Significance of smoking in patients receiving thrombolytic therapy for acute myocardial infarction. Experience gleaned from the International Tissue Plasminogen Activator/Streptokinase Mortality Trial

The biology behind the atherothrombotic effects of cigarette smoke

Cigarette smoke is an aerosol that contains >4,000 chemicals, including nicotine, carbon monoxide, acrolein, and oxidant compounds. Exposure to cigarette smoke induces multiple pathological effects in the endothelium, several of which are the result of oxidative stress initiated by reactive oxygen species, reactive nitrogen species, and other oxidant constituents of cigarette smoke. Cigarette-smoke exposure interferes adversely with the control of all stages of plaque formation and development and pathological thrombus formation. The reactive oxygen species in cigarette smoke contribute to oxidative stress, upregulation of inflammatory cytokines, and endothelial dysfunction, by reducing the bioavailability of nitric oxide. Plaque formation and the development of vulnerable plaques also result from exposure to cigarette smoke via the enhancement of inflammatory processes and the activation of matrix metalloproteases. Moreover, exposure to cigarette smoke results in platelet activation, stimulation of the coagulation cascade, and impairment of anticoagulative fibrinolysis. Many cigarette-smoke-mediated prothrombotic changes are quickly reversible upon smoking cessation. Public health efforts should urgently promote our understanding of current cigarette-smoke-induced cardiovascular pathology to encourage individuals to reduce their exposure to cigarette smoke and, therefore, the detrimental consequences of associated atherothrombotic disease.

Cigarette smoking is paradoxically associated with low mortality risk after acute myocardial infarction

BACKGROUND

Cigarette smoking has been shown to be associated with a decreased risk of death after acute myocardial infarction (AMI), which is also known as the "smokers' paradox." This study aimed to investigate the relationship between smoking and all-cause mortality after AMI.

METHODS

We extracted the data of patients who were hospitalized for AMI between November 2005 and September 2010 from nationwide multicenter prospective registries in Korea.

RESULTS

Among a total of 29,199 patients with AMI, 10,251 (42.3%) were current smokers, and 14,006 (57.7%) were nonsmokers. Current smokers were younger, more likely to be male, and had lower frequencies of hypertension, diabetes mellitus, dyslipidemia, and previous history of ischemic heart disease than nonsmokers. The initial presentation was less severe in terms of hemodynamic status, and angiography showed less complex coronary involvement in smokers. The overall mortality rate was 5.4% for current smokers and 9.9% for nonsmokers (hazard ratio [HR], 0.52; 95% confidence interval [CI], 0.47-0.58; p < .001). The gap in risk was attenuated after multivariable adjustment but remained statistically significant (HR, 0.85; 95% CI, 0.76-0.95; p = .005). Propensity score matching corroborated the results of reduced mortality among current smokers (6.7% vs. 7.6%; p = .005).

CONCLUSIONS

In this study, in which the patients received up-to-date treatment options, smoking was associated with a 48% decrease in the risk of all-cause mortality at 1 year after AMI.

Smoking status on outcomes after percutaneous coronary intervention

BACKGROUND

The effect of smoking on prognosis among patients undergoing percutaneous coronary intervention (PCI) is controversial, and data on the importance of smoking cessation or reductions were lacking.

HYPOTHESIS

Smoking cessation or reductions could reduce the risk of adverse outcomes in patient after PCI.

METHODS

There were 19 506 consecutive patients who had undergone successful PCI between April 2004 and January 2010 followed. Extensive data, including self-reported smoking habits, were obtained at baseline and during follow-up.

RESULTS

Compared with post-PCI quitters and persistent smokers, the nonsmokers and pre-PCI quitters were older and had a higher prevalence of comorbid factors such as hypertension and impaired left ventricle function. The adjusted hazard ratios for mortality were 2.52 (95% confidence interval [CI]: 1.92-3.30) for nonsmokers, 0.52 (95% CI: 0.32-0.84) for pre-PCI quitters, and 0.11 (95% CI: 0.06-0.22) for post-PCI quitters, compared to persistent smokers. With respect to additional revascularizations, a higher risk was observed among the quitters (1.70 [95% CI: 1.40-2.08] for pre-PCI quitters and 1.59 [95% CI: 1.36-1.85] for post-PCI quitters) as well as the nonsmokers (1.40 [95% CI: 1.20-1.64]). Among persistent smokers, each reduction of 5 cigarettes/day was associated with a 72% decline in mortality risk (P < 0.001) but did not reach statistical significant for repeated revascularizations (0.80 [95% CI: 0.46-1.37], P = 0.4132).

CONCLUSIONS

Despite a higher risk of revascularization, the cessation of smoking either before or after PCI is beneficial in all-cause mortality. The apparent smoker's paradox may be explained by the differences in baseline risk or the reduced sensitivity to adverse outcomes as well as the reluctance to seek medical help among smokers.

Endothelial function and soluble endoglin in smokers with heart failure

BACKGROUND

Although cigarette smoking is a risk factor for heart failure (HF), smokers with HF have lower mortality rates during/following hospitalization compared to nonsmokers. We examined vascular endothelial function in chronic smokers and nonsmokers with HF as it relates to this smoker's paradox.

HYPOTHESIS

Smokers with HF will have attenuated endothelial dysfunction compared to non-smokers with HF.

METHODS

Brachial artery flow-mediated dilation (FMD), a measure of conduit vessel endothelial function, was measured in 33 smoking and nonsmoking patients with HF vs controls. In addition, soluble endoglin (sEng), a circulating mediator of endothelial function, was measured in a separate group of 36 smoking and nonsmoking patients with HF vs controls.

RESULTS

FMD was significantly lower in smokers without HF compared to the nonsmokers without HF (P < 0.05). FMD was significantly higher in smokers with HF vs nonsmokers with HF (P < 0.05) and did not differ from values seen in nonsmokers without HF (P > 0.05). There were no differences in sEng between smokers and nonsmokers without HF (P > 0.05). sEng was lower in smokers with HF vs nonsmokers with HF (P < 0.05) and did not differ from values seen in nonsmokers without HF (P > 0.05).

CONCLUSIONS

Smokers with HF had higher brachial FMD and lower sEng than nonsmokers with HF, and values were comparable to nonsmokers without HF. These findings offer novel insight into the smoker's paradox and suggest that improved short-term outcome in patients hospitalized with HF may in part be mediated by preservation of vascular endothelial function in this setting.

Five-year prognosis in an incident cohort of people presenting with acute myocardial infarction

BACKGROUND

Following an AMI, it is important for patients and their physicians to appreciate the subsequent risk of death, and the potential benefits of invasive cardiac procedures and secondary preventive therapy. Studies, to-date, have focused largely on high-risk populations. We wished to determine the risk of death in a population-derived cohort of 2,887 patients after a first acute myocardial infarction (AMI).

METHODS

Logistic regression and survival analysis were conducted to investigate the effect of different baseline characteristics, pharmacological therapies and revascularization procedures on coronary heart disease (CHD) and all-cause mortality outcomes.

RESULTS

Within five years 44.4% of patients died (27.1% short-term [<30 days] and 23.7% longer-term [≥30 days]). Percutaneous transluminal coronary angioplasty (Adjusted Hazards Ratio (AHR) = 0.49, 95% Confidence Interval (CI) 0.26-0.93), β-blockers (AHR = 0.58, 95%CI 0.46-0.74) and statins (AHR = 0.60, 95%CI 0.47-0.77) were all associated with significant reductions in longer-term CHD-related mortality. However, not all patients received secondary preventive therapy (8.7%). Diabetes (AHR = 1.83, 95%CI 1.43-2.34), stroke (AHR = 1.73, 95%CI 1.35-2.22), heart failure (AHR = 1.69, 95%CI 1.28-2.22), smoking (AHR = 1.72, 95%CI 1.18-2.51) and obesity (>30 kg/m2; AHR = 1.39, 95%CI 1.01-1.90) increased the risk of longer-term mortality independent of other risk factors.

CONCLUSIONS

It is encouraging that the coronary procedure PTCA and pharmacological secondary prevention therapies were found to be strongly associated with an important reduced risk of subsequent death, although not all patients received these interventions. Smoking, being obese and having cardiovascular related disease at baseline were also associated with an increased likelihood of longer-term mortality, independent of other baseline characteristics. Thus, the provision of smoking cessation, advice on diet (for obese patients) and optimal treatment is likely to be crucial for reducing mortality in all patients after AMI.

