Cessation of smoking after myocardial infarction. Effects on mortality after 10 years

Smoking cessation for secondary prevention of cardiovascular disease

BACKGROUND

Smoking is a leading cause of cardiovascular disease (CVD), particularly coronary heart disease (CHD). However, quitting smoking may prevent secondary CVD events in people already diagnosed with CHD.  OBJECTIVES: To examine the impact of smoking cessation on death from CVD and major adverse cardiovascular events (MACE), in people with incident CHD.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's Specialised Register, CENTRAL, MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and the trials registries clinicaltrials.gov and the International Clinical Trials Registry Platform. We ran all searches from database inception to 15 April 2021.  SELECTION CRITERIA: We included cohort studies, and both cluster- and individually randomised controlled trials of at least six months' duration. We treated all included studies as cohort studies and analysed them by smoking status at follow-up. Eligible studies had to recruit adults (> 18 years) with diagnosed CHD and who smoked tobacco at diagnosis, and assess whether they quit or continued smoking during the study. Studies had to measure at least one of our included outcomes with at least six months' follow-up. Our primary outcomes were death from CVD and MACE. Secondary outcomes included all-cause mortality, non-fatal myocardial infarction, non-fatal stroke, new-onset angina and change in quality of life.  DATA COLLECTION AND ANALYSIS: We followed standard Cochrane methods for screening and data extraction.  We assessed the risk of bias for the primary outcomes using the ROBINS-I tool. We compared the incidence of death from CVD and of MACE (primary outcomes) between participants who quit smoking versus those who continued to smoke for each included study that reported these outcomes. We also assessed differences in all-cause mortality, incidence of non-fatal myocardial infarction, incidence of non-fatal stroke and new onset angina. We calculated hazard ratios (HRs) and 95% confidence intervals (95% CI). For our outcome, change in quality of life, we calculated the pooled standardised mean difference (SMD) and 95% CI for the difference in change in quality of life from baseline to follow-up between those who had quit smoking and those who had continued to smoke. For all meta-analyses we used a generic inverse variance random-effects model and quantified statistical heterogeneity using the I²statistic. We assessed the certainty of evidence for our primary outcomes using the eight GRADE considerations relevant to non-randomised studies.

MAIN RESULTS

We included 68 studies, consisting of 80,702 participants. For both primary outcomes, smoking cessation was associated with a decreased risk compared with continuous smoking: CVD death (HR 0.61, 95% CI 0.49 to 0.75; I² = 62%; 18 studies, 17,982 participants; moderate-certainty evidence) and MACE (HR 0.57, 95% CI 0.45 to 0.71; I² = 84%; 15 studies, 20,290 participants; low-certainty evidence). These findings were robust to our planned sensitivity analyses. Through subgroup analysis, for example comparing adjusted versus non-adjusted estimates, we found no evidence of differences in the effect size. While there was substantial heterogeneity, this was primarily in magnitude rather than the direction of the effect estimates. Overall, we judged 11 (16%) studies to be at moderate risk of bias and 18 (26%) at serious risk, primarily due to possible confounding. There was also some evidence of funnel plot asymmetry for MACE outcomes. For these reasons, we rated our certainty in the estimates for CVD death as moderate and MACE as low.  For our secondary outcomes, smoking cessation was associated with a decreased risk in all-cause mortality (HR 0.60, 95% CI 0.55 to 0.66; I² = 58%; 48 studies, 59,354 participants), non-fatal myocardial infarction (HR 0.64, 95% CI 0.58 to 0.72; I² = 2%; 24 studies, 23,264 participants) and non-fatal stroke (HR 0.70, 95% CI 0.53 to 0.90; I² = 0%; 9 studies, 11,352 participants). As only one study reported new onset of angina, we did not conduct meta-analysis, but this study reported a lower risk in people who stopped smoking. Quitting smoking was not associated with a worsening of quality of life and suggested improvement in quality of life, with the lower bound of the CI also consistent with no difference (SMD 0.12, 95% CI 0.01 to 0.24; I² = 48%; 8 studies, 3182 participants).  AUTHORS' CONCLUSIONS: There is moderate-certainty evidence that smoking cessation is associated with a reduction of approximately one-third in the risk of recurrent cardiovascular disease in people who stop smoking at diagnosis. This association may be causal, based on the link between smoking cessation and restoration of endothelial and platelet function, where dysfunction of both can result in increased likelihood of CVD events.  Our results provide evidence that there is a decreased risk of secondary CVD events in those who quit smoking compared with those who continue, and that there is a suggested improvement in quality of life as a result of quitting smoking. Additional studies that account for confounding, such as use of secondary CVD prevention medication, would strengthen the evidence in this area.

