biobank Cohort Study is a three way collaboration among the Guangzhou 12th Hospital, China, the University of Hong Kong, and the University of Birmingham, UK. The study aims to examine environmental and occupational factors, genetic and lifestyle determinants of the common chronic diseases. We plan to recruit about 30,000–50,000 older (>50 years) subjects from Guangzhou in southern China. The first phase recruitment of 10,413 subjects has been completed in November 2004 and

Results

Of the 10,301 subjects, 3022 were male (mean age 66.21 ± 5.77 years) and 7279 were female (mean age 63.99 ± 6.03 years). The crude prevalence of AAC in men (38.58%) was significantly lower than that in women (41.37%, p < 0.001), and the age-adjusted prevalence (95% confidence interval) was 37.7% (35.9%, 39.5%) and 40.6% (39.4%, 41.8%), respectively (p < 0.001). The age-adjusted odds ratio for men vs. women was 0.69 (0.63, 0.76). The prevalence of AAC in ex- and current smokers was significantly higher

Discussion

To our knowledge, this is the first report describing the positive association of AAC with smoking and the benefits of quitting. Our results clearly show that smoking has strong association with AAC both in Chinese men and women. Smoking increased the risk of AAC, whereas smoking cessation decreased the risk in the male light ex-smokers. Our results further confirm the risk of smoking on vascular disease due to the well-known association between AAC and the increased risk of vascular disease [4]

Acknowledgements

The study is funded by The University of Hong Kong Foundation for Educational Development and Research, Hong Kong; the Guangzhou Public Health Bureau and the Guangzhou Science and Technology Bureau, Guangzhou, China; and The University of Birmingham, UK. We thank Professor Zhang C.H. and Dr. Jiao S.H. for reviewing the chest radiographs. The Guangzhou Biobank Cohort Study investigators include: the Guangzhou No. 12 Hospital: X.Q. Lao, W.S. Zhang, M. Cao, T. Zhu, B. Liu, C.Q. Jiang (Co-PI); The

References (27)

P.A. Tunick et al.
Protruding atherosclerotic plaque in the aortic arch of patients with systemic embolization: a new finding seen by transesophageal echocardiography
Am Heart J
(1990)
J. Li et al.
Aortic calcification on plain chest radiography increases risk for coronary artery disease
Chest
(2002)
A.J. Dobson et al.
How soon after quitting smoking does risk of heart attack decline?
J Clin Epidemiol
(1991)
X.Q. Lao et al.
c-Reactive protein and the metabolic syndrome in older Chinese: Guangzhou Biobank Cohort Study
Atherosclerosis
(2007)
J.C. Witteman et al.
Aortic calcification as a predictor of cardiovascular mortality
Lancet
(1986)
J.A. Ambrose et al.
The pathophysiology of cigarette smoking and cardiovascular disease: an update
J Am Coll Cardiol
(2004)
K.K. Koh et al.
Inflammatory markers and the metabolic syndrome: insights from therapeutic interventions
J Am Coll Cardiol
(2005)
Y. Ota et al.
Impairment of endothelium-dependent relaxation of rabbit aortas by cigarette smoke extract—role of free radicals and attenuation by captopril
Atherosclerosis
(1997)
C. Napoli et al.
Nitric oxide and atherosclerosis
Nitric Oxide
(2001)
R. Danielsen et al.
Predominance of aortic calcification as an atherosclerotic manifestation in women: the Reykjavik study
J Clin Epidemiol
(1996)

L. Wexler et al.

Coronary artery calcification: pathophysiology, epidemiology, imaging methods, and clinical implications A statement for health professionals from the American Heart Association. Writing Group

Circulation

(1996)

A. Simon et al.

Extracoronary atherosclerotic plaque at multiple sites and total coronary calcification deposit in asymptomatic men Association with coronary risk profile

Circulation

(1995)

C. Iribarren et al.

Calcification of the aortic arch: risk factors and association with coronary heart disease, stroke, and peripheral vascular disease

JAMA

(2000)

Cited by (24)

