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No evidence of ‘smoker’s paradox’ found in STEMI registry
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SAN DIEGO — Previous research has suggested that patients with ACS who smoke have lower mortality than nonsmokers, but results from a large, single-center registry of patients with STEMI who underwent PCI indicate no evidence of a smoker’s paradox.
Researchers in the United Kingdom studied differences between smokers and nonsmokers in a registry including all patients admitted with acute STEMI undergoing primary PCI in South Yorkshire, England, from January 2009 to June 2012.
Lloyd Steele, a medical student at the University of Sheffield, told Cardiology Today that no large registry had previously been undertaken to evaluate the smoker’s paradox in ACS.
The analysis included 1,715 STEMI events in 1,680 patients. Of those, 49.1% of patients were smokers, 27.2% former smokers and 23.7% nonsmokers. One hundred fourteen patients (6.6%) died after 1 year. Researchers reported data on the smoking status of 99 deceased patients (87%) and 1,562 surviving patients (98%).
Smoking was associated with better survival at 1 year after STEMI compared with nonsmokers and former smokers (P = .4).
Age was identified as a significant confounder (P = .001). The average age upon presentation of STEMI was 57 years for smokers compared with 66 years for nonsmokers and 68 years for former smokers.
“When we adjusted for age and gender, we found that smokers actually had a worse outcome,” Steele said. After adjustment, the rate of 1-year survival was worse among current smokers (HR = 1.3; 95% CI, 0.77-2.2) compared with former smokers (HR = 1.03; 95% CI, 0.61-1.75) and nonsmokers (HR = 1); however, this difference was not significant (P = .55).
“In this large, single-center registry of STEMI patients managed by primary PCI, we did not find any evidence of the ‘smoker’s paradox,’” the researchers concluded. – by Rob Volansky
Reference:
Steele L, et al. Poster 1107-115. Presented at: American College of Cardiology Scientific Sessions; March 14-16, 2015; San Diego.
Disclosure: The researchers report no relevant financial disclosures.
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David E. Kandzari, MD
This is an interesting study regarding the smoker’s paradox. There have been historical studies that suggested that smokers, paradoxically, had improved survival after MI. In most instances, these studies have been critiqued because they didn’t fully adjust for confounding variables. Smokers typically could be younger and overall have general better health than, for example, elderly patients with greater comorbidities. This analysis is limited because it is a single-center experience. Also, it was not statistically powered to truly detect differences in mortality. That said, the findings indicate that current smokers may have similar, if not numerically better, survival by statistics than ex-smokers and nonsmokers. But when these investigators appropriately adjusted for confounding factors, including sex and age, the smoker population had a worse outcome, as we would expect from the risks associated with cigarette smoking.
These adjustments really level the discussion about the risks associated with smoking when you start to include factors around the health status of patients. In addition, there is one upside to this study that shows that ex-smokers, even after risk adjustment, had a similar survival as nonsmokers. The good news here is that it highlights the benefits of discontinuing smoking on survival after a heart attack.
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