Association of Smoking Cessation and Survival Among Young Adults With Myocardial Infarction in the Partners YOUNG-MI Registry

IMPORTANCE

Despite significant progress in primary prevention, the rate of myocardial infarction (MI) continues to increase in young adults.

OBJECTIVES

To identify the prevalence of tobacco use and to examine the association of both smoking and smoking cessation with survival in a cohort of adults who experienced an initial MI at a young age.

DESIGN, SETTING, AND PARTICIPANTS

The Partners YOUNG-MI registry is a retrospective cohort study from 2 large academic centers in Boston, Massachusetts, that includes patients who experienced an initial MI at 50 years or younger. Smoking status at the time of presentation and at 1 year after MI was determined from electronic medical records. Participants were 2072 individuals who experienced an MI at 50 years or younger between January 2000 and April 2016. The dates of analysis were October to December 2019.

MAIN OUTCOMES AND MEASURES

Deaths were ascertained from the Social Security Administration Death Master File, the Massachusetts Department of Vital Statistics, and the National Death Index. Cause of death was adjudicated independently by 2 cardiologists. Propensity score-adjusted Cox proportional hazards modeling was used to evaluate the association between smoking cessation and both all-cause and cardiovascular mortality.

RESULTS

Among the 2072 individuals (median age, 45 years [interquartile range, 42-48 years]; 1669 [80.6%] men), 1088 (52.5%) were smokers at the time of their index hospitalization. Of these, 910 patients were further classified into either the cessation group (343 [37.7%]) or the persistent smoking group (567 [62.3%]) at 1 year after MI. Over a median follow-up of 11.2 years (interquartile range, 7.3-14.2 years), individuals who quit smoking had a statistically significantly lower rate of all-cause mortality (hazard ratio [HR], 0.35; 95% CI, 0.19-0.63; P < .001) and cardiovascular mortality (HR, 0.29; 95% CI, 0.11-0.79; P = .02). These values remained statistically significant after propensity score adjustment (HR, 0.30 [95% CI, 0.16-0.56; P < .001] for all-cause mortality and 0.19 [95% CI, 0.06-0.56; P = .003] for cardiovascular mortality).

CONCLUSIONS AND RELEVANCE

In this cohort study, approximately half of individuals who experienced an MI at 50 years or younger were active smokers. Among them, smoking cessation within 1 year after MI was associated with more than 50% lower all-cause and cardiovascular mortality.

Electronic Cigarette Use and Myocardial Infarction Among Adults in the US Population Assessment of Tobacco and Health

Background E-cigarettes are popular for smoking cessation and as an alternative to combustible cigarettes. We assess the association between e-cigarette use and having had a myocardial infarction ( MI ) and whether reverse causality can explain the observed cross-sectional association between e-cigarette use and MI . Methods and Results Cross-sectional analysis of the Population Assessment of Tobacco and Health Wave 1 for association between e-cigarette use and having had and MI . Longitudinal analysis of Population Assessment of Tobacco and Health Waves 1 and 2 for reverse causality analysis. Logistic regression was performed to determine the associations between e-cigarette initiation and MI , adjusting for cigarette smoking, demographic and clinical variables. Every-day (adjusted odds ratio, 2.25, 95% CI : 1.23-4.11) and some-day (1.99, 95% CI : 1.11-3.58) e-cigarette use were independently associated with increased odds of having had an MI with a significant dose-response ( P<0.0005). Odds ratio for daily dual use of both products was 6.64 compared with a never cigarette smoker who never used e-cigarettes. Having had a myocardial infarction at Wave 1 did not predict e-cigarette use at Wave 2 ( P>0.62), suggesting that reverse causality cannot explain the cross-sectional association between e-cigarette use and MI observed at Wave 1. Conclusions Some-day and every-day e-cigarette use are associated with increased risk of having had a myocardial infarction, adjusted for combustible cigarette smoking. Effect of e-cigarettes are similar as conventional cigarette and dual use of e-cigarettes and conventional cigarettes at the same time is risker than using either product alone.