Association of sleep duration and napping with stroke mortality in older Chinese: A 14-year prospective cohort study of the Guangzhou Biobank Cohort study
2023, Sleep Medicine
Citation Excerpt :
Current smokers were defined as participants with current smoking at least one cigarette/day or seven cigarettes/week for at least half a year. Former smokers were defined as participants who used to smoke daily but had quitted smoking, and never smokers were those who did not use tobacco product during their life [31–33]. Definition of alcohol use was based on the usual frequency and amount per occasion of beverage types (beer, wine, spirits, and Chinese wine/spirits) in the past 12 months, as described in our previous studies [34,35].
Evidence regarding the association of short sleep duration and napping with stroke remains limited and controversial. We examined the association of sleep duration and napping with risk of stroke mortality in an older Chinese cohort.
Sleep duration and daytime napping were assessed by face-to-face interview during 2003–2008. Information of causes of death until April 30, 2021 was collected via record linkage with the Death Registry. Cox regression was used to calculate the hazard ratio (HR) and 95% confidence interval (CI).
Of 27,254 participants aged average 62.0 (standard deviation = 7.1) years, 818 stroke deaths occurred within 388,798 person-years (mean = 14.3 years) of follow-up. A U-shaped relation between sleep duration and risk of stroke mortality was observed. Participants with short (≤5 h/day) or long sleep duration (≥9 h/day) showed higher risks of total stroke mortality, with adjusted HRs (95% CIs) being 1.27 (1.01–1.59) and 1.37 (1.07–1.75), respectively. However, non-significant association of short or long sleep duration with hemorrhagic or ischemic stroke mortality was found. The associations of short and long sleep duration with total stroke mortality were more pronounced in those with hypertension (P for interaction with hypertension = 0.01), with HRs (95% CIs) being 1.37 (1.04–1.82) and 1.77 (1.33–2.36), respectively. No association between napping and risk of stroke mortality was found.
Both short and long sleep duration, but not daytime napping, were associated with higher risk of stroke mortality. Public health messages to encourage good sleep hygiene may be important, especially for people with hypertension.
Abdominal aortic calcification: A reappraisal of epidemiological and pathophysiological data
2016, Bone
Citation Excerpt :
Similarly to BMD measured by DXA, the weak associations may be explained by the low number of individuals with severe AAC and shared risk factors used as confounders in the statistical model. For instance, smoking is associated with severe AAC and impaired bone microarchitecture [69–70]. However, the strong effect of the adjustment for age suggests the importance of unmeasured age-related confounders which may be common determinants of AAC and bone microarchitecture, e.g. low grade inflammation, oxidative stress etc.
In men and women, there is a significant association between the risk of cardiovascular event (myocardial infarction, stroke) and risk of major fragility fracture (hip, vertebra). Abdominal aortic calcification (AAC) can be assessed using semiquantitative scores on spine radiographs and spine scans obtained by DXA. Severe AAC is associated with higher risk of major cardiovascular event. Not only does severe AAC reflect poor cardiovascular health status, but also directly disturbs blood flow in the vascular system. Severe (but not mild or moderate) AAC is associated with lower bone mineral density (BMD), faster bone loss and higher risk of major fragility fracture. The fracture risk remains increased after adjustment for BMD and other potential risk factors. The association between severe AAC and fracture risk was found in both sexes, mainly in the follow-ups of less than 10 years.
Many factors contribute to initiation and progression of AAC: lifestyle, co-morbidities, inorganic ions, dyslipidemia, hormones, cytokines (e.g. inflammatory cytokines, RANKL), matrix vesicles, microRNAs, structural proteins (e.g. elastin), vitamin K-dependent proteins, and medications (e.g. vitamin K antagonists). Osteogenic transdifferentiation of vascular smooth muscle cells (VSMC) and circulating osteoprogenitors penetrating into vascular wall plays a major role in the AAC initiation and progression. Vitamin K-dependent proteins protect vascular tunica media against formation of calcified deposits (matrix GLA protein, GLA-rich protein) and against VSMC apoptosis (Gas6).