The "smoker's paradox" in patients with acute coronary syndrome: a systematic review

BACKGROUND

Smokers have been shown to have lower mortality after acute coronary syndrome than non-smokers. This has been attributed to the younger age, lower co-morbidity, more aggressive treatment and lower risk profile of the smoker. Some studies, however, have used multivariate analyses to show a residual survival benefit for smokers; that is, the "smoker's paradox". The aim of this study was, therefore, to perform a systematic review of the literature and evidence surrounding the existence of the "smoker's paradox".

METHODS

Relevant studies published by September 2010 were identified through literature searches using EMBASE (from 1980), MEDLINE (from 1963) and the Cochrane Central Register of Controlled Trials, with a combination of text words and subject headings used. English-language original articles were included if they presented data on hospitalised patients with defined acute coronary syndrome, reported at least in-hospital mortality, had a clear definition of smoking status (including ex-smokers), presented crude and adjusted mortality data with effect estimates, and had a study sample of > 100 smokers and > 100 non-smokers. Two investigators independently reviewed all titles and abstracts in order to identify potentially relevant articles, with any discrepancies resolved by repeated review and discussion.

RESULTS

A total of 978 citations were identified, with 18 citations from 17 studies included thereafter. Six studies (one observational study, three registries and two randomised controlled trials on thrombolytic treatment) observed a "smoker's paradox". Between the 1980s and 1990s these studies enrolled patients with acute myocardial infarction (AMI) according to criteria similar to the World Health Organisation criteria from 1979. Among the remaining 11 studies not supporting the existence of the paradox, five studies represented patients undergoing contemporary management.

CONCLUSION

The "smoker's paradox" was observed in some studies of AMI patients in the pre-thrombolytic and thrombolytic era, whereas no studies of a contemporary population with acute coronary syndrome have found evidence for such a paradox.

Acute ST-elevation myocardial infarction in young patients: 15 years of experience in a single center

BACKGROUND

There have been few studies done regarding young patients with ST-elevation myocardial infarction (STEMI). The purpose of this study was to investigate the clinical characteristics and coronary angiographic features in young patients with STEMI.

METHODS

We collected data on 849 consecutive patients with STEMI from 1992 to 2006. Baseline clinical characteristics, coronary anatomy, and outcome were compared in young (< or =45 yrs) and older patients (>45 yrs).

RESULTS

Young patients presented 11.6% of all patients with STEMI. These patients were predominantly male (92.9% vs 80.3%, P < 0.001), more likely to smoke (75.8% vs 47.2%, P < 0.001), obese (48.2% vs 27.9%, P = 0.002), have higher triglyceride levels (176.9 +/- 153.8 mg/dL vs 140.7 +/- 112.7 mg/dL, P = 0.005), and lower high-density lipoprotein cholesterol (37.1 +/- 7.9 mg/dL vs 42.8 +/- 14.3 mg/dL, P = 0.005) than older patients. Also, younger patients had a shorter hospital stay (7.1 +/- 4.9 d vs 8.5 +/- 6.7 d, P = 0.04), less in-hospital morbidity (29.3% vs 39.7%, P = 0.02), and mortality (3.0% vs 12.3%, P = 0.002). Killip class III or IV could predict in-hospital morbidity and mortality in young patients. Both groups had similar rates of repeated percutaneous coronary intervention (PCI; 45.5% vs 41.5%, P = 0.23) and reinfarction (6.1% vs 3.2%, P = 0.32). Mortality rate during follow-up was significantly lower in younger patients (3.0% vs 19.6%, P < 0.001).

CONCLUSION

Cigarette smoking, obesity, and dyslipidemia were the most important modifiable risk factors in young patients with STEMI. These patients had a better outcome than older patients without differences in repeated PCI and reinfarction between them. Only Killip class III or IV could predict in-hospital morbidity and mortality in young patients with STEMI.

Influence of smoking on the location of acute myocardial infarctions

Objective. To determine whether there is an association between smoking and the location of acute myocardial infarctions. Methods. Using a cohort from our hospital and published cohorts from Ireland, Uruguay, and Israel, we calculated odds of having an inferior wall as opposed to an anterior wall acute myocardial infarction among smokers and nonsmokers. Results. In our cohort, there was a higher proportion of smokers than nonsmokers in patients with inferior acute myocardial infarctions than in patients with anterior infarctions. This difference was also present in each of the other cohorts. Odds ratios for an inferior versus an anterior acute myocardial infarction among smokers ranged from 1.15 to 2.00 (median odds ratio, 1.32). When the cohorts were combined (n = 3, 160), the pooled odds ratio for an inferior as opposed to an anterior acute myocardial infarction among smokers was 1.38 (95% confidence interval, 1.20 to 1.58) (P < .002). Conclusions. Cigarette smoking increases the risk of inferior wall acute myocardial infarction more than the risk of anterior wall infarction. Smoking thus appears to adversely affect the right coronary arterial circulation to a greater extent than the left coronary arterial circulation by a mechanism not yet understood.

["Smoker's paradox" and reperfusion's strategy in acute myocardial infarction]

Previous studies have shown that smokers with acute myocardial infarction (AMI) treated by thrombolysis have lower mortality rates than nonsmokers, a phenomenon often termed "smoker's paradox". This "smoker's paradox" has been rarely studied in case of primary angioplasty.

AIM OF THE STUDY

To evaluate the impact of smoking status on the early mortality of patients admitted with AMI with regard to the strategy of reperfusion (intravenous thrombolysis versus primary angioplasty).

PATIENTS AND METHODS

Study undertaken from the Monsatir registry of ST elevation MI including 688 patients having had either a hospital or a prehospital thrombolysis (n=397) or a primary angioplasty (n=291). Among those patients, 482 (70.1%) were active smokers.

RESULTS

In the thrombolysis group, the prevalence of hypertension, diabetes and anterior location of MI was significantly less among smokers. In the group primary angioplasty, only diabetes and hypertension were less frequent. The immediate mortality was significantly less among smokers in case of thrombolysis comparatively to non-smokers (5.3 vs 13%; p=0.008). By multivariate analysis, cardiogenic shock (p<0.0001), anterior MI (p=0.03) and active smoking (p=0.03) were independent predictive factors of mortality in case of thrombolysis. A trend toward a lower mortality among smokers was observed in the primary angioplasty group (10 vs 17.6%; p=0.07).

CONCLUSION

"The smoker's paradox" seems to be observed mainly among patients having had thrombolysis.

Clinical and angiographic predictors of ST-segment recovery after primary percutaneous coronary intervention

Important determinants of incomplete ST-segment recovery in patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) have been incompletely characterized. Early risk stratification could identify patients with STEMI and incomplete ST-segment recovery who may benefit from adjunctive therapy. For the present study, we analyzed 12-lead electrocardiograms from 2,124 patients with STEMI who underwent primary PCI at our institution from 2000 to 2007. ST-segment recovery was defined as percent change in cumulative ST-segment deviation between preprocedural and immediately postprocedural electrocardiograms and categorized as incomplete when <50%. A total of 1,032 patients (49%) had incomplete ST-segment recovery. After multivariable adjustment, age >60 years (adjusted odds ratio [OR] 1.28, 95% confidence interval [CI] 1.06 to 1.54, p = 0.011), diabetes mellitus (OR 1.36, 95% CI 1.02 to 1.82, p = 0.034), left anterior descending coronary artery-related STEMI (OR 1.92, 95% CI 1.61 to 2.30, p<0.001), and multivessel disease (OR 1.34, 95% CI 1.10 to 1.63, p = 0.004) were independent predictors of incomplete ST-segment recovery. Current smoking (OR 0.79, 95% CI 0.65 to 0.95, p = 0.013) and a preprocedural Thrombolysis In Myocardial Infarction grade <3 flow (OR 0.70, 95% CI 0.53 to 0.93, p = 0.014) were inversely related to ST-segment recovery. Incomplete ST-segment recovery was a strong predictor of long-term mortality (hazard ratio 2.07, 95% CI 1.59 to 2.69, p <0.001) in addition to identified characteristics that independently predicted incomplete ST-segment recovery. In conclusion, incomplete ST-segment recovery at the end of PCI occurred significantly more often in the presence of an age >60 years, nonsmoking, diabetes mellitus, left anterior descending coronary artery-related STEMI, multivessel disease, and preprocedural Thrombolysis In Myocardial Infarction grade 3 flow. Patients with STEMI and these clinical features are at increased risk of impaired myocardial salvage and are appropriate candidates for adjunctive therapy.

Plasma BDNF and tPA are associated with late-onset geriatric depression

AIMS

Studies in the recent decade have shown that brain-derived neurotrophic factor (BDNF) may play an important role in the pathogenesis of major depressive disorder (MDD). Tissue-type plasminogen activator (tPA) has been implicated in the control of the direction of BDNF action. The aim of the study was therefore to investigate the changes of BDNF/tPA levels and their clinical meanings in geriatric depression.