Acute changes in Atherogenic and Thrombogenic Factors with Cessation of Smoking

Tobacco smoking is associated with alterations in several factors considered to be important in the atherosclerotic process. Thirty chronic smokers were studied 2 weeks before and 2 weeks after complete tobacco withdrawal. Significant reductions in fibrinogen, haematocrit, plasma viscosity and whole blood viscosity as well as a significant increase in HDL-cholesterol were observed. As these factors are important in both atherogenesis and thrombogenesis, these observations may give insight into tobacco-induced atherosclerotic disease and may be responsible for the more rapid reduction in the incidence of cardiovascular disease that is believed to occur after stopped smoking.

Smoking, APOE Genotype, and Cognitive Decline: The Rotterdam Study

The association of smoking with preclinical cognitive decline remains unclear and may be modified by the APOEɛ4 genotype. In 5,705 participants (mean age: 63.9±9.1 years; 57.4% women) from the population-based Rotterdam Study, we investigated the relationship between smoking and cognitive decline over a 5.5-year period and examined potential effect modification by APOEɛ4 genotype. We found that current smoking was related to decline in global cognition [difference compared to never smoking: -0.06 (95% C.I.-0.10;-0.01)], as well as decline on specific cognitive tests including the Letter Digit Substitution Task, the 15-Word Learning Test, and the Purdue Pegboard. We found no evidence for effect modification by APOEɛ4 genotype on this relation.

Approach to cardiac rehabilitation

Cardiac rehabilitation is now considered an integral part of the management of cardiac disease. However, the approach to objectives has been variable and not well defined. To have a more structured approach towards the goals and objectives of cardiac rehabilitation, this paper discusses the interrelationship of the different factors which determine quality of life, who are the candidates for rehabilitation, the effectiveness of the various modes of intervention, the interface between the rehabilitation process and traditional medical modes of intervention and evaluation of outcome.

A new diagnosis of asthma or COPD is linked to smoking cessation - the Tromsø study

Background

Patients with COPD have had a lower tendency to quit smoking compared to patients with coronary heart disease (CHD). We wanted to investigate if this is still true in a Norwegian population.

Methods

Our data came from the fifth and sixth Tromsø surveys, which took place in 2001–2002 and 2007–2008. The predictors of smoking cessation were evaluated in a cohort of 4,497 participants who had stated their smoking status in both surveys.

Results

Of the 4,497 subjects in the cohort, 1,150 (25.6%) reported daily smoking in Tromsø 5. In Tromsø 6, 428 had quit (37.2%). A new diagnosis of obstructive lung disease (asthma or COPD) and CHD were both associated with increased quitting rates, 50.6% (P=0.01) and 52.1% (P=0.02), respectively. In multivariable logistic regression analysis with smoking cessation as outcome, the odds ratios (ORs) of a new diagnosis of obstructive lung disease and of CHD were 1.7 (1.1–2.7) and 1.7 (1.0–2.9), respectively. Male sex had an OR of 1.4 (1.1–1.8) compared to women in the multivariable model, whereas the ORs of an educational length of 13–16 years and ≥17 years compared to shorter education were 1.6 (1.1–2.2) and 2.5 (1.5–4.1), respectively.

Conclusion

The general trend of smoking cessation in the population was confirmed. Increased rates of smoking cessation were associated with a new diagnosis of heart or lung disease, and obstructive lung disease was just as strongly linked to smoking cessation as was CHD. This should encourage the pursuit of early diagnosis of COPD.

Effects of smoking and smoking cessation on human serum metabolite profile: results from the KORA cohort study

BACKGROUND

Metabolomics helps to identify links between environmental exposures and intermediate biomarkers of disturbed pathways. We previously reported variations in phosphatidylcholines in male smokers compared with non-smokers in a cross-sectional pilot study with a small sample size, but knowledge of the reversibility of smoking effects on metabolite profiles is limited. Here, we extend our metabolomics study with a large prospective study including female smokers and quitters.

METHODS

Using targeted metabolomics approach, we quantified 140 metabolite concentrations for 1,241 fasting serum samples in the population-based Cooperative Health Research in the Region of Augsburg (KORA) human cohort at two time points: baseline survey conducted between 1999 and 2001 and follow-up after seven years. Metabolite profiles were compared among groups of current smokers, former smokers and never smokers, and were further assessed for their reversibility after smoking cessation. Changes in metabolite concentrations from baseline to the follow-up were investigated in a longitudinal analysis comparing current smokers, never smokers and smoking quitters, who were current smokers at baseline but former smokers by the time of follow-up. In addition, we constructed protein-metabolite networks with smoking-related genes and metabolites.