Further studies are needed to investigate clinical utility of AAC for the assessment of fracture and cardiovascular risk at the individual level and develop new medications permitting to prevent AAC progression.
Role of bone mineral density in the inverse relationship between body size and aortic calcification: Results from the Baltimore longitudinal study of aging
2014, Atherosclerosis
Citation Excerpt :
Excess cardiovascular risk in lean individuals has also been attributed to deleterious lifestyles, particularly smoking and excess alcohol intake, contributing to both leanness and risk of death [25,29]. Remarkably, in our study, as in others [25,30], former and current smoking was an independent predictor of the severity of AC, but no significant interaction was found between smoking and BMI or body weight, and the prevalence of smokers was comparable in normal weight, overweight and obese study participants (43%, 49% and 40%, respectively). On the other hand, one may emphasize the role of vascular calcification as a marker of advanced atherosclerosis, thus able to identify patients with higher change of developing cardiovascular diseases such as ischemic heart disease [31] and heart failure [32].
There is a J-shaped relationship between body mass index (BMI) and cardiovascular outcomes in elderly patients (obesity paradox). Whether low BMI correlates with aortic calcification (AC) and whether this association is accounted for by bone demineralization is uncertain.
Presence of AC was evaluated in 687 community-dwelling individuals (49% male, mean age 67 ± 13 years) using CT images of the thoracic, upper and lower abdominal aorta, and scored from 0 to 3 according to number of sites that showed any calcification. Whole-body bone mineral density (BMD) was evaluated by dual-energy X-ray absorptiometry. Predictors of AC were assessed by logistic regression, and the role of BMD using mediation analysis.
Age and cardiovascular risk factors were positively associated while both BMI (r = −0.11, p < 0.01) and BMD (r = −0.17, p < 0.0001) were negatively associated with AC severity. In multivariate models, lower BMI (OR 0.96, 95%CI 0.92–0.99, p = 0.01), older age, higher systolic blood pressure, use of lipid-lowering drugs and smoking were independent predictors of AC. A nonlinear relationship between BMI and AC was noticed (p = 0.03), with decreased AC severity among overweight participants. After adjusting for BMD, the coefficient relating BMI to AC was reduced by 14% and was no longer significant, whereas BMD remained negatively associated with AC (OR 0.82, 95%CI 0.069–0.96, p = 0.01), with a trend for a stronger relationship in older participants.
Low BMI is associated with increased AC, possibly through calcium mobilization from bone, resulting in low BMD. Prevention of weight loss and bone demineralization with aging may help reducing AC.
Alcohol consumption and aortic arch calcification in an older Chinese sample: The Guangzhou Biobank Cohort Study
2013, International Journal of Cardiology
Citation Excerpt :
As a reliability check, 300 radiographs were randomly selected for re-diagnosis by the two specialist radiologists. The inter-observer consistency was satisfactory (Kappa = 0.68, P < 0.001) [10,15]. Alcohol drinking was classified into never, occasional, moderate and excessive based on the usual frequency of intake and the usual amount per occasion as described in our previous papers [8,9].
To examine the association between alcohol consumption and aortic arch calcification (AAC) in an older Chinese sample.
In 27,844 older people aged 50–85, socioeconomic position and lifestyle factors were assessed by a questionnaire. The presence and severity of AAC were diagnosed from chest X-ray by two experienced radiologists.
In men, the risk for AAC increased significantly in frequent or excessive drinkers [adjusted odds ratio (OR) = 1.36 (95% confidence interval (CI) 1.16–1.59) and 1.49 (1.21–1.83) for those who drank >5 times/week and those who drank excessively, respectively] (P for trend from 0.002 to 0.001). When AAC was analyzed as an outcome variable with 3 categories of severity, significant dose–response relations between the severity of AAC and alcohol consumption were observed, with those who drank frequently (> 5/week) or excessively having more serious AAC (P for trend = 0.03 and 0.02, respectively). No significant association was found in women as few drank excessively.
The presence and severity of AAC were associated with quantity or frequency of alcohol consumption in a dose–response pattern, suggesting that alcohol drinking, even when moderate, has no benefit for AAC. Excessive drinking increased the risk of AAC by 50% compared to never drinkers.
