Temporal trends in all-cause mortality of smokers versus non-smokers hospitalized with ST-segment elevation myocardial infarction

doi:10.1016/j.ijcard.2014.07.010

International Journal of Cardiology

Volume 176, Issue 1, September 2014, Pages 171-176

https://doi.org/10.1016/j.ijcard.2014.07.010 Get rights and content

Highlights

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Evidence based therapies have increased over the past decade in STEMI Patients.
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Non Smokers have demonstrated a reduction in mortality during the past decade.
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Smokers have not demonstrated a reduction of mortality during the past decade.
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Special attention should be placed on smokers.

Abstract

Background/objectives

Over the past decade, the development of novel management strategies has resulted in improved outcomes among patients hospitalized with ST-segment myocardial infarction (STEMI). The aim of the present study was to compare temporal trends in the mortality of smokers versus non-smokers admitted with STEMI in a real world setting between 2000 and 2010.

Methods

We evaluated time-dependent changes in the clinical characteristics, management strategies, and one year all-cause mortality of STEMI patients who were enrolled in the biannual Acute Coronary Syndrome Israeli Survey (ACSIS) between 2000 and 2010, categorized as smokers (n = 2399) and non-smokers (n = 3069). We divided the survey periods into early (2000–2004) and late (2006–2010). The primary endpoint of the study was the occurrence of one-year all-cause mortality.

Results

A total of 4564 STEMI patients were enrolled in the study. Compared with non-smokers, smokers were significantly younger and displayed a significantly lower rate of all-cause mortality at 30 days and 1-year. Both smokers and non-smokers who were enrolled in the late survey period received more evidence-based therapies (primary PCI and guideline-based medications) (p < 0.001 for all). There was a significant reduction in the risk of 1-year all-cause mortality only among non-smokers (HR = 0.664 CI 95% 0.52–0.85, p = 0.0009), whereas smokers who were enrolled in more recent survey periods did not display a significant risk reduction (HR = 1.08 CI 95% 0.77–1.51, p = 0.67).

Conclusion

Survival following STEMI among smokers has not improved over the past decade despite corresponding changes in management strategies. Future trials should focus on reducing the risk in smokers.

Introduction

Our approach to ST-segment myocardial infarction (STEMI) has evolved rapidly over the past decade with major advances in management techniques. Percutaneous coronary intervention (PCI) gradually became the preferred method of primary reperfusion in patients presenting with STEMI in many centers. Evidence based medical treatments including aspirin, P2Y12 inhibitors, angiotensin converting enzyme inhibitors (ACEI)/angiotensin receptor blockers (ARBs), statins, anticoagulants and beta blockers have been incorporated into management guidelines and are the standard of care [1], [2].

In parallel to this progress, the awareness of the hazards of smoking has increased as well as the therapies available to help smokers quit [3], [4]. However, success rates of smoking cessation are still low even in randomized trials [3], [5]. The incidence of smoking in the Israeli population has decreased over the past decade by 25% (31% versus 24%) [6].

Historically, smokers have a paradoxically lower mortality after STEMI compared with non-smokers, coined the smoker's paradox [7]. Smokers have less conventional risk factors and are younger compared to non-smokers. Currently, however, there are limited data regarding temporal trends in outcomes of smokers hospitalized with a STEMI. Specifically, it is possible that changes in management strategies over the last decade were associated with a differential effect between smokers and non-smokers hospitalized with STEMI.

In the present study, we evaluated the temporal trends in the clinical characteristics and outcomes of smokers and non-smokers presenting with STEMI in a real world setting of patients enrolled in the Acute Coronary Syndrome Israeli Survey (ACSIS) 2000–2010.