RESULTS

We identified 21 smoking-related metabolites in the baseline investigation (18 in men and six in women, with three overlaps) enriched in amino acid and lipid pathways, which were significantly different between current smokers and never smokers. Moreover, 19 out of the 21 metabolites were found to be reversible in former smokers. In the follow-up study, 13 reversible metabolites in men were measured, of which 10 were confirmed to be reversible in male quitters. Protein-metabolite networks are proposed to explain the consistent reversibility of smoking effects on metabolites.

CONCLUSIONS

We showed that smoking-related changes in human serum metabolites are reversible after smoking cessation, consistent with the known cardiovascular risk reduction. The metabolites identified may serve as potential biomarkers to evaluate the status of smoking cessation and characterize smoking-related diseases.

WITHDRAWN: Smoking cessation for the secondary prevention of coronary heart disease

BACKGROUND

Although the importance of smoking as a risk factor for coronary heart disease is beyond doubt, the speed and magnitude of risk reduction when a smoker with coronary heart disease quits are still subjects of debate.

OBJECTIVES

To estimate the magnitude of risk reduction when a patient with CHD stops smoking.

SEARCH METHODS

We searched the Cochrane Register of Controlled Trials (CENTRAL) , MEDLINE, EMBASE, Science Citation Index, CINAHL, PsychLit, Dissertation Abstracts, BIDS ISI Index to Scientific and Technical Proceedings, UK National Research Register from the start of each database. Sixty-one large international cohort studies of cardiovascular disease were identified, and contact made with authors to search for any unpublished results. The search was supplemented by cross-checking references and contact with various experts. Date of last search was April 2003.

SELECTION CRITERIA

Any prospective cohort studies of patients with a diagnosis of CHD, which include all-cause mortality as an outcome measure. Smoking status must be measured on at least two occasions to ascertain which smokers have quit, and followed-up for at least two years.

DATA COLLECTION AND ANALYSIS

Eligibility and trial quality were assessed independently by two reviewers.

MAIN RESULTS

Twenty studies were included. There was a 36% reduction in crude relative risk (RR) of mortality for those who quit smoking compared with those who continued to smoke (RR 0.64, 95% confidence interval (CI) 0.58 to 0.71). There was also a reduction in non-fatal myocardial infarctions (crude RR 0.68, 95% CI 0.57 to 0.82). Many studies did not adequately address quality issues, such as control of confounding, and misclassification of smoking status. However, there was little difference in the results for the six 'higher quality' studies, and little heterogeneity between these studies. This review was not able to assess how quickly the risk of mortality was reduced.

AUTHORS' CONCLUSIONS

Quitting smoking is associated with a substantial reduction in risk of all-cause mortality among patients with CHD. The pooled crude RR was 0.64 (95% CI 0.58 to 0.71). This 36% risk reduction appears substantial compared with other secondary preventive therapies such as cholesterol lowering which have received greater attention in recent years. The risk reduction associated with quitting smoking seems consistent regardless of differences between the studies in terms of index cardiac events, age, sex, country, and time period. However, relatively few studies have included large numbers of older people, women, or people of non-European descent, and most were carried out in Western countries.

The effect of tobacco smoking and treatment strategy on the one-year mortality of patients with acute non-ST-segment elevation myocardial infarction

Background

The aim of the present study was to investigate whether a previously shown survival benefit resulting from routine early invasive management of unselected patients with acute non-ST-segment elevation myocardial infarction (NSTEMI) may differ according to smoking status and age.

Methods

Post-hoc analysis of a prospective observational cohort study of consecutive patients admitted for NSTEMI in 2003 (conservative strategy cohort [CS]; n = 185) and 2006 (invasive strategy cohort [IS]; n = 200). A strategy for transfer to a high-volume invasive center and routine early invasive management was implemented in 2005. Patients were subdivided into current smokers and non-smokers (including ex-smokers) on admission.

Results

The one-year mortality rate of smokers was reduced from 37% in the CS to 6% in the IS (p < 0.001), and from 30% to 23% for non-smokers (p = 0.18). Non-smokers were considerably older than smokers (median age 80 vs. 63 years, p < 0.001). The percentage of smokers who underwent revascularization (angioplasty or coronary artery bypass grafting) within 7 days increased from 9% in the CS to 53% in the IS (p < 0.001). The corresponding numbers for non-smokers were 5% and 27% (p < 0.001). There was no interaction between strategy and age (p = 0.25), as opposed to a significant interaction between strategy and smoking status (p = 0.024). Current smoking was an independent predictor of one-year mortality (hazard ratio 2.61, 95% confidence interval 1.43-4.79, p = 0.002).