METHODS

Plasma BDNF and tPA levels were measured in late-onset geriatric depression (LGD) before treatment (n = 24) and after 6 weeks of antidepressant treatment (n = 24) compared with control subjects (n = 30) using enzyme-linked immunosorbent assay. The severity of depression was assessed with the Hamilton Depression Rating Scale.

RESULTS

Baseline plasma BDNF and tPA levels were significantly lower in LGD patients compared to controls (P = 0.037 and P = 0.000, respectively). There was a heightening tendency of plasma BDNF level after treatment.

CONCLUSIONS

Plasma BDNF and tPA levels are associated with LGD. The complex mechanism of BDNF and tPA in LGD should be further explored in future studies.

Smoking, clopidogrel, and mortality in patients with established cardiovascular disease

BACKGROUND

Smoking increases platelet aggregability and the degree of platelet inhibition by clopidogrel on ex vivo platelet function tests. Whether smoking status affects the relationship between clopidogrel and clinical outcomes is unknown.

METHODS AND RESULTS

We evaluated the relationship between smoking status (current smoker, former smoker, or never-smoker) and treatment with clopidogrel on the risk of all-cause, cardiovascular, and cancer mortality among the 12 152 participants from the CHARISMA (Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance) trial who had established cardiovascular disease. Current smoking was associated with an increase in all-cause (adjusted hazard ratio [HR] 2.58, 95% confidence interval [CI] 1.85 to 3.60), cardiovascular (HR 2.26, 95% CI 1.48 to 3.45), and cancer (HR 3.56, 95% CI 1.96 to 6.46) mortality compared with never smoking. The impact of clopidogrel on mortality differed by smoking status (P for interaction=0.018 for current smokers). Among current smokers, clopidogrel was associated with a reduction in all-cause mortality (HR 0.68, 95% CI 0.49 to 0.94); clopidogrel did not reduce all-cause mortality among former smokers (HR 0.95, 95% CI 0.75 to 1.19) or never-smokers (HR 1.14, 95% CI 0.83 to 1.58). A similar pattern was noted for cardiovascular mortality. As expected, no relationship was observed between clopidogrel and cancer mortality by smoking status. The risk of bleeding appeared to differ according to smoking status; randomized clopidogrel was associated with a significantly increased risk of severe or moderate bleeding (HR 1.62, P=0.04) among current smokers but a smaller and nonsignificant increase among never-smokers (HR 1.31, P=0.15).

CONCLUSIONS

Clopidogrel therapy may be more effective in current smokers, but it may also confer a greater bleeding risk than in nonsmokers. Further studies are needed to investigate this possibility.

Does smoking influence outcome after intravenous thrombolysis for acute ischaemic stroke?

BACKGROUND AND PURPOSE

It remains uncertain whether current smoking influences outcome in patients with acute ischaemic stroke.

OBJECTIVES

To evaluate the effect of current smoking in routinely tissue plasminogen activator (tPA)-treated stroke patients on the 3-month functional outcome and the occurrence of symptomatic intracerebral hemorrhage (ICH).

METHODS

We analyzed data from a single stroke care unit registry of 345 consecutive patients with ischaemic stroke, treated with tPA. Logistic regression models were used to assess if smoking was independently associated with 3-months good outcome defined as a modified Rankin Scale score of < or =2, and the occurrence of symptomatic ICH.

RESULTS

In the multivariable models, smoking was not associated with a good outcome or a decreased risk of symptomatic ICH.

CONCLUSION

Current smoking did not affect functional outcome at 3 months or the risk of symptomatic ICH in patients routinely treated with tPA for ischaemic stroke.

Predictors of in-hospital mortality in patients hospitalized for heart failure: insights from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF)

OBJECTIVES

The aim of this study was to develop a clinical model predictive of in-hospital mortality in a broad hospitalized heart failure (HF) patient population.

BACKGROUND

Heart failure patients experience high rates of hospital stays and poor outcomes. Although predictors of mortality have been identified in HF clinical trials, hospitalized patients might differ greatly from trial populations, and such predictors might underestimate mortality in a real-world population.

METHODS

The OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) is a registry/performance improvement program for patients hospitalized with HF in 259 U.S. hospitals. Forty-five potential predictor variables were used in a stepwise logistic regression model for in-hospital mortality. Continuous variables that did not meet linearity assumptions were transformed. All significant variables (p < 0.05) were entered into multivariate analysis. Generalized estimating equations were used to account for the correlation of data within the same hospital in the adjusted models.

RESULTS

Of 48,612 patients enrolled, mean age was 73.1 years, 52% were women, 74% were Caucasian, and 46% had ischemic etiology. Mean left ventricular ejection fraction was 0.39 +/- 0.18. In-hospital mortality occurred in 1,834 (3.8%). Multivariable predictors of mortality included age, heart rate, systolic blood pressure (SBP), sodium, creatinine, HF as primary cause of hospitalization, and presence/absence of left ventricular systolic dysfunction. A scoring system was developed to predict mortality.

CONCLUSIONS

Risk of in-hospital mortality for patients hospitalized with HF remains high and is increased in patients who are older and have low SBP or sodium levels and elevated heart rate or creatinine at admission. Application of this risk-prediction algorithm might help identify patients at high risk for in-hospital mortality who might benefit from aggressive monitoring and intervention.

The etiology of 'smoker's paradox' in acute myocardial infarction with special emphasis on the association with inflammation

Despite increased risk for coronary artery disease and acute myocardial infarction (AMI), prior studies have found that smokers with AMI have lower mortality rates than nonsmokers, a phenomenon often termed 'smoker's paradox'. The present study was designed to examine the etiology of 'smoker's paradox', especially with respect to the association with inflammation. The subjects included 528 consecutive AMI patients who were admitted within 24 hours of onset and underwent successful coronary intervention. Of the 528 subjects, 232 (44%) were smokers. The cardiac mortality rates over a 6 month period was significantly lower in the smoking group than the nonsmoking group (3% versus 9%, P = 0.01). There were significantly more male patients in the smoking group, and the smoking group was significantly younger than the nonsmoking group (P < 0.0001). The value of high sensitivity C-reactive protein (hs-CRP) on admission and 24 hours after onset, and serum amyloid A protein (SAA) were significantly higher, and acute phase BNP was significantly lower (hs-CRP on admission 1.36 +/- 1.03 mg/dL versus 0.75 +/- 0.82 mg/dL, P = 0.02, hs-CRP at 24 hours 3.86 +/- 4.32 mg/dL versus 2.90 +/- 3.46 mg/dL, P = 0.008, SAA; 288 +/- 392 microg/dL versus 176 +/- 206 microg/dL, P < 0.05, BNP; 248 +/- 342 pg/mL versus 444 +/- 496 pg/mL, P = 0.0002) in the smoking group than in the nonsmoking group. The early ST-segment resolution rate was higher in the smoking group compared with the nonsmoking group (80% versus 66%, P = 0.003). The reason why smokers with AMI have lower mortality rates than nonsmokers, the so-called 'smoker's paradox', is believed to be because smoking induces inflammation and smokers may have less damage to microvascular function after primary percutaneous coronary intervention.

Smoking and myocardial infarction case-fatality: hospital and population approach

BACKGROUND

Smoking is a risk factor for coronary heart disease, but it has been associated with better short-term prognosis in hospitalized patients with acute myocardial infarction. The aims of this study were to determine the association between smoking and myocardial infarction 28-day case-fatality in hospitalized patients and at the population level; and, whether smokers presenting with fatal myocardial infarction are more likely to die before reaching a hospital.

DESIGN AND METHODS

Population-based myocardial infarction registry, carried out in 1997-1998 in seven regions of Spain, used standardized methods to find and analyze suspected myocardial infarction patients (10 654 patients; 7796 hospitalized). Four categories of smoking status were defined: never-smokers, former smokers for more than 1 year, former smokers for less than 1 year, and current smokers.

RESULTS

The main end-point was 28-day case-fatality, found to be 20.1, 17.1, 15.6, and 8.9%, in the four smoking status categories, respectively, for hospitalized patients; and 37.4, 33.0, 24.5, and 23.2%, respectively, at population level. Hospitalized current smokers had lower age, sex, and comorbidity-adjusted 28-day case-fatality than never-smokers (odds ratio=0.71; 95% confidence interval: 0.56-0.90). This association held at population level (odds ratio=0.68; 95% confidence interval: 0.60-0.76), in which former smoking was also associated with lower case-fatality. In fatal cases, recent former smokers presented a lower risk of out-of-hospital death than never-smokers (odds ratio=0.47; 95% confidence interval: 0.29-0.77), whereas current smoking was marginally associated with out-of-hospital death (odds ratio=1.22; 95% confidence interval: 0.99-1.50).

