Elsevier

American Heart Journal

Volume 150, Issue 2, August 2005, Pages 358-364
American Heart Journal

Clinical Investigation
Impact of smoking status on outcomes of primary coronary intervention for acute myocardial infarction—The smoker's paradox revisited

https://doi.org/10.1016/j.ahj.2004.01.032Get rights and content

Objectives

We sought to determine the relationship between cigarette smoking and outcomes after mechanical reperfusion therapy in acute myocardial infarction (AMI).

Background

Prior studies have found that smokers with AMI have lower mortality rates and a more favorable response to fibrinolytic therapy than nonsmokers. The impact of cigarette smoking in patients undergoing primary percutaneous coronary intervention has not been examined.

Methods

In the CADILLAC trial, 2082 patients with AMI were randomized to percutaneous transluminal coronary angioplasty ± abciximab versus stenting ± abciximab. Data on smoking status were prospectively collected and follow-up continued for 1 year.

Results

At the time of presentation, 638 (31%) patients had never smoked, 546 (26%) were former smokers, and 898 (45%) were currently smoking. In comparison to nonsmokers, current smokers were younger, more often men, and less frequently had diabetes, hypertension, prior AMI, and triple-vessel coronary disease. Procedural success rates were unrelated to smoking status. Mortality was lowest in current smokers, intermediate in former smokers, and highest in nonsmokers at 30 days (1.3% vs 1.7% vs 3.5%, respectively, P = .02) and 1 year (2.9% vs 3.7% vs 6.6%, P = .0008). After multivariate correction for differences in baseline variables, however, current smoking status was no longer protective from late mortality (hazard ratio 0.96, 95% CI 0.52-1.76, P = .89).

Conclusions

The “smoker's paradox” extends to patients undergoing primary PCI for AMI, with increased survival seen in current smokers, an effect entirely explained by differences in baseline risk and not smoking status per se. The deleterious effects of smoking are expressed in the occurrence of AMI nearly a decade earlier than in nonsmokers, with similar age-adjusted risk, mandating intensive primary and secondary cigarette-cessation efforts.

Section snippets

Study population and protocol

The CADILLAC study protocol has been described in detail elsewhere.14 Briefly, 2082 patients >18 years of age with the presence of >30 minutes but <12 hours of symptoms consistent with AMI, and ST-segment elevation in ≥2 contiguous leads or left bundle-branch were enrolled. Patients with other electrocardiographic patterns were also eligible if angiography demonstrated a high-grade stenosis and associated regional wall motion abnormalities. Major exclusion criteria included cardiogenic shock;

Results

Of the 2082 patients randomized in CADILLAC, 638 (31%) never smoked, 898 (43%) were current smokers, and 546 (26%) quit smoking at least 1 month before the AMI.

Discussion

In this analysis from the CADILLAC trial, the largest prospective study to date of mechanical reperfusion strategies in patients with AMI, current smokers had greater survival compared to nonsmokers or former smokers, both at 30 days and at 1 year of follow-up. In addition, rates of reinfarction were lower in current smokers during the 1-year follow-up period, resulting in lower composite rates of major adverse cardiac events in cigarette users. Indeed, a “dose-response” curve was evident, with

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