Section snippets

Study population

The ACSIS (acute coronary syndrome Israeli survey) registry is a biannual prospective national survey of all patients with ACS hospitalized in all 25 coronary care units and cardiology wards in all general hospitals in Israel during a 2 month period (March–April) [8], [9], [10]. ACSIS recruits only patients from Israel in order to allow proper follow up. Demographic, historic, and clinical data are recorded on pre-specified forms for all patients admitted with a diagnosis of acute coronary

Results

The study population comprised a total of 4564 STEMI patients who were enrolled in the 6 surveys composing the ACSIS 2000–2010. In the 2000–2004 surveys (early period), 2616 patients were enrolled, of whom 1253 (48%) were smokers and 1363 (52%) were non-smokers. In the 2006–2010 surveys (late period), 1948 patients were enrolled, of whom 1146 (59%) were smokers and 802 (41%) non-smokers. The rate of smokers presenting with STEMI has increased over the past decade from 42% to 47% (p for trend ≤

Discussion

Our main finding is that over the past decade smokers presenting with STEMI have not demonstrated a significant reduction in the risk of all-cause mortality at 30 days and at 1-year, whereas non-smokers displayed significantly improved corresponding survival rates during this time period. This was an unexpected finding since both cohorts were treated with more evidence based therapies during the latter half of the past decade.

It has been repeatedly shown that those who start smoking in early

Conflict of interest

No conflicts to report.

Acknowledgment

RK, YA, NGY and IG had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Sources of funding: The study was self-funded.

Relationship with industry: None.

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Cited by (22)