Conclusions

The treatment effect of an early invasive strategy in unselected patients with NSTEMI was more pronounced among smokers than non-smokers. The benefit for smokers was not entirely explained by differences in baseline confounders, such as their younger age.

The potential association between smoking and endodontic disease

The aim of this review was to analyse the literature to assess the possibility of an association between smoking and endodontic disease and the prognosis of endodontically treated teeth. The review of the prognosis of endodontically treated teeth involved taking account of any potential associations with smoking and endodontic disease and marginal periodontitis, and smoking and prosthodontic outcomes. In addition, the role of smoking in implant failure and surgical wound healing was analysed with a view to drawing parallels regarding the possible implications of smoking on the outcome of surgical endodontics. A MEDLINE and Cochrane library search including smoking and various endodontic keyword searches identified three papers which discussed the variables, and did not just mention them separately in the text. The literature demonstrates a paucity of evidence relating smoking with endodontic disease and prognosis, but nevertheless presents evidence of a possible influence on the prognosis of endodontically treated teeth in smokers and a likely increase in surgical complications. The possible merits of a smoking cessation protocol prior to surgical endodontics are also discussed.

Efficacy of psychosocial interventions for smoking cessation in patients with coronary heart disease: a systematic review and meta-analysis

BACKGROUND

Quitting smoking improves prognosis after a cardiac event. Therefore smoking cessation is highly recommended for patients with coronary heart disease (CHD), but many patients continue to smoke, and improved cessation aids are urgently required.

PURPOSE

The objective was to conduct a systematic review of the efficacy of psychosocial interventions to quit smoking in patients with CHD.

METHODS

Seven electronic databases were searched from the start of the database to August 2003. Search terms were coronary or cardio or heart or cvd or chd and smok* and cessation or absti*. Results were supplemented by cross-checking references. More than 2,000 papers were screened in a first step. Eligibility of studies was assessed (by reviewer Jürgen Barth) and reasons for exclusion were coded. Abstinence rates were computed both according to an intention to treat analysis, and based on follow-up results only.

RESULTS

We found 19 randomized controlled trials, comparing a specific psychosocial intervention with "usual care," with a minimum of 6-month follow-up. Interventions consist of behavioral therapeutic approaches, telephone support, and self-help material. The trials mostly included older male patients with CHD, predominantly myocardial infarction. Overall results found a positive effect of interventions on abstinence after 6 to 12 months (OR = 1.66, 95% CI = 1.24-2.21), but substantial heterogeneity between trials. Clustering the trials by type of intervention reduced heterogeneity, although many trials used more than one type of intervention. Trials involving behavioral therapies or telephone contact were little different from self-help techniques (OR = 1.65, 95% CI = 1.28-2.13 for behavioral therapies; OR = 1.58, 95% CI = 1.26-1.98 for telephone support; OR = 1.47, 95% CI = 1.10-1.97 for self-help). Treatment intensity was associated with study outcome. More intense interventions showed increased quit rates (OR = 1.95, 95% CI = 1.61-2.35) whereas interventions of low intensity did not appear effective (OR = 0.92, 95% CI = 0.70-1.22). Studies with validated assessment of smoking status at follow-up had lower efficacy than nonvalidated trials.

CONCLUSIONS

Smoking cessation interventions are effective in promoting abstinence up to 1 year, provided they are of sufficient intensity with a minimum length of 1 month. Further studies should compare different psychosocial intervention strategies, or the combination of a psychosocial intervention strategy with nicotine replacement therapy or bupropion compared with nicotine replacement or bupropion alone.

Smokers are at markedly increased risk of appropriate defibrillator shocks in a primary prevention population

BACKGROUND

Cigarette smoking is a known risk factor for sudden cardiac death (SCD). It is unknown whether smoking status affects implantable cardioverter-defibrillator (ICD) therapy.

OBJECTIVE

The primary end point was appropriate ICD therapy according to smoking status.

METHODS

A total of 105 consecutive patients who underwent ICD implantation for primary prevention of SCD were retrospectively analyzed. All patients had an abnormal response to programmed ventricular stimulation performed for nonsustained ventricular tachycardia in the setting of ischemic cardiomyopathy between January 1999 and December 2003.

