Cigarette smoking and acute coronary syndromes: A multinational observational study☆
Introduction
Cigarette smoking is a well-established risk factor for the development of coronary heart disease [1]. Several studies have shown lower mortality after ST-segment elevation myocardial infarction in smokers compared with non-smokers [2], [3], [4]. This is the ‘smokers’ paradox’, where an individual who smokes is not only more likely than a non-smoker to suffer a heart attack but is also more likely to survive it. One explanation for this paradox is that smokers may have a larger thrombus burden, leading to a greater efficacy of intravenous thrombolysis [3], [4], [5], [6], [7]. Also, smokers tend to be younger and have more favourable baseline characteristics than non-smokers [2], [8], [9], [10]. More recent studies suggest that smoking is not an independent prognostic factor in terms of early survival after ST-segment elevation myocardial infarction [11]. However, there are few data regarding smoking status and outcome across the whole range of acute coronary syndromes, particularly among patients with unstable angina and non-ST-segment elevation myocardial infarction. Another problem is the potential selection bias of studies performed among patients participating in randomized clinical trials, whose characteristics may not match those of patients encountered in routine care.
The Global Registry of Acute Coronary Events (GRACE) is an ongoing, multinational, observational registry of patients hospitalized with acute coronary syndromes [12]. To assess the impact of smoking status on presentation, treatment, and outcomes in acute coronary syndromes, we analysed data from 19,325 patients consecutively enrolled in GRACE.
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Materials and methods
Full details of the GRACE rationale and methodology have been published [12]. In brief, GRACE is designed to reflect a representative population of patients with ACS, irrespective of geographic region. Currently, 94 public and private hospitals located in 14 countries (Argentina, Australia, Austria, Belgium, Brazil, Canada, France, Germany, Italy, New Zealand, Poland, Spain, United Kingdom, United States) are participating in this observational study.
Characteristics of current smokers, former smokers, and non-smokers
The study sample consisted of 19,325 patients with acute coronary syndromes admitted between April 1999 and March 2002. Of these, 5276 (27.3%) were current smokers, 5691 (29.5%) were former smokers, and 8358 (43.2%) were non-smokers. ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction, and unstable angina were each present in approximately one-third of the population. The baseline characteristics of the study population are presented in Table 1. The median
Discussion
Most previous studies investigating the effect of smoking status on short-term prognosis in patients with an acute coronary syndrome have been derived from highly selected patient populations, for example individual with ST-segment elevation myocardial infarction [13], [14] treated with thrombolytic therapy [3], [4], [5], [6], [9], [15]. Few recent data are available regarding the impact of smoking status on presentation and outcome in patients with the spectrum of acute coronary syndromes,
Acknowledgements
The authors would like to express their gratitude to the physicians and nurses participating in GRACE. Further information about the project, along with the complete list of participants, can be found at www.outcomes.org/grace. GRACE is supported by an unrestricted educational grant from Aventis Pharma to the Center for Outcomes Research, University of Massachusetts Medical School. Aventis had no involvement in the collection, analysis, and interpretation of data; in the writing of the report;
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2019, JACC: Cardiovascular InterventionsCitation Excerpt :Given decades of evidence related to the detrimental effect of cigarette smoking on health in general (33,34), the role of smoking in relation to cardiovascular outcomes has been controversial at best since the first description of the so-called smoker’s paradox (4,5). Some studies have supported its existence (i.e., smoking improves cardiovascular outcomes in the context of an acute event such as an MI) (3–9), whereas others have refuted its existence (i.e., smoking is not associated with better cardiovascular outcomes) (10–12). Moreover, many of these studies were registry analyses or were conducted in the era of thrombolytic therapy and balloon angioplasty; this limits their applicability to modern PCI.
The smoker's paradox in acute coronary syndrome: Is it real?
2018, Revista Portuguesa de CardiologiaCitation Excerpt :Their coronary anatomy is less complex, with less three-vessel disease and fewer left main and left anterior descending lesions, features that are typically associated with a worse prognosis.39 The rate of adherence to evidence-based treatment was greater in smokers, both during the index hospitalization (revascularization and medical treatment)12,26,29–31 and at discharge (medical treatment).31 Moreover, smokers were treated more promptly than never-smokers, as shown by a significantly shorter time from first medical contact to reperfusion (reported only in STEMI).11
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GRACE is supported by an unrestricted educational grant from Aventis Pharma.
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A complete list of investigators and institutions can be found in the appendix.