By Dr Ajay Mosur

1. ARTHEROSCLEROTIC RISK FACTOR :SMOKING
DR. AJAY B MOSUR
NARAYANA HEALTH CITY
BENGALURU

2. ATHEROSCLEROSIS
• THEORIES:
1. Lipid hypothesis.
2. Response to injury/ inflammation hypothesis.
3. Monoclonal hypothesis.

3. INFLAMMATORY HYPOTHESIS:
• Atherosclerosis is recognized as a inflammatory disease .
• LDL retention
• Monocytes
• Macrophages
• Lymphocytes
• Smooth muscles cells
• C Reactive Protein

6. PLAQUE COMPOSITION:
MMP:
• Plaque composition is influenced by MMP ( matrix metalloproteinase) activity.
• MMP are responsible for extra cellular matrix break down leading to plaque
rupture.
• Unstable plaque:
1. Large lipid core
2. Thin fibrous cap
3. Little proportion of ECM.
• Cap thinning with in unstable plaque-
1. enhanced breakdown by MMP.
2. less proportion of ECM in the plaque

7. COX 2:
• Progression of atherosclerosis:
1. Sustained activities of macrophages
2. Induction of chemotaxis
3. Propagation of inflammatory cytokine cascade
4. Stimulation of SMC migration.
• COX 2 couples with prostaglandin E synthases leading to formation of PGE 2
which has pro inflammatory properties.
• PGE 2 activity influences MMP dependent ECM break down causing plaque
instability.

10. C REACTIVE PROTEIN
• hsCRP- leading biochemical marker for clinical application.
• Inflammatory cytokines ( IL 6 and IL 8) and acute phase reactants ( CRP, fibrinogen,
serum amyloid A) are associated with progression of atherosclerosis.
• hsCRP is a stronger predicator of cardio vascular event when compared to LDL
cholesterol or other markers of inflammation and thrombosis.

11. JUPITER TRIAL:
• hsCRP > 2.0mg/dl and LDL < 130mg/dl
• Rosuvastatin resulted in 44% reduction primary end point MI, stroke, arterial
revascularization.
ASTEROID TRIAL:
• 80 mg of rosuvastatin resulted in a change of atheroma volume of 0.98% over 24 months.
REVERSAL TRIAL:
• 40 mg pravastatin/ 80 mg atorvastatin
• LDL reduced to 79 mg/dl total atheroma progression 0.4% atorvastatin
• LDL reduced to 110 mg/dl total atheroma progression 2.7 % pravastatin

12. SMOKING
• Smoking is an independent modifiable major risk factor for development of
atherosclerosis.
• Smoking cessation : level 1A recommendation for atherosclerotic occlusive disease
of lower extremities.

13. AMERICAN COLLEGE OF CARDIOLOGY GUIDELINES

15. ATHEROSCLEROSIS RISK IN COMMUNITIES STUDY(ARIC)
• ARIC study enrolled 15,792 participants: 492 cases of PAD
• Age group 45-64 years.
• Median follow up of 26 years.
• Smokers >40 pack years had 4 fold increased risk of PAD.
• Smokers > 35 years of smoking demonstrated HR of 5.56(95% CI) for PAD.
• Smokers > 1 pack/day demonstrated HR of 5.36(95% CI) for PAD.
• Younger age for initiation of smoking showed statistically significant association
with PAD ( p value <0.001).

16. • 1 year cessation of smoking was associated with 4% lower risk of PAD.
• Compared to never smokers, smokers had elevated risk of PAD even after 30 years
of smoking cessation.

17. MULTI ETHNIC STUDY OF ATHEROSCLEROSIS(MESA)
• MESA studied impact of smoking on inflammation, vascular dynamics and sub
clinical atherosclerosis.
• Study population : 6814 out of which 971(14%) were smokers
• INFLAMMATION :
1. hsCRP, fibrinogen, IL 6
• VASCULAR DYNAMICS
1. Distensibility: Aortic MRI, carotid USG
2. Endothelial function: brachial artery flow mediated dilation( FMD).
• SUBCLINICAL ATHEROSCLEROSIS
1. Carotid intima-media thickness(CIMT)
2. Coronary artery calcification (CAC)
3. Ankle brachial index (ABI)

18. INFLAMMATION:
• hsCRP significantly higher in current smokers, 37% higher as compared to non
smokers ( p value <0.001).
• Adjusted hsCRP and IL6 increased in monotonic fashion as PAC years increased.
• Smoker with elevated inflammatory markers had increased burden of subclinical
atherosclerosis.
• (hsCRP > 2 mg/dl more likely to have higher adjusted CAC than non smokers).
• Statistically significant reduction in both hsCRP and IL6 after 1 year of smoking
cessation.

19. VASCULAR DYNAMICS:
• Carotid and aortic distensibility was lower in smokers.
• Brachial FMD showed no significant difference.
SUBCLINICAL ATHEROSCLEROSIS:
• CIMT and CAC score where higher along with lower ABI in smokers.
• In former smokers cumulative exposure (increased CIMT and CAC score ) was seen
in the highest quartile of pack years.
• Reduced burden of atherosclerosis was seen in former smokers 5 years after
smoking cessation.

21. ACS-NSQIP
• American college of surgeons national surgical quality improvement
program
• 12655 procedures :
1. 31% endovascular procedure
2. 69% infra inguinal bypass
• 2011-2014.
• 4706 (37.2%) were active smokers.
• Smoking status on 30 day graft failure rate: 5.0% patients developed graft
failure.
• Early graft failure was 21% higher in smokers.

23. • Active smokers undergoing endovascular intervention:
1. intermittent claudication – higher re intervention rates < 30 days.
2. Critical limb ischemia: higher amputation rates.

24. UNIVERSITY OF CALFORNIA DAVIS REGISTRY:
• 739 patients, 204(28%) active smokers.
• 2006-2013.
• 61 patients (30%) successfully quit smoking after intervention.
• 5 year follow up patients who quit smoking for > 1 year post intervention had
improved amputation free survival( 81% vs 60%).

25. BEHAVIORAL AND PHARMACOTHERAPY FOR SMOKING CESSATION

26. THANK YOU