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Smoking increases STEMI risk in women more than men
Women who smoke had a significantly increased risk for STEMI compared with men who smoke, according to a study published in the Journal of the American College of Cardiology.
“The study is the first to quantify the differential effect of cigarette smoking between sexes on STEMI risk,” James Palmer, BMedSci, MBChB, of the Sheffield Medical School at The University of Sheffield in the United Kingdom, and colleagues wrote. “It has provided strong evidence that smoking incurs a greater STEMI risk to all female patients compared with male.”
Researchers analyzed data from 3,343 patients with acute STEMI between 2009 and 2014. Data collected throughout the study included sex, age, other key CV risk factors, smoking status, culprit artery of STEMI and cardioprotective drugs taken before STEMI onset.
The peak STEMI rate for current smokers was age 50 to 59 years in men (425 per 100,000 patient-years) and 70 to 79 years in women (235 per 100,000 patient-years).
Women who smoked had a significantly greater increase in STEMI rate (incidence rate ratio [IRR] = 6.62; 95% CI, 5.98-7.31) compared with men who smoked (IRR = 4.4; 95% CI, 4.15-4.67). The greatest increase in the risk for STEMI was seen in women aged 18 to 49 years (IRR = 13.22; 95% CI, 10.33-16.66) vs. men (IRR = 8.6; 95% CI, 7.7-9.59).
The risk difference between men and women was greatest at age 50 to 64 years, with women having an IRR of 9.66 (95% CI, 8.3-11.18) and men having an IRR of 4.47 (95% CI, 4.1-4.86).
“The work of Palmer et al underscores the important role that smoking plays in the morbidity and mortality of every cardiologist’s patients, and it reminds us of the great impact we can have if we approach our task with constancy and purpose,” Erik C. Stecker, MD, MPH, associate professor of medicine in the division of cardiovascular medicine at Oregon Health and Science University School of Medicine, and Thomas A. Dewland, MD, assistant professor of medicine in the division of cardiovascular medicine at Oregon Health and Science University School of Medicine, wrote in a related editorial. – by Darlene Dobkowski
Disclosures: The authors of the study and the editorial report no relevant financial disclosures.
Perspective
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The important findings here are not that smoking is associated with increased risk for coronary events; we already know that. What is important is the magnitude of risk seen in individuals who smoke when examined by age and sex. The study highlights the vastly increased risk — up to 13-fold — associated in younger women who smoke.
In this study, ex-smokers had event rates across all ages fairly comparable to those who never smoked. This study reinforces the message: it’s never too late to quit.
There is also considerable opportunity to modify additional important risk factors that aggravate risk for STEMI in women who smoke, particularly hypertension and diabetes, as seen here.
An important limitation, and one recognized by the authors, is the categorization of smoking as current, prior or never. We know that not all smoking is equivalent (just as, for example, not all exercise is equivalent), and that more nuanced assessment of smoking as an exposure is essential. We need to build from this research to determine how volume of smoking, tobacco strength, secondhand smoke and now electronic cigarette exposure contribute to cardiac risk.
There are well-recognized differences in treatment and outcomes of coronary disease by sex; women present later with an MI, have delayed treatment compared to men and have worse outcomes. We learn from this study that with the addition of smoking, women have an increased risk for STEMI compared to men. We have to tailor our interventions to modify this critical risk factor and make sure that we address smoking aggressively in both men and women.