Coronary artery disease
Impact of Smoking on Outcomes of Patients With ST-Segment Elevation Myocardial Infarction (from the HORIZONS-AMI Trial)

https://doi.org/10.1016/j.amjcard.2011.06.063Get rights and content

We assessed the impact of smoking on outcomes in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention using alternative antithrombotic regimens and stent types. In the HORIZONS-AMI trial 3,602 patients were randomly assigned to unfractionated heparin (UFH) plus a glycoprotein IIb/IIIa inhibitor (GPI) or bivalirudin alone and paclitaxel-eluting stents or bare-metal stents. Compared to nonsmokers, smokers had significantly lower rates of mortality and major bleeding at 30 days and at 1 year; however, the differences were no longer significant after covariate adjustment. Smoking was associated with increased rates of definite/probable stent thrombosis (ST) at 1 year (adjusted RR 1.99, 95% confidence interval 1.28 to 3.10) mainly because of a higher rate of late ST after paclitaxel-eluting stent implantation (1.9% vs 0.4%, p = 0.0006). In smokers bivalirudin monotherapy compared to UFH plus a GPI was associated with lower mortality at 30 days (0.5% vs 2.2%, p = 0.002) and at 1 year (1.8% vs 4.0%, p = 0.008). No decrease in mortality was seen with bivalirudin in nonsmokers. Major bleeding was significantly decreased with bivalirudin regardless of smoking status (smokers 3.7% vs 8.9%, p <0.0001; nonsmokers 6.5% vs 9.6%, p = 0.01). In conclusion, in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention, smoking is an independent predictor of definite/probable ST at 1 year. Bivalirudin monotherapy compared to UFH plus a GPI decreased major bleeding regardless of smoking status but may have different effects on individual components of ischemic events.

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Methods

The design and results of the HORIZONS-AMI trial have been previously published.1, 2 Briefly, 3,602 patients with ST-segment elevation myocardial infarction were randomized in an open-label fashion and in a 1:1 ratio to treatment with bivalirudin alone (1,800 patients) or UFH plus a GPI (1,802 patients). Emergency coronary angiography with left ventriculography was performed after randomization with subsequent triage to treatment with percutaneous coronary intervention, coronary artery bypass

Results

In the HORIZONS-AMI trial primary percutaneous coronary intervention was performed in 3,340 of 3,602 patients (93%). Information on smoking status was available for 3,328 of 3,340 patients (99.6%), of whom 1,563 (47%) were current smokers and 1,765 (53%) were nonsmokers.

As presented in Table 1, smokers compared to nonsmokers were younger, more frequently men, had lower body mass index, less commonly had hypertension, hyperlipidemia, diabetes, renal insufficiency, and anemia at baseline, had

Discussion

The main findings of this analysis from the HORIZONS-AMI, the largest contemporary trial of primary percutaneous coronary intervention for ST-segment elevation myocardial infarction, are the following: (1) approximately 1/2 of patients (47%) undergoing mechanical reperfusion were smokers; (2) smokers compared to nonsmokers had significantly lower rates of mortality and major bleeding at 30 days and at 1 year, but the differences no longer existed after covariate adjustment; (3) smoking was

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