The Impact of Smoking Status 1 Year After ST-Segment Elevation Myocardial Infarction on Cardiovascular Events and Mortality in Patients Aged ≤60 Years
2022, American Journal of Cardiology
Smoking is associated with increased risk for acute ST-elevation myocardial infarction (STEMI) at a young age. Although smoking is a modifiable risk factor, smoking cessation rates after STEMI are suboptimal. We investigated the association between smoking status 1 year after STEMI and adverse events in patients (n = 765) aged ≤60 years. Patients were categorized as: (1) nonsmokers, (2) quit smoking, and (3) continued/resumed smoking. The association between smoking status and risk for major adverse cardiovascular events (MACEs) was analyzed during a median follow-up of 8 years. At presentation with STEMI, the mean age was 51 ± 7 years (88% men) and 427 (56%) were smokers. A year after STEMI, 272 continued smoking, 35 quit but later resumed smoking (summed to a single group; n = 307), and 120 quit smoking. Continued smoking was associated with younger age, male gender, lower weight, and low socioeconomic status. Compared with nonsmokers, the adjusted hazard ratio (95% confidence interval) for myocardial infarction, stroke, unstable angina, death, and MACE was 2.51 (1.67 to 3.73), 2.07 (0.94 to 4.56), 3.73 (1.84 to 7.58), 2.52 (1.53 to 4.13), and 2.40 (1.80 to 3.22), accordingly, in those who continued to smoke. However, the adjusted hazard ratio was not significantly associated with these outcomes in patients who quit smoking (MACE: 1.20 [0.77 to 1.87], p=0.414; nonsignificant for individual end points). In conclusion, the prevalence of smoking in young and middle-aged patients presenting with STEMI is high and smoking cessation rates are low. A year after STEMI, those who continued to smoke had worse cardiovascular outcomes and death compared with nonsmokers; however, the long-term outcomes among those who quit smoking appear to be comparable with nonsmokers. The results highlight the contrast between health benefits of quitting smoking after STEMI and low abstinence rates in clinical practice.
Machine learning-based prediction of 1-year mortality for acute coronary syndrome<sup>✰</sup>
2022, Journal of Cardiology
Clinical risk assessment with quantitative formal risk scores may add to intuitive physician risk assessment and are advised by the international guidelines for the management of acute coronary syndrome (ACS) patients. Most previous studies have used the binary regression/classification approach (dead/alive) for long-term mortality post-ACS, without considering the time-to-event as in survival analysis. The use of machine learning (ML)-based survival models has yet to be validated.
The primary objective was to compare survival prediction performance of 1-year mortality following ACS of two newly developed ML-based models [random survival forest (RSF) and deep learning (DeepSurv)] with the traditional Cox-proportional hazard (CPH) model. The secondary objective was external validation of the findings.
This was a retrospective, supervised learning data mining study based on the Acute Coronary Syndrome Israeli Survey (ACSIS) and the Myocardial Ischemia National Audit Project (MINAP). The ACSIS data were divided to train/test in a 70/30 fashion. Next, the models were externally validated on the MINAP data. Harrell's C-index, inverse probability of censoring weighting (IPCW), and the Brier-score were used for models’ performance comparison.
RSF performed best among the three models, with Harrell's C-index on training and testing sets reaching 0.953 and 0.924 respectively, followed by CPH multivariate selected model (0.805/0.849), CPH Univariate selected model (0.828/0.806), DeepSurv model (0.801/0.804), and the traditional CPH model (0.826/0.738). The RSF model also had the highest performance on the validation data set with 0.811 for Harrell's C-index, 0.844 for IPCW, and 0.093 for Brier score. The CPH model performance on the validation set had C-index range between 0.689 to 0.790, 0.713 to 0.826 for IPCW, and 0.094 to 0.103 Brier score.
RSF survival predictions for long-term mortality post-ACS show improved model performance compared with the classic statistical method. This may benefit patients by allowing better risk stratification and tailored therapy, however further prospective evaluations are required.
Predicting 30-day mortality after ST elevation myocardial infarction: Machine learning- based random forest and its external validation using two independent nationwide datasets
2021, Journal of Cardiology
Citation Excerpt :
ACSIS is a biennial prospective observational national survey of all patients with acute coronary syndrome (ACS) hospitalized in Israel since 2000 [22,23]. In every survey during a two-month period, data are prospectively collected from all ACS admissions in each of the 25 cardiology wards operating in Israel [22–25]. All patients with STEMI are included in the survey and followed for one month.
Various prognostic models for mortality prediction following ST-segment elevation myocardial infarction (STEMI) have been developed over the past two decades. Our group has previously demonstrated that machine learning (ML)-based models can outperform known risk scores for 30-day mortality post-STEMI. The study aimed to redevelop an ML-based random forest prediction model for 30-day mortality post-STEMI and externally validate it on a large cohort.
This was a retrospective, supervised learning, data mining study developed on the Acute Coronary Syndrome Israeli Survey (ACSIS) registry and the Myocardial Ischemia National Audit Project (MINAP) for external validation. Patients included received reperfusion therapy for STEMI between 2006 and 2016. Discrimination and calibration performances were assessed for two developed models and compared with the Global Registry of Acute Cardiac Events (GRACE) score.
The ACSIS cohort (2,782 included /15,212 total) and MINAP cohort (22,693 included/735,000 total) were significantly different in most variables, yet similar in 30-day mortality rate (4.3–4.4%). Random forest models were developed on the ACSIS cohort with a full model including all 32 variables and a simple model including the 10 most important ones. Features’ importance was calculated using the varImp function measuring how much each feature contributes to the data's homogeneity. Applying the optimized models on the MINAP validation cohort showed high discrimination of area under the curve (AUC) = 0.804 (0.786–0.822) for the full model, and AUC = 0.787 (0.748–0.780) using the simple model, compared with the GRACE risk score discrimination of AUC = 0.764 (0.748–0.780). All models were not well calibrated for the MINAP data. Following Platt scaling on 20% of the MINAP data, the random forest models calibration improved while the GRACE calibration did not change.
The random forest predictive model for 30-day mortality post STEMI, developed on the ACSIS national registry, has been validated in the MINAP large external cohort and can be applied early at admission for risk stratification. The model performed better than the commonly used GRACE score. Furthermore, to the best of our knowledge, this is the first externally validated ML-based model for STEMI.
Temporal trends of patients with acute coronary syndrome and multi-vessel coronary artery disease - from the ACSIS registry
2020, International Journal of Cardiology
Citation Excerpt :
The finding of decline in the relative proportion of STEMI among ACS patients with MV-CAD is consistent with the trends of decline in STEMI hospitalizations, but not of NSTE-ACS in several contemporary registries [20–22]. This trend was previously attributed to improved primary and secondary preventive measures and adherence to guidelines-recommended treatments over time [23–28]. The latter suggested explanations could also be responsible, at least in part, to the decline in the proportion of MV-CAD observed in our report.
Multi-vessel coronary artery disease (MV-CAD) is common among patients with acute coronary syndrome (ACS) and is associated with worse outcomes.