CONCLUSIONS

Current smoking is associated with lower 28-day case-fatality in hospitalized myocardial infarction patients. This association held at population level. Among fatal cases, smoking is associated with higher and recent former smoking with lower risk of dying out-of-hospital.

Early and late coronary stent thrombosis of sirolimus-eluting and paclitaxel-eluting stents in routine clinical practice: data from a large two-institutional cohort study

BACKGROUND

Stent thrombosis is a safety concern associated with use of drug-eluting stents. Little is known about occurrence of stent thrombosis more than 1 year after implantation of such stents.

METHODS

Between April, 2002, and Dec, 2005, 8146 patients underwent percutaneous coronary intervention with sirolimus-eluting stents (SES; n=3823) or paclitaxel-eluting stents (PES; n=4323) at two academic hospitals. We assessed data from this group to ascertain the incidence, time course, and correlates of stent thrombosis, and the differences between early (0-30 days) and late (>30 days) stent thrombosis and between SES and PES.

FINDINGS

Angiographically documented stent thrombosis occurred in 152 patients (incidence density 1.3 per 100 person-years; cumulative incidence at 3 years 2.9%). Early stent thrombosis was noted in 91 (60%) patients, and late stent thrombosis in 61 (40%) patients. Late stent thrombosis occurred steadily at a constant rate of 0.6% per year up to 3 years after stent implantation. Incidence of early stent thrombosis was similar for SES (1.1%) and PES (1.3%), but late stent thrombosis was more frequent with PES (1.8%) than with SES (1.4%; p=0.031). At the time of stent thrombosis, dual antiplatelet therapy was being taken by 87% (early) and 23% (late) of patients (p<0.0001). Independent predictors of overall stent thrombosis were acute coronary syndrome at presentation (hazard ratio 2.28, 95% CI 1.29-4.03) and diabetes (2.03, 1.07-3.83).

INTERPRETATION

Late stent thrombosis was encountered steadily with no evidence of diminution up to 3 years of follow-up. Early and late stent thrombosis were observed with SES and with PES. Acute coronary syndrome at presentation and diabetes were independent predictors of stent thrombosis.

Evaluation of serial QT dispersion in patients with first non-Q-wave myocardial infarction: relation to the severity of underlying coronary artery disease

BACKGROUND

Increased QT dispersion (QTD) has been correlated with ventricular arrhythmias. Recent reports suggest that it may serve as a marker of the severity of underlying coronary artery disease (CAD).

HYPOTHESIS

The aim of this study was to examine in-hospital changes of QTD and their possible correlation with the severity of underlying CAD in patients with first non-Q-wave myocardial infarction.

METHODS

In 62 patients we estimated QTD, precordial QTD, as well as their values corrected for heart rate on Days 3 and 7 after admission. The severity of underlying ischemic burden was estimated by means of the number of diseased vessels as well as by the jeopardy score.

RESULTS

On Day 3, patients with jeopardy score > or = 6 exhibited greater QTD, corrected QTD, precordial QTD, and corrected precordial QTD (p = 0.001, p = 0.003, p = 0.02, p = 0.036, respectively); patients with multivessel disease had greater QTD (p = 0.007). On Day 7, patients with jeopardy score > or = 6 and multivessel disease exhibited greater QTD, corrected QTD, precordial QTD, and corrected precordial QTD (p < 0.001 for all). Multiple regression analysis revealed a jeopardy score of > or = 6 as the most significant independent predictor for QTD variables. From Days 3 to 7, only patients with none or one diseased vessel orjeopardy score < 6 had shortened QTD (p = 0.01 and p = 0.015, respectively) and corrected QTD (p < 0.001 for both).

CONCLUSIONS

In patients with first non-Q-wave myocardial infarction, QTD variables and their in-hospital changes reflect the severity of underlying CAD.

Planned versus provisional use of glycoprotein IIb/IIIa inhibitors in smokers undergoing percutaneous coronary intervention

Postmortem and angiographic studies have demonstrated that thrombosis is the primary cause of coronary artery occlusion in smokers. Further, smokers have high levels of fibrinogen, increased platelet aggregation, and more platelet-dependent thrombin generation than do nonsmokers, suggesting that glycoprotein (GP) IIb/IIIa inhibitor use during percutaneous coronary intervention (PCI) may be especially useful among smokers. We evaluated a subpopulation of active smokers in the REPLACE-2 trial to assess the effect of treating smokers with bivalirudin and provisional GP IIb/IIIa blockade compared with heparin and planned GP IIb/IIIa blockade. The REPLACE-2 trial enrolled 1,558 smokers and 4,305 nonsmokers. Smokers who were treated with bivalirudin had an absolute 3.2% increase in the composite end point of death and myocardial infarction at 48 hours compared with smokers who were treated with heparin and GP IIb/IIIa inhibitors (7.7% vs 4.5%, p=0.008, interaction p=0.016). This difference was ameliorated when GP IIb/IIIa inhibitors were used consistently in a previous trial that compared bivalirudin with heparin during PCI (4.6% vs 6.7%, p=0.322). In conclusion, these results suggest that smokers may derive particular benefit with GP IIb/IIIa inhibitors for decreasing myocardial infarction and death after PCI. These findings require further validation from other large, randomized trials.

Effect of smoking status on outcome after acute ischemic stroke

BACKGROUND

The status of smoking as a risk factor for the occurrence of stroke is well established. However, there is a paucity of data on the relationship between smoking status and acute stroke outcomes. We evaluated the role of recent smoking as a prognostic factor following acute ischemic stroke.

METHODS

We analyzed data from patients enrolled in the Intravenous Magnesium Efficacy in Stroke (IMAGES) trial. Outcome measures studied included change in IMAGES stroke score, poor functional outcomes at day 30 and 90 (defined as Rankin Scale >1 and Barthel Index <95), and survival over the first 3 months after stroke. The independent effect of smoking status (subjects who had smoked in the past year) on outcome was evaluated by logistic regression analysis and Cox's proportional hazards model, adjusting for variables known to predict outcome after ischemic stroke.

RESULTS

There were 2,386 subjects in the IMAGES efficacy dataset, including 615 recent or current smokers and 1,771 nonsmokers, among whom smokers were younger (p < 0.0001). After adjusting for covariates, smokers had increased odds of poor 90-day functional outcome independently of other statistically significant predictor variables, as assessed by Rankin Scale (odds ratio 1.38; 95% confidence interval 1.09-1.75) and Barthel Index (odds ratio 1.42; 95% confidence interval 1.13-1.79) at day 90. Smoking status did not affect survival at day 90.

CONCLUSIONS

Current or recent smokers experience poorer functional outcomes than nonsmokers 3 months after acute ischemic stroke.

Elevated body mass index and intermediate-term clinical outcomes after acute coronary syndromes

PURPOSE

Obesity is a coronary disease risk factor, but its independent effect on clinical outcomes following acute coronary syndromes has not been quantified. We evaluated the relationship between elevated body mass index (BMI) and 30-day, 90-day, and 1-year clinical outcomes postacute coronary syndromes.

SUBJECTS AND METHODS

Using 15 071 patients (normal weight [BMI = 18.5-24.9 kg/m(2)], overweight [BMI = 25-29.9 kg/m(2)], obese [BMI = 30-34.9 kg/m(2)] or very obese [BMI > or =35 kg/m(2)]) randomized from 1997-1999 in the SYMPHONY (Sibrafiban vs aspirin to Yield Maximum Protection from ischemic Heart events postacute cOroNary sYndromes) and 2nd SYMPHONY trials, we evaluated the relationships between BMI and 30-day, 90-day, and 1-year mortality and 30-day and 90-day death or myocardial infarction.

RESULTS

Increasing BMI was associated with younger age, multiple comorbidities, and greater cardiac medication and procedure use; however, systolic function and coronary disease extent were similar for all BMI categories. Unadjusted Kaplan-Meier mortality estimates were higher for normal-weight patients than for all other BMI groups. After multivariable adjustment, the 30-day mortality hazard ratios (95% confidence interval [CI]) were: overweight, 0.66 (95% CI: 0.47 to 0.94); obese, 0.61 (95% CI: 0.39 to 0.97); very obese, 0.89 (95% CI: 0.48 to 1.64). Adjusted hazard ratios were similar for 90-day and 1-year mortality. There were no statistically significant differences among BMI groups in 30-day and 90-day death or myocardial infarction (unadjusted or adjusted).

