Smoking and infarct size among STEMI patients undergoing primary angioplasty

The enigma of the 'smoker's paradox': Results from a single-center registry of patients with STEMI undergoing primary percutaneous coronary intervention

BACKGROUND

Smoker's paradox usually refers to the observation of a favorable outcome of smoking patients in acute myocardial infarction.

METHODS

From April 2006 to December 2018 a population of 2456 patients with ST segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (pPCI) were prospectively enrolled in the MATRIX registry. Ischemic time, clinical, demographics, angiographic data, and 1-year follow-up were collected.

RESULTS

Among 2546 patients admitted with STEMI, 1007 (41 %) were current smokers. Smokers were 10 years younger and had lower crude in-hospital and 1-year mortality (1.5 % vs 6 %, p < 0.0001 and 5 % vs 11 %, p < 0.0001), shorter ischemic time (203 [147-299] vs 220 [154-334] minutes, p = 0.002) and shorter decision time (60 [30-135] vs 70 [36-170] minutes, p = 0.0063). Smoking habit [OR:0.37(95 % CI:0.18-0.75)-p < 0.01], younger age [OR 1.06 (95%CI:1.04-1.09)-p < 0.001] and shorter ischemic time [OR:1.01(95%CI:1.01-1.02)-p < 0.05] were associated to lower in-hospital mortality. Only smoking habit [HR:0.65(95 % CI: 0.44-0.9)-p = 0.03] and younger age [HR:1.08 (95%CI:1.06-1.09)-p < 0.001] were also independently associated to lower all-cause death at 1-year follow-up. After propensity matching, age, cardiogenic shock and TIMI flow <3 were associated with in-hospital mortality, while smoking habit was still associated with reduced mortality. Smoking was also associated with reduced mortality at 1-year follow-up (HR 0.54, 95 % CI [0.37-0.78]; p < 0.001).

CONCLUSIONS

Smoking patients show better outcome after PCI for STEMI at 1-year follow-up. Although "Smoking paradox" could be explained by younger age of patients, other factors may have a role in the explanation of the phenomenon.

The Effect of Periprocedural Clinical Factors Related to the Course of STEMI in Men and Women Based on the National Registry of Invasive Cardiology Procedures (ORPKI) between 2014 and 2019

BACKGROUND

There are several sex-related differences in the course, management, and outcomes of ST-elevation myocardial infarction (STEMI). This study aimed to identify the risk factors that may affect the odds of procedure-related death in patients with STEMI.

METHODS

The observational cohort study group consisted of 118,601 participants recruited from the National Registry of Invasive Cardiology Procedures (ORPKI).

RESULTS

Procedure-related death occurred in 802 (1.0%) men and in 663 (1.7%) women. The odds of procedure-related death among women were significantly higher than among men (OR, 1.76; 95% CI, 1.59-1.95; p < 0.001). The probability of procedure-related mortality was highest in both men and women with cardiac arrest in the cath lab, critical stenosis of the left main coronary artery, and direct transfer to the cath lab. The factors that reduced the probability of procedure-related mortality in both men and women were thrombolysis in myocardial infarction (TIMI) flow grade and the use of P2Y12 inhibitors in the peri-infarct period. Psoriasis was associated with increased odds of procedure-related death among men, whereas cigarette smoking reduced the odds among women.

CONCLUSIONS

Procedure-related deaths occurred more frequently in women than men with STEMI. Additional scrutiny needs to be undertaken to identify factors influencing survival regarding gender differences.

The bizzare phenomenon of smokers' paradox in the immediate outcome post acute myocardial infarction: an insight into the Malaysian National Cardiovascular Database-Acute Coronary Syndrome (NCVD-ACS) registry year 2006-2013

Background

‘Smoker’s paradox’ is a controversial phenomenon of an unexpected favourable outcome of smokers post acute myocardial infarction. There are conflicting evidences from the literature so far. We investigate for the existence of this phenomenon in our post acute myocardial infarction patients.

Methods

We analysed 12,442 active smokers and 10,666 never-smokers diagnosed with STEMI and NSTEMI from the Malaysian National Cardiovascular Database-Acute Coronary Syndrome (NCVD-ACS) year 2006–2013 from 18 hospitals across Malaysia. Comparisons in the baseline characteristics, clinical presentation, in-hospital treatment and short term clinical outcome were made between the two groups. To compare the clinical outcome, an extensive multivariate adjustment was made to estimate the allcause mortality risk ratios for both groups.

Results

The active smokers were younger (smokers 53.7 years vs non-smokers 62.3 years P < 0.001) and had lower cardiovascular risk burden and other co-morbidities. STEMI is more common in smokers and intravenous thrombolysis was the main reperfusion therapy in both groups. Smokers had a higher rate of in-hsopital coronary revascularisation in NSTEMI group (21.6 % smokers vs 16.7 % non-smokers P < 0.001) but similar to non-smokers in the STEMI group. Multivariate adjusted mortality risk ratios showed significantly lower mortality risks of smokers at both in-hospital (RR 0.510 [95 % CI 0.442–0.613]) and 30-day post discharge (RR 0.534 [95 % CI 0.437–0.621]).

Conclusion

Smoking seems to be associated with a favourable outcome post myocardial infarction. The phenomenon of ‘smoker’s paradox’ is in fact a reality in our patients population. The definitive explanation for this unexpected protective effect of smoking remains unclear.

Change in left ventricular systolic function in patients with ST elevation myocardial infarction: Evidence for smoker's paradox or pseudo-paradox?

Background

The ‘smoker's paradox’ refers to the observation of favorable prognosis in current smokers following an acute ST elevation myocardial infarction (STEMI) in the era of fibrinolysis, however, several STEMI studies have demonstrated conflicting results in patients undergoing primary percutaneous coronary intervention (p-PCI).

Objective

Aim of the current study was to evaluate the impact of cigarette smoking on left ventricular function in STEMI patients undergoing p-PCI.

Methods

Our population is represented by 74 first-time anterior STEMI patients undergoing p-PCI, 37 of whom were smokers. We assessed left ventricular function by left ventricular ejection fraction (LVEF) on the second day after admission and at 3-month follow-up. Early predictors of adverse left ventricular remodelling after STEMI treated by p-PCI were examined.

Results

Basal demographics and comorbidities were similar between groups. Although the LVEF during the early phase was higher in smokers compared to non-smokers (44.95 ± 7.93% vs. 40.32 ± 7.28%; p = 0.011); it worsened in smokers at follow-up (mean decrease in LVEF: −2.70 ± 5.95%), whereas it improved in non-smokers (mean recovery of LVEF: +2.97 ± 8.45%). In univariate analysis, diabetes mellitus, peak troponin I, current smoking, and lower TIMI flow grade after p-PCI, pain-to-door time and door-to-balloon times were predictors of adverse left ventricular remodelling. After multivariate logistic regression analysis, smoking at admission, lower TIMI flow grade after p-PCI, the pain-to-door time and door-to-balloon times remained independent predictors of deterioration in LVEF.

Conclusion

True or persistent ‘smoker's paradox’ does not appear to be relevant among STEMI patients undergoing p-PCI. The ‘smoker's paradox’ is in fact a pseudo-paradox. Further studies with larger numbers may be warranted.