To examine temporal trends of patients presenting with ACS and MV-CAD.
Time-dependent analysis of patients enrolled in the ACS Israeli Surveys (ACSIS) between 2004–2016 by 3 time periods: early (2004–2006; n = 2111), mid (2008–2010; n = 2049), and late (2013–2016; n = 2010). MV-CAD was defined as >50% stenosis in ≥2 separate coronary territories at the index coronary catheterization. Outcomes were 30-day MACE and 1-year all-cause mortality.
Overall 6170/9321 patients (66%) had MV-CAD (age 64.5 ± 12.1, males 80%). Patients from later periods were older with a higher prevalence of cardiovascular risk-factors and comorbidity. Among patients with MV-CAD, STEMI decreased significantly (early-46% vs. late-37%, p < 0.001). The rates of PCI were similar, however rates of MV-PCI have increased (early-16.8% vs. late −37.1%, p < 0.001) while the rates of CABG decreased over-time (early-12.7% vs. late −9.2%, p < 0.001). Thirty-day outcomes improved significantly; MACE (early-18.2%, mid-12.6%, late-11.2%, p < 0.001), mortality (early-4.7%, mid-4.2%, late-3.1%, p = 0.03) and re-infarction (early = 3.0%, mid = 2.4% and late 1.1%, p < 0.001). No significant change in 1-year mortality was observed (early = 9.3%, mid = 7.8%, late = 7.7%, p = 0.13). A multivariate adjusted analysis demonstrated that the mid and late periods (vs. the early period) were associated with significantly reduced risk for 30-day MACE (OR = 0.65 [0.54–0.77] and 0.54 [0.45–0.65], respectively).
During the last decade, the burden of cardiovascular risk factors among ACS patients with MV- CAD has increased, more invasive treatment was provided and a significant improvement in 30-day outcomes was observed.
Long-term Follow-up of the Trial of Routine Angioplasty and Stenting After Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI)
2018, Canadian Journal of Cardiology
Citation Excerpt :
In addition, as other studies have shown, some patients (high troponin, high Global Registry of Acute Coronary Event [GRACE] scores) have elevated event rates regardless of treatment strategy.17,18 The widespread use of adenosine diphosphate (ADP) receptor-inhibitor therapy (eg, clopidogrel) that was used in our study may help reduce the thrombotic risks associated with an early intervention after fibrinolysis.6,19,20 Therefore, medical therapy has a pivotal role in secondary prevention that transcends any differences seen in the first year.
The Trial of Routine Angioplasty and Stenting after Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI) demonstrated superiority of routine early coronary angiography (and percutaneous coronary intervention [PCI]) compared with standard therapy in fibrinolytic-treated patients with ST-segment elevation myocardial infarction (STEMI) at 30 days. The aim of the current study was to evaluate the long-term (>7 year) effects of an early invasive strategy.
We linked the study cohort and administrative datasets to assess long-term follow-up status including repeat procedures, hospitalizations, and major adverse cardiovascular events (MACE). Kaplan-Meier and Cox regression analysis were used to evaluate the relationship between randomized treatment and long-term adverse outcomes.
A total of 881 patients had long-term follow-up and were included in our study. After a mean follow-up of 7.8 years, there were no significant differences in death, myocardial infarction (MI), unstable angina, stroke, transient ischemic attack (TIA), or heart failure admissions (hazard ratio [HR] 0.91; 95% confidence interval [CI] 0.73–1.13]; P = 0.41) between those randomized to an early invasive vs standard treatment strategy. Following the index hospitalization, there were no significant difference in the rates of coronary revascularization between the early invasive and the standard therapy groups (81 [19.3%] vs 76 [17.9%]; P = 0.61).
Despite the short-term benefit and safety of an early invasive strategy in patients with STEMI receiving fibrinolysis, no statistically significant differences in MACE were observed over 7.8 years.
L’essai TRANSFER-AMI (Trial of Routine Angioplasty and Stenting after Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction) a démontré la supériorité de la coronarographie précoce systématique (et d’une intervention coronarienne percutanée) comparativement au traitement standard après 30 jours chez les patients sous fibrinolytiques ayant subi un infarctus du myocarde (IM) avec sus-décalage du segment ST. La présente étude visait à évaluer les effets à long terme (> 7 ans) d’une stratégie invasive précoce.
Nous avons établi un lien entre l’étude de cohorte et des ensembles de données administratives pour évaluer l’état des patients suivis à long terme, y compris la reprise d’interventions, les hospitalisations et les événements cardiovasculaires indésirables majeurs (ECIM). Des analyses fondées sur la méthode de Kaplan-Meier et le modèle de régression de Cox ont servi à évaluer la relation entre un traitement attribué de façon aléatoire et les résultats défavorables à long terme.
Notre étude a porté sur 881 patients ayant fait l’objet d’un suivi à long terme. Après un suivi moyen de 7,8 années, aucune différence significative n’a été relevée au chapitre des décès et des hospitalisations pour cause d'IM, d’angine de poitrine instable, d’accident vasculaire cérébral, d'ischémie cérébrale transitoire ou d’insuffisance cardiaque (RRI : 0,91, intervalle de confiance [IC] à 95 % : 0,73-1,13; p = 0,41) entre les patients soumis à une stratégie thérapeutique invasive précoce et les patients soumis à une stratégie thérapeutique standard après répartition aléatoire. Après l’hospitalisation de référence, aucune différence significative n’a été notée entre les deux groupes de traitement quant aux taux de revascularisation coronarienne (19,3 % [81] dans le cadre d’une stratégie thérapeutique invasive précoce comparativement à 17,9 % [76] dans le cadre d’une stratégie thérapeutique standard; p = 0,61).
Malgré les bénéfices à court terme et l’innocuité d’une stratégie effractive précoce chez les patients sous fibrinolytiques ayant subi un IM avec sus-décalage du segment ST, aucune différence statistiquement significative n’a été observée au chapitre des ECIM sur une période de 7,8 ans.
Machine learning for prediction of 30-day mortality after ST elevation myocardial infraction: An Acute Coronary Syndrome Israeli Survey data mining study
2017, International Journal of Cardiology
Risk scores for prediction of mortality 30-days following a ST-segment elevation myocardial infarction (STEMI) have been developed using a conventional statistical approach.
To evaluate an array of machine learning (ML) algorithms for prediction of mortality at 30-days in STEMI patients and to compare these to the conventional validated risk scores.
This was a retrospective, supervised learning, data mining study. Out of a cohort of 13,422 patients from the Acute Coronary Syndrome Israeli Survey (ACSIS) registry, 2782 patients fulfilled inclusion criteria and 54 variables were considered.
Prediction models for overall mortality 30 days after STEMI were developed using 6 ML algorithms. Models were compared to each other and to the Global Registry of Acute Coronary Events (GRACE) and Thrombolysis In Myocardial Infarction (TIMI) scores.
Depending on the algorithm, using all available variables, prediction models' performance measured in an area under the receiver operating characteristic curve (AUC) ranged from 0.64 to 0.91. The best models performed similarly to the Global Registry of Acute Coronary Events (GRACE) score (0.87 SD 0.06) and outperformed the Thrombolysis In Myocardial Infarction (TIMI) score (0.82 SD 0.06, p < 0.05). Performance of most algorithms plateaued when introduced with 15 variables. Among the top predictors were creatinine, Killip class on admission, blood pressure, glucose level, and age.
We present a data mining approach for prediction of mortality post-ST-segment elevation myocardial infarction. The algorithms selected showed competence in prediction across an increasing number of variables. ML may be used for outcome prediction in complex cardiology settings.