CONCLUSION

Overweight and obese BMI classifications were associated with better intermediate-term survival after acute coronary syndromes than normal weight and very obese, but death or myocardial infarction rates were similar. Further study is required to understand the apparent association of overweight and moderate obesity with better intermediate-term outcomes.

Cardiovascular risk factors and clinical presentation in acute coronary syndromes

OBJECTIVE

To investigate the hypothesis that risk factors may be differently related to severity of acute coronary syndromes (ACS), with ST elevation used as a marker of severe ACS.

DESIGN

Cross sectional study of patients with ACS.

SETTING

103 hospitals in 25 countries in Europe and the Mediterranean basin.

PATIENTS

10,253 patients with a discharge diagnosis of ACS in the Euro heart survey of ACS.

MAIN OUTCOME MEASURES

Presenting with ST elevation ACS.

RESULTS

Patients with ACS who were smokers had an increased risk to present with ST elevation (age adjusted odds ratio (OR) 1.84, 95% confidence interval (CI) 1.67 to 2.02). Hypertension (OR 0.65, 95% CI 0.60 to 0.70) and high body mass index (BMI) (p for trend 0.0005) were associated with less ST elevation ACS. Diabetes mellitus was also associated with less ST elevation, but only among men. Prior disease (infarction, chronic angina, revascularisation) and treatment with aspirin, beta blockers, or statins before admission were also associated with less ST elevation. After adjustment for age, sex, prior disease, and prior medication, smoking was still significantly associated with increased risk of ST elevation (OR 1.53, 95% CI 1.38 to 1.69), whereas hypertension was associated with reduced risk (OR 0.75, 95% CI 0.69 to 0.82). Obesity (BMI > 30 kg/m2 versus < 25 kg/m2) was independently associated with less risk of presenting with ST elevation among women, but not among men.

CONCLUSION

Among patients with ACS, presenting with ST elevation is strongly associated with smoking, whereas hypertension and high BMI (in women) are associated with less ST elevation, independently of prior disease and medication.

Impact of smoking status on outcomes of primary coronary intervention for acute myocardial infarction--the smoker's paradox revisited

OBJECTIVES

We sought to determine the relationship between cigarette smoking and outcomes after mechanical reperfusion therapy in acute myocardial infarction (AMI).

BACKGROUND

Prior studies have found that smokers with AMI have lower mortality rates and a more favorable response to fibrinolytic therapy than nonsmokers. The impact of cigarette smoking in patients undergoing primary percutaneous coronary intervention has not been examined.

METHODS

In the CADILLAC trial, 2082 patients with AMI were randomized to percutaneous transluminal coronary angioplasty +/- abciximab versus stenting +/- abciximab. Data on smoking status were prospectively collected and follow-up continued for 1 year.

RESULTS

At the time of presentation, 638 (31%) patients had never smoked, 546 (26%) were former smokers, and 898 (45%) were currently smoking. In comparison to nonsmokers, current smokers were younger, more often men, and less frequently had diabetes, hypertension, prior AMI, and triple-vessel coronary disease. Procedural success rates were unrelated to smoking status. Mortality was lowest in current smokers, intermediate in former smokers, and highest in nonsmokers at 30 days (1.3% vs 1.7% vs 3.5%, respectively, P = .02) and 1 year (2.9% vs 3.7% vs 6.6%, P = .0008). After multivariate correction for differences in baseline variables, however, current smoking status was no longer protective from late mortality (hazard ratio 0.96, 95% CI 0.52-1.76, P = .89).

CONCLUSIONS

The "smoker's paradox" extends to patients undergoing primary PCI for AMI, with increased survival seen in current smokers, an effect entirely explained by differences in baseline risk and not smoking status per se. The deleterious effects of smoking are expressed in the occurrence of AMI nearly a decade earlier than in nonsmokers, with similar age-adjusted risk, mandating intensive primary and secondary cigarette-cessation efforts.

The smoker's paradox and the real risk of smoking

No satisfactory explanations have been offered for the smoker's paradox, the greater short-term survival of smokers after a myocardial infarction nor for the large variations in the coronary risk rate for smoking ranging between 1 and 5.9. These discrepancies as well as the smoker's paradox may be caused by different baseline characteristics of smokers and nonsmokers, whereas the usually quoted coronary risk of 2 is derived from studies based on the assumption of equal baseline characteristics. As neither this assumption nor the possibility of unequal starting conditions have been tested, we examined the main cardiovascular risk factors in smoking and nonsmoking boys as near as possible to baseline, at the age of fourteen. This age appeared to be best suited, because boys starting to smoke early are most likely to become regular and heavy smokers. Of 336 boys, 39 had smoked 8.3+/-6.0 cigarettes/day for 15.5+/-11.2 months. Compared to nonsmokers, boys who started to smoke early had lower LDL cholesterol and alpha2-antiplasmin, greater handgrip strength, vital capacity and forced expiratory volume, better perfomance on bicycle ergometry and higher testosterone. The differences in total cholesterol, LDL cholesterol, vital capacity, handgrip strength, testosterone and alpha2-antiplasmin persisted after adjustment for age, body mass, and testosterone. In addition, the differences in perfomance on bicycle ergometry and forced expiratory volume persisted after adjustment for age. These favourable baseline characteristics of those starting to smoke early can explain the smoker's paradox. In addition, they suggest that the individual coronary risk in smokers is considerably higher than 2, because the assumption of equal baseline characteristics of smokers and nonsmokers cannot be upheld.

Current smoking and the risk of non-fatal myocardial infarction in the WHO MONICA Project populations

BACKGROUND

Cohort studies have shown that smoking has a substantial influence on coronary heart disease mortality in young people. Population based data on non-fatal events have been sparse, however.

OBJECTIVE

To study the impact of smoking on the risk of non-fatal acute myocardial infarction (MI) in young middle age people.

METHODS

From 1985 to 1994 all non-fatal MI events in the age group 35-64 were registered in men and women in the WHO MONICA (multinational monitoring of trends and determinants in cardiovascular disease) project populations (18,762 events in men and 4047 in women from 32 populations from 21 countries). In the same populations and age groups 65,741 men and 66,717 women participated in the surveys of risk factors (overall response rate 72%). The relative risk of non-fatal MI for current smokers was compared with non-smokers, by sex and five year age group.

RESULTS

The prevalence of smoking in people aged 35-39 years who experienced non-fatal MI events was 81% in men and 77% in women. It declined with increasing age to 45% in men aged 60-64 years and 36% in women, respectively. In the 35-39 years age group the relative risk of non-fatal MI for smokers was 4.9 (95% confidence interval (CI) 3.9 to 6.1) in men and 5.3 (95% CI 3.2 to 8.7) in women, and the population attributable fractions were 65% and 55%, respectively.

CONCLUSIONS

During the study period more than half of the non-fatal MIs occurring in young middle age people can be attributed to smoking.

Comparison of mortality rates after acute myocardial infarction in smokers versus nonsmokers

Patients who smoke paradoxically have favorable outcomes after acute myocardial infarctions compared with nonsmokers. However, after adjustment for age only, the decrease in all-cause mortality in the smoker population is explained by the smokers' generally younger age, with better prognoses due to their age.

Paradoxical Effect of Smoking in the Spanish Population With Acute Myocardial Infarction or Unstable Angina

OBJECTIVES

The paradoxical effect of smoking after acute myocardial infarction (AMI) is a phenomenon consisting of a reduction in the mortality of smokers compared to nonsmokers. However, it is not known whether the benefit of this reduction in mortality is due to smoking itself or to other covariables. Despite acceptance of the paradoxical effect of smoking in AMI, it is not known whether a similar phenomenon occurs in unstable angina. The objective of this study was to investigate the paradoxical effect of smoking in AMI and unstable angina, and to study specifically whether smoking is an independent prognostic variable.

METHODS AND RESULTS

The study population was selected from the multicentric ARIAM (Análisis del Retraso en el Infarto Agudo de Miocardio [analysis of delay in AMI]) Register, a register of 29,532 patients with a diagnosis of unstable angina or AMI. Tobacco smokers were younger, presented fewer cardiovascular risk factors such as diabetes or hypertension, fewer previous infarcts, a lower Killip and Kimball class, and a lower crude and adjusted mortality in AMI (odds ratio, 0.774; 95% confidence interval, 0.660 to 0.909; p = 0.002). Smokers with unstable angina were younger, with less hypertension or diabetes. In the multivariate analysis, no statistically significant difference in mortality was found.