Cardiovascular disease risk factors are highly prevalent in the office-working population of Nanjing in China
2012, International Journal of Cardiology
Citation Excerpt :
One probable reason was that most of our subjects were white collars with 76.8% having high education background (college or above). As Jiang et al. reported in the Guangzhou Biobank Cohort Study Phase 3 (2006–2007), current and ex-smokers tended to have a lower education level [21]. An inverse association has been reported between physical activity and CVD in the general population [22].
To establish a profile of the modifiable cardiovascular disease (CVD) risk factors in the office-working population of Nanjing, China.
With increasing modernization in China, CVD is now common among Chinese. Relevant information on the prevalence of CVD risk factors in China is, however, limited.
We recruited 2648 office working people aged 23–79 years without history of CVD or diabetes from 7 work units of Nanjing during the years 2003 to 2005. Information from a self-reported questionnaire on lifestyle, physical examination, fasting blood for lipid profiles, and a 75-gram oral glucose tolerance test (OGTT) were obtained from each participant. We analyzed the following 7 CVD risk factors: smoking, inadequate physical activity, unhealthy dietary habit, obesity, hypertension, dyslipidemia, and hyperglycemia.
The whole study population had an average of 2.8 risk factors, while 95.6%, 79.4% and 55.6% of them had respectively ≥ 1, ≥ 2 and ≥ 3 of the 7 CVD risk factors. Men had a higher proportion of smoking, hypertension, dyslipidemia, hyperglycemia, but lower in light physical activity compared with women. Number of CVD risk factors increased with age. Although risk factors in men were more common than women, they increased alarmingly in postmenopausal women.
CVD risk factors are common in office-working people in Nanjing, China. Effective interventions and treatment against risk factors should be adopted in the high risk population, which may greatly reduce the future burden of CVD in the Chinese population.
A polymorphism in transforming growth factor-β1 is associated with carotid plaques and increased carotid intima-media thickness in older Chinese men: The Guangzhou Biobank Cohort Study-Cardiovascular Disease Subcohort
2011, Atherosclerosis
Polymorphisms of the transforming growth factor-β1 (TGFB1) gene have not been associated with asymptomatic atherosclerosis previously. We investigated the relationship between a single nucleotide polymorphism (SNP) rs4803455 in TGFB1 and atherosclerosis identified by the presence of carotid plaque and increased intima–media thickness (IMT) in an older Chinese population.
1996 subjects (992 (49.7%) men aged 50–85 years) from the Guangzhou Biobank Cohort Study-Cardiovascular Subcohort (GBCS-CVD) were genotyped. Carotid plaque and IMT were assessed by B-mode ultrasonography.
In male subjects, the C allele of TGFB1 rs4803455 was significantly associated with prevalence of carotid plaque (adjusted OR: 2.49, 95% CI: 1.16–5.36, P = 0.03). The C allele was related to increased number of common carotid artery (CCA) plaques (P = 0.03) and larger carotid plaque area (P = 0.02) in men. The homozygous carriers of allele C in male subjects also had a higher risk of having carotid IMT ≥1 mm (adjusted OR: 1.75, 95% CI: 1.05–2.93, P = 0.03). These associations were independent of age, smoking, physical activity, body mass index, blood pressure, lipid profile, fasting glucose and high sensitivity C-reactive protein.
This is the first study to show that the C allele in TGFB1 was associated with increased risk of atherosclerosis in older Chinese men. Further investigations on the linkage between the TGFB1 gene and progression of atherosclerosis in asymptomatic populations are warranted.

View all citing articles on Scopus

View full text

Smoking, smoking cessation and aortic arch calcification in older Chinese: The Guangzhou Biobank Cohort Study

Abstract

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Methods

Results

Discussion

Acknowledgements

Am Heart J

Chest

J Clin Epidemiol

Atherosclerosis

Lancet

J Am Coll Cardiol

J Am Coll Cardiol

Atherosclerosis

Nitric Oxide

J Clin Epidemiol

Coronary artery calcification: pathophysiology, epidemiology, imaging methods, and clinical implications A statement for health professionals from the American Heart Association. Writing Group

Circulation

Extracoronary atherosclerotic plaque at multiple sites and total coronary calcification deposit in asymptomatic men Association with coronary risk profile

Circulation

Calcification of the aortic arch: risk factors and association with coronary heart disease, stroke, and peripheral vascular disease

JAMA