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^☆: Decade-long outcomes from the Acute Coronary Syndrome Israeli Survey (ACSIS) 2000–2010.

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Temporal trends in all-cause mortality of smokers versus non-smokers hospitalized with ST-segment elevation myocardial infarction☆

Highlights

Abstract

Background/objectives

Methods

Results

Conclusion

Introduction

Section snippets

Study population

Results

Discussion

Conflict of interest

Acknowledgment

J Am Coll Cardiol

J Am Coll Cardiol

Lancet

Am J Cardiol

Int J Cardiol

2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

Circulation

ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation

Eur Heart J

Mortality risk reduction associated with smoking cessation in patients with coronary heart disease: a systematic review

JAMA

Impact of smoking on acute phase outcomes of myocardial infarction

Coron Artery Dis

The ACSIS Registry and primary angioplasty following coronary bypass surgery

Catheter Cardiovasc Interv

Sitagliptin pretreatment in diabetes patients presenting with acute coronary syndrome: results from the Acute Coronary Syndrome Israeli Survey (ACSIS)

Cardiovasc Diabetol

Contemporary use and outcome of percutaneous coronary interventions in patients with acute coronary syndromes: insights from the 2010 ACSIS and ACSIS-PCI surveys

EuroIntervention

Impact of smoking on mortality and life expectancy in Japanese smokers: a prospective cohort study

BMJ