CONCLUSIONS

The reduced mortality observed in smokers with AMI during their stay in the ICU cannot be explained solely by clinical covariables such as age, sex, other cardiovascular factors, Killip and Kimball class, or treatment received. Therefore, smoking may have a direct beneficial effect on reduced mortality in the AMI population. The lower mortality rates found in smokers with unstable angina are not supported by the multivariate analysis. In this case, the difference in mortality can be explained by the other covariables.

Mortalidad del infarto de miocardio en el registro PRIMVAC. Factores pronósticos

BACKGROUND AND OBJECTIVE

The aim of this study was to determine the mortality due to acute myocardial infarction in the coronary units from Comunidad Valenciana (Spain) and the prognostic factors associated with a higher mortality.

PATIENTS AND METHOD

Demographic characteristics, coronary risk factors, electrocardiographic ischemic signs, complications and mortality of patients with acute myocardial infarction admitted in the coronary units were collected. The study period comprised January 1995-December 1999. Death incidence was measured during coronary unit's stay. Factors associated with poor prognosis were analyzed.

RESULTS

10.213 patients entered into the study. Mean age at admission was 65 12 years. 23.8% were females (76.2% males). Global mortality in coronary units was 13.3%. Independent variables associated with higher mortality were (p < 0.05): advanced age (OR=1.06 [1.05-1.06]), female sex (OR=1.45 [1.26-1.66]), diabetes mellitus (OR=1.53 [1.35-1.74]), previous myocardial infarction (OR=1.46 [1.23-1.70]), previous angor pectoris (OR=1.29 [1.13-1.49]) and Q-wave infarction (OR=1.23 [1.03-1.43]). Factors associated with lower mortality were: hypercholesterolemia (OR=0.76 [0.66-0.78]), smoking (OR=0.65 [0.57-0.74]) and thrombolysis (OR=0.85 [0.78-0.92]).

CONCLUSIONS

At present, in the reperfusion therapy era, acute myocardial infarction has a high mortality after coronary unit admission. Several clinical factors are associated with a worse prognosis.

Risk factors for myocardial infarction case fatality and stroke case fatality in type 2 diabetes: UKPDS 66

OBJECTIVE

Patients with diabetes have a higher case fatality rate in myocardial infarction (MI) or stroke than those without diabetes: that is, MI and stroke are more often fatal if diabetes is present. We investigated whether the risk of MI or stroke being fatal in type 2 diabetes can be estimated using information available around the time diabetes is diagnosed.

RESEARCH DESIGN AND METHODS

Analyses were based on 674 cases of MI (351 fatal) that occurred in 597 of 5,102 U.K. Prospective Diabetes Study (UKPDS) patients for whom covariate data were available during a median follow-up of 7 years. Multivariate logistic regression was used to examine differences in risk factors, measured within 2 years of diagnosis of diabetes, between fatal and nonfatal MI. Similar analyses were performed for 234 strokes (48 fatal) that occurred in 199 patients.

RESULTS

Patients with fatal MI had higher HbA(1c) than those with nonfatal MI (odds ratio 1.17 per 1% HbA(1c), P = 0.014). Patients with fatal stroke had higher HbA(1c) than those with nonfatal stroke (odds ratio 1.37 per 1% HbA(1c), P = 0.007). Other risk factors for MI case fatality included increased age, blood pressure, and urine albumin level.

CONCLUSIONS

The risk of MI or stroke being fatal in type 2 diabetes is associated with risk factors, including HbA(1c), measured many years before onset of MI or stroke. Equations have been added to the UKPDS Risk Engine to estimate likely case fatality rates in MI and stroke.

Epidemiology of smoking-induced cardiovascular disease

Cigarette smoking is a major cause of coronary heart disease, stroke, aortic aneurysm, and peripheral vascular disease. The risk is manifest both as an increased risk for thrombosis of narrowed vessels and as an increased degree of atherosclerosis in those vessels. The cardiovascular risks owing to cigarette smoking increase with the amount smoked and with the duration of smoking. Risks are not reduced by smoking cigarettes with lower machine-measured yields of tar and nicotine, but those who have only smoked pipes or cigars seem to have a lower risk for cardiovascular diseases. Cessation of cigarette smoking reduces disease risks, although risks may remain elevated for a decade or more after cessation.

Implications of cigarette smoking for the management of patients with acute coronary syndromes

Smokers differ from nonsmokers in the way they present with acute coronary syndromes and in how they respond to treatment. Although smoking increases the risk of a coronary event and accelerates the progression of established atherosclerosis, paradoxically, smokers have better short-term survival after an acute myocardial infarction, mainly because they are younger and have more favorable coronary anatomy. Thrombolysis appears to be a better treatment in smokers than in nonsmokers, probably because thrombosis plays a more important role in the pathogenesis of acute coronary events in smokers. Patients who continue to smoke after angioplasty or bypass surgery have a worse outcome than nonsmokers or quitters. The 2.5- to 3-fold increase in risk for myocardial infarction or stroke in smokers compared with nonsmokers decreases exponentially after smoking cessation. By 4 years the risk is only slightly higher than the risk of a subject who never smoked.

The smoker's paradox: insights from the angiographic substudies of the TIMI trials

BACKGROUND

Despite increased risk for coronary artery disease and acute myocardial infarction (AMI), smokers have a paradoxically lower mortality after thrombolysis for AMI than non-smokers. We determined the clinical risk profiles and coronary flow characteristics of patients in the TIMI trials according to smoking status, focusing on microvascular flow.

METHODS

Among 2,573 patients in the TIMI 4, 10A, 10B and TIMI 14 trials, epicardial flow post-thrombolysis was measured using angiographic TIMI flow grades and the corrected TIMI frame count (CTFC). Microvascular flow was measured by TIMI Myocardial Perfusion Grade (TMPG) and, in TIMI 14, the percentage of ST segment resolution.

RESULTS

Clinically, the mean age (54 vs. 62 years), the prevalence of diabetes mellitus (11% vs. 16%) and hypertension (26% vs. 40%), and the 30-day mortality (2.6% vs. 6.2%) were lower among smokers than non-smokers (all p < or = 0.001). Angiographically, single-vessel disease (48% vs. 40%) and non-left anterior descending infarct arteries (65.4% vs. 60.8%) were more common among smokers (both p < or = 0.01). Epicardial TIMI grade 3 flow was achieved more often in smokers than non-smokers (61% vs. 56%) and the CTFC was faster (34 vs. 37 frames/sec, both p < or = 0.01), especially in LAD lesions. However, the frequency of normal microvascular flow (TMPG 3) was similar among smokers and non-smokers (24% vs. 29%, p = 0.16), as was the frequency of complete ST segment resolution (50% vs. 46%, p = 0.29).

CONCLUSIONS

Smokers have lower mortality after AMI than non-smokers, due in large part to lower clinical risk profiles and faster epicardial flow. Differences in tissue-level perfusion do not appear to contribute to lower mortality in smokers.

Atherosclerosis, cigarette smoking, and endogenous fibrinolysis: is there a direct link?

Acute myocardial infarction is caused by thrombotic occlusion of a coronary artery at the site of a ruptured or eroded atheromatous plaque. The maintenance and regulation of tissue perfusion critically depend upon the integrity of endothelial function and the release of potent endothelium-derived factors, such as the fibrinolytic factor tissue plasminogen activator (tPA). Atherosclerosis and cigarette smoking are associated with dysfunction of the endothelium, and in particular, appear to impair the acute local endogenous fibrinolytic activity. This provides a potential mechanism whereby atherosclerosis and cigarette smoking can markedly influence the initiation, propagation, and resolution of the acute and chronic thrombotic complications of coronary artery disease through reductions in the capacity to release tPA acutely.

Hypercholesterolaemia and lipid lowering treatment do not affect the acute endogenous fibrinolytic capacity in vivo

OBJECTIVE

To assess acute tissue plasminogen activator (t-PA) release in vivo in patients with hypercholesterolaemia in the presence and absence of lipid lowering treatment and in matched normocholesterolaemic controls.

DESIGN

Parallel group comparison and double blind randomised crossover.

SETTING

University hospital.

PATIENTS

Eight patients with hypercholesterolaemia (> 7.8 mmol/l) and eight matched normocholesterolaemic controls (< 5.5 mmol/l).

METHODS

Blood flow and plasma fibrinolytic factors were measured in both forearms during unilateral brachial artery infusions of the endothelium dependent vasodilator substance P (2-8 pmol/min) and the endothelium independent vasodilator sodium nitroprusside (1-4 microg/min).

INTERVENTIONS

In patients, measurements were made on three occasions: at baseline and after six weeks of placebo or pravastatin 40 mg daily administered in a double blind randomised crossover design.

MAIN OUTCOME MEASURES

Acute release of t-PA.

RESULTS

Compared with patients, in normocholesterolaemic control subjects substance P caused greater dose dependent increases in forearm blood flow (p < 0.05) but similar increases in plasma t-PA antigen and activity concentrations. During pravastatin treatment in patients, total serum cholesterol fell by 22% from a mean (SEM) of 8.1 (0.3) to 6.4 (0.4) mmol/l (p = 0.002) and substance P induced vasodilatation was no longer significantly impaired in comparison with controls. However, despite reproducible responses, pravastatin treatment was not associated with significant changes in basal or substance P induced t-PA release.

CONCLUSIONS

Hypercholesterolaemia and lipid lowering treatment cause no demonstrable effects on acute substance P induced t-PA release in vivo. This suggests that the preventative benefits of lipid lowering treatment are unlikely to be mediated by improvements in endogenous fibrinolysis.

Important factors for the 10-year mortality rate in patients with acute chest pain or other symptoms consistent with acute myocardial infarction with particular emphasis on the influence of age

OBJECTIVE

Our purpose was to describe the mortality rate and mode of death over 10 years and factors associated with death among patients admitted to the emergency department with acute chest pain or other symptoms consistent with acute myocardial infarction (AMI).

METHODS

All patients who came to the emergency department at Sahlgrenska University Hospital in Göteborg, Sweden, with acute chest pain or other symptoms consistent with AMI during a 21-month period were studied.

RESULTS

In all, 5362 patients were registered, for whom information on 10-year mortality was available in 5158 (96.2%). In all, there were 2126 deaths (41.2%). Fifty-two percent of patients were </=65 years old. Independent predictors of death registered on admission to hospital during the subsequent 10 years were age (relative risk 1.08, 95% CI 1.07-1.09), male sex (1.38, 1.25-1.52), initial degree of suspicion of AMI (1.13, 1.06-1.19), a pathologic initial electrocardiogram (1.76, 1.56-1.98), symptoms of congestive heart failure (1.66, 1.39-1.98), "other" nonspecific symptoms (1.22, 1.07-1.39), a history of diabetes mellitus (1.65, 1.44-1.88), a history of congestive heart failure (1.42, 1.26-1.60), a history of previous myocardial infarction (1.26, 1.12-1.40), and a history of hypertension (1.14, 1.03-1.26). For all these predictors there was a strong interaction with age, thus a much more marked influence on outcome among patients </=65 years old than among patients >65 years old. When the above risk indicators were simultaneously considered, development of AMI during the first 3 days after hospital admission was still an independent predictor of death (1.63, 1.43-1.86).

CONCLUSION

For patients admitted to the emergency department with acute chest pain or other symptoms consistent with AMI, several predictors based on clinical history and clinical presentation are related to the 10-year prognosis. They are more strongly associated with outcome among patients aged </=65 years. However, whether the patients have an AMI during the subsequent days will independently influence the long-term prognosis from observations on admission.

Effects of smoking on myocardial injury in patients with conservatively treated acute myocardial infarction: a study with resting 123I-15-iodophenyl 3-methyl pentadecanoic acid/201Tl myocardial single photon emission computed tomography

Many reports have demonstrated that smokers who have suffered an acute myocardial infarction (AMI) have a better prognosis than nonsmokers. The present study investigated the effects of current smoking on myocardial injury with resting 123I-15-iodophenyl 3-methyl pentadecanoic acid (BMIPP)/201Tl myocardial single photon emission computed tomography in 103 patients with conservatively treated AMI. The left ventricular myocardium was divided into 9 segments and BMIPP and 201Tl defects were scored using a 5-point grading system (0 = normal and 4 = no uptake). The sum of the defect scores was defined as the total defect score. There was no significant difference in either the baseline severity of the coronary artery disease or the total defect scores for BMIPP and 201Tl between the current smoker and nonsmoker groups. The difference between the total defect scores for BMIPP and 201Tl tended to be larger in the current smoker group than in the nonsmoker group (2.0 +/- 1.9 vs 1.3 +/- 1.6, p = 0.056). Forty-one (53%) of 77 patients in the current smoker group exhibited a BMIPP/201Tl mismatch, whereas only 8 (31%) of 26 patients in the nonsmoker group did (p = 0.047). In conclusion, current smokers had more likelihood of salvageable myocardium in areas at risk, as demonstrated by BMIPP/201Tl mismatch, in AMI than nonsmokers.

Ten-year mortality rate in relation to observations at a bicycle exercise test in patients with a suspected or confirmed ischemic event but no or only minor myocardial damage: influence of subsequent revascularization

AIM

Our purpose was to describe symptoms and electrocardiographic findings at a bicycle exercise test 4 weeks after hospitalization for a suspected or confirmed acute ischemic event but either no or only minor myocardial necrosis and its relationship to long-term prognosis and subsequent revascularization.

METHODS

In all patients a symptom-limited bicycle exercise test was performed 4 weeks after discharge from the hospital. The total mortality rate over 10 years was registered.

RESULTS

In all, 770 patients participated in the evaluation. The median age was 63 years, and 34% were women. The most frequent reason for stopping the exercise test was fatigue (69%) followed by dyspnea (33%) and angina pectoris (15%). Angina pectoris was observed in 24% of the patients. ST-segment depression >or=1 mm was observed in 50% and ST-segment depression >or=2 mm was observed in 15% of the patients. The 10-year mortality rate in patients with ST-segment depression >or=2 mm was 24.7%, in patients with ST-segment depression 1.0 to 1.9 mm 33.5%, and in patients with ST-segment depression <1 mm 26.9% (not significant [NS]). Patients with symptoms of angina pectoris had a 10-year mortality rate of 29.4% compared with 27.9% among patients without such symptoms (NS). Patients who had either a drop in systolic blood pressure or failure to raise systolic blood pressure (13%) had a 10-year mortality rate of 36.2% compared with 27.2% among patients without such signs (NS). However, there was a significant association between maximum exercise capacity (in watts) and mortality (P < .0001): 53.8% in the lowest quartile (30-70 W) and 10.2% in the highest (>120 w). When clinical history was considered simultaneously, a low exercise capacity remained as a strong independent predictor of death together with age and a history of either acute myocardial infarction, smoking, or diabetes mellitus. Mechanical revascularization during the subsequent 5 years interacted only with angina pectoris and prognosis; thus patients who had angina during the exercise test had a worse prognosis than those without if they were not being revascularized.

CONCLUSION

Among patients hospitalized with a suspected or confirmed acute ischemic event but either no or only minor myocardial necrosis, we found the maximum working capacity at a symptom-limited bicycle exercise test to be independently associated with the long-term prognosis but not other signs of myocardial ischemia. Further predictors for long-term prognosis were age, a history of acute myocardial infarction, current smoking, and diabetes mellitus. Mechanical revascularization during the subsequent 5 years interacted with the influence of symptoms of angina during test and prognosis.

Case fatality after an acute cardiac event: the effect of smoking and alcohol consumption

The objective of this study was to use a population-based register of acute cardiac events to investigate the association between survival after an acute event and history of smoking and alcohol consumption. The population was all residents of the Lower Hunter Region of Australia aged 25 to 69 years who suffered myocardial infarction or sudden cardiac death between 1986 and 1994. Among 10,170 events, 2504 resulted in death within 28 days. After adjusting for sex, age and medical history, current smokers had a similar risk of dying after an acute cardiac event to never-smokers [odds ratio (OR)=1.10, 95% confidence interval (CI) 0.94-1.29]. People who consumed more than 8 alcoholic drinks per day on more than 2 days per week (OR=1.93, 95% CI 1.39-2.69) and former moderate to heavy drinkers (OR=4.59, 95% CI 3.65-5.76) were more likely to die than people who were nondrinkers. The results of this large community study, suggesting no effect of smoking on case fatality and an increased risk of death after an acute cardiac event for heavy drinkers and former moderate to heavy drinkers, highlight the importance of a population view of case fatality. These results can also shed some light on reasons for the paradoxical results from clinical trials.

Influence of a history of smoking on short term (six month) clinical and angiographic outcome after successful coronary angioplasty

OBJECTIVES

To assess the influence of smoking on restenosis after coronary angioplasty.

DESIGN AND PATIENTS

The incidence of smoking on restenosis was investigated in 2948 patients. They were prospectively enrolled in four major restenosis trials in which quantitative angiography was used before and immediately after successful angioplasty and again at six months.

RESULTS

Within the study population there were 530 current smokers, 1690 ex-smokers, and 728 non-smokers. Smokers were more likely to be men (85.9% v 87. 5% v 65.3%, current v ex- v non-, p < 0.001), to be younger (54.0 (9. 0) v 57.0 (9.1) v 59.9 (9.4) years, p < 0.001), to have peripheral vascular disease (7.2% v 5.5% v 2.3%, p < 0.001), and have sustained a previous myocardial infarction (42.9% v 43.9% v 37.9%, p = 0.022), but were less likely to be diabetic (9.1% v 9.5% v 12.6%, p = 0.043) or hypertensive (24.9% v 29.3% v 37.2, p < 0.001). There was no significant difference in the categorical restenosis rate (> 50% diameter stenosis) at six months (35.28% v 35.33% v 37.09%, current v ex- v non-), or the absolute loss (0.29 (0.54) v 0.33 (0.52) v 0. 35 (0.55) mm, respectively; p = 0.172).

CONCLUSIONS

Although smokers have a lower incidence of known predisposing risk factors for atherosclerosis, they require coronary intervention almost six years earlier than non-smokers and three years earlier than ex-smokers. Once they undergo successful coronary angioplasty, there appears to be no evidence that smoking influences their short term (six month) outcome, but because of the known long term effects of smoking, patients should still be encouraged to discontinue the habit.

Influence of previous aspirin treatment and smoking on the electrocardiographic manifestations of injury in acute myocardial infarction

OBJECTIVE

To examine demographic and clinical characteristics of patients with acute myocardial infarction in order to identify factors affecting the electrocardiographic evolution of injury.

METHODS

Prospective cohort study of 1399 consecutive patients with a first myocardial infarction. Baseline clinical data associated with ST elevation and Q wave development were identified and 12 month survival was estimated.

RESULTS

Smoking had complex effects on the evolution of injury, increasing the odds of ST elevation (odds ratio (OR) 1.61; 95% confidence interval (CI) 1.08 to 2.36), but reducing the odds of Q wave development (OR 0.69, 95% CI 0.49 to 0.96). The effects of previous aspirin treatment were more consistent with reductions in the odds of ST elevation (OR 0.57, 95% CI 0.35 to 0.94) and Q wave development (OR 0.53, 95% CI 0.34 to 0. 84). ST elevation and Q wave development were both associated with an adverse prognosis, with estimated 12 month survival rates of 80. 6% (95% CI 78.2% to 83.1%) and 80.0% (95% CI 77.5% to 82.5%), respectively, compared with 86.5% (95% CI 81.2% to 91.9%) and 89.9% (95% CI 86.2% to 93.7%) for patients without these ECG changes.

CONCLUSIONS

The thrombogenicity of the blood may be a major determinant of infarct severity. Smoking increases thrombogenicity and the likelihood of ST elevation, but because coronary occlusion is relatively more thrombotic in smokers, responses to both endogenous and exogenous thrombolysis are better, reducing the risk of Q wave development. Previous aspirin treatment reduces thrombogenicity, protecting against ST elevation and Q wave development.

Ten-year mortality amongst patients with a very small or unconfirmed acute myocardial infarction in relation to clinical history, metabolic screening and signs of myocardial ischaemia

AIM

To evaluate the long-term prognosis amongst patients with a very small or unconfirmed acute myocardial infarction (AMI) in relation to clinical history, metabolic screening and signs of myocardial ischaemia at exercise test.

METHODS

Patients with a very small or unconfirmed AMI, aged < 76 years, were selected and given a clinical evaluation, metabolic screening and checked for ischaemia at an exercise test 4 weeks after admittance. The 10-year mortality was related to age, sex, clinical history, body weight, serum (S) cholesterol, S-triglycerides, S-gammaglutamyltranspeptidase (GT), S-glucose and various indices of myocardial ischaemia at exercise test.

RESULTS

In all, 714 patients participated in the evaluation. The median age was 63 years and 33% were women. The overall 10-year mortality was 33%. In univariate analysis, the following factors appeared as risk indicators for death: age (P < 0.0001), a history of previous AMI (P < 0.0001), angina pectoris (P < 0.001), diabetes mellitus (P < 0.0001), congestive heart failure (P < 0.0001), smoking (P = 0.030), S-triglycerides (P < 0.0001), S-gamma GT (P < 0. 0001) and S-glucose (P < 0.0001). In multivariate analysis, the following remained as independent risk indicators for death: age (P < 0.0001), S-gamma GT (P < 0.0001), previous AMI (P < 0.0001), smoking (P < 0.0001) and S-glucose (P = 0.010).

CONCLUSION

Amongst patients with a very small or a unconfirmed AMI, factors reflecting their clinical history, including age, a history of AMI and current smoking, as well as factors reflecting their metabolic status, including S-gamma GT and S-glucose, were important predictors for the long-term outcome.

Cigarette smoking status and outcome among patients with acute coronary syndromes without persistent ST-segment elevation: effect of inhibition of platelet glycoprotein IIb/IIIa with eptifibatide. The PURSUIT trial investigators

BACKGROUND

Studies have shown that cigarette smokers constitute a substantial proportion of patients with acute coronary syndromes (ACS) and have platelet-rich coronary thrombi. We characterized the influence of smoking status on outcome of patients with ACS without persistent ST-segment elevation and tested the hypothesis that selective inhibition of the platelet glycoprotein IIb/IIIa receptor with eptifibatide would improve outcomes among cigarette smokers.

METHODS

The study population included patients enrolled in the PURSUIT trial (Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy) with known smoking status presenting with ischemic chest pain </=24 hours and having either ischemic electrocardiographic changes without persistent ST-segment elevation or elevated creatine kinase MB levels. Patients were randomly assigned to receive a bolus and infusion of either eptifibatide or placebo in addition to standard therapy. The primary end point was a composite of death or nonfatal myocardial infarction within 30 days.

RESULTS

Of the 9406 patients with known smoking status, 2677 were current smokers, 3086 were former smokers, and 3643 were nonsmokers. Cigarette smokers had better 30-day outcomes (12.3%, 16.8%, and 15.4% for smokers, former smokers, and nonsmokers, respectively; P =.001). However, after adjusting for differences in baseline clinical variables, smoking status was not a predictor of 30-day outcome (P =.45). There was a reduction in the composite end point overall with eptifibatide compared with placebo (14.3% vs 15. 7%, P =.054) but no interaction between smoking status and treatment strategy (P =.68).

CONCLUSIONS

Among patients with ACS without persistent ST-segment elevation, cigarette smokers had better short-term outcomes because of their more favorable clinical profile. Although prior studies have suggested that smokers more commonly have platelet-rich thrombi than nonsmokers, eptifibatide did not result in more improvement in their outcome compared with former smokers or nonsmokers.

Is hospital care of major importance for outcome after out-of-hospital cardiac arrest? Experience acquired from patients with out-of-hospital cardiac arrest resuscitated by the same Emergency Medical Service and admitted to one of two hospitals over a 16-year period in the municipality of Göteborg

AIM

To describe patient characteristics, hospital investigations and interventions and early mortality among patients being hospitalized after out-of-hospital cardiac arrest in two hospitals.

SETTING

Municipality of Göteborg, Sweden.

PATIENTS

All patients suffering an out-of-hospital cardiac arrest who were successfully resuscitated and admitted to hospital between 1 October 1980 and 31 December 1996. All patients were resuscitated by the same Emergency Medical Service and admitted alive to one of the two city hospitals in Göteborg.

RESULTS

Of 579 patients admitted to Sahlgrenska Hospital, 253 (44%) were discharged alive and of 459 patients admitted to Ostra Hospital, 152 (33%) were discharged alive (P < 0.001). More patients in Sahlgrenska Hospital were still receiving cardiopulmonary resuscitation (CPR) treatment (P = 0.03), but patients in Ostra had a lower systolic blood pressure and higher heart rate on admission. A larger percentage of patients admitted to Sahlgrenska Hospital underwent coronary angiography (P < 0.001), electrophysiological testing (P < 0.001), Holter recording (P < 0.001), echocardiography (P = 0.004), percutaneous transluminal coronary angioplasty (PTCA, P = 0.009), implantation of automatic implantable cardioverter defibrillator (AICD, P = 0.03) and exercise stress tests (P = 0.003). Inhabitants in the catchment area of Ostra Hospital had a less favourable socio-economic profile.

CONCLUSION

Survival after out-of-hospital cardiac arrest may be affected by the course of hospital management. Other variables that might influence survival are socio-economic factors and cardiorespiratory status on admission to hospital. Further investigation is called for as more patients are being hospitalised alive after out-of-hospital cardiac arrest.