RESULTS

Among the 105 patients, 6 (37.5%) of 16 current smokers, 14 (25.9%) of 54 former smokers, and 2 (5.7%) of 35 of never smokers received an appropriate ICD therapy (P = .02). Kaplan-Meier analysis for survival free of appropriate ICD therapy comparing never smokers with both current smokers (P = .002) and former smokers (P = .01) demonstrated statistically significant differences by log rank over a mean follow-up of 21.8 +/- 13.7 months. Cox regression analysis found that current smoking was associated with an increased risk of appropriate therapy (hazard ratio 7.36; 95% confidence interval 1.42-38.10; P = .02) as was former smoking (hazard ratio 5.42; 95% confidence interval 1.20-24.47; P = .03). There was no difference in inappropriate therapy between groups (P = .12).

CONCLUSIONS

Cigarette smoking is an independent predictor of appropriate ICD therapy in a primary prevention population. While outcomes differences among current smokers, former smokers, and never smokers are demonstrable, the effect of smoking cessation on ICD therapy requires further study.

Smoking cessation and cardiovascular disease risk factors: results from the Third National Health and Nutrition Examination Survey

BACKGROUND

Cigarette smoking is a major risk factor for the development and progression of cardiovascular disease. While smoking is associated with increased levels of inflammatory markers and accelerated atherosclerosis, few studies have examined the impact of smoking cessation on levels of inflammatory markers. The degree and rate at which inflammation subsides after smoking cessation are uncertain. It also remains unclear as to whether traditional risk factors can adequately explain the observed decline in cardiovascular risk following smoking cessation.

METHODS AND FINDINGS

Using data from 15,489 individuals who participated in the Third National Health and Nutrition Examination Survey (NHANES III), we analyzed the association between smoking and smoking cessation on levels of inflammatory markers and traditional cardiovascular risk factors. In particular, we examined changes in C-reactive protein, white blood cell count, albumin, and fibrinogen. Inflammatory markers demonstrated a dose-dependent and temporal relationship to smoking and smoking cessation. Both inflammatory and traditional risk factors improved with decreased intensity of smoking. With increased time since smoking cessation, inflammatory markers resolved more slowly than traditional cardiovascular risk factors.

CONCLUSION

Inflammatory markers may be more accurate indicators of atherosclerotic disease. Inflammatory markers returned to baseline levels 5 y after smoking cessation, consistent with the time frame associated with cardiovascular risk reduction observed in both the MONICA and Northwick Park Heart studies. Our results suggest that the inflammatory component of cardiovascular disease resulting from smoking is reversible with reduced tobacco exposure and smoking cessation.

Impact of Smoking Status on Long-Term Mortality in Patients With Acute Myocardial Infarction

BACKGROUND

Cessation of smoking after a cardiovascular event has been shown in Western countries to have a beneficial effect on clinical events during long-term follow-up. However, knowledge of the effect of smoking status after acute myocardial infarction (AMI) on the long-term mortality based on a large-scale sample is still limited in Japan.

METHODS AND RESULTS

In the present study 2,579 AMI patients were enrolled in the Osaka Acute Coronary Insufficiency Study (OACIS) between April 1998 and March 2003. Smoking status was assessed at baseline and 3 months after hospital discharge by mailed questionnaire. Patients were divided into nonsmokers (n=823), former smokers (those who had stopped smoking before AMI onset, n=332), quitters (those who stopped smoking after AMI onset, n=1,056), and persistent smokers (those who smoked before and after AMI, n=368). Quitters had lower long-term mortality rates than persistent smokers (3.0% vs 5.2%; log rank, p=0.032). Multivariate Cox regression analysis revealed that smoking cessation was independently associated with a reduction in risk of long-term mortality (hazard ratio, 0.39; 95% confidence interval, 0.20-0.77).

CONCLUSIONS

Patients who continue to smoke after AMI are at greater risk for death than patients who quit smoking. Cessation of smoking benefits the long-term prognosis in patients with AMI.

The Relative Impact of Inadequate Primary and Secondary Prevention on Cardiovascular Mortality in the United States

BACKGROUND AND PURPOSE

We developed a model to estimate the costs incurred by ineffective primary and secondary prevention in terms of excess cardiovascular disease (CVD) mortality in a nationally representative sample of the US population.

METHODS

Cox proportional hazards analyses were used to examine the effect of inadequate risk factor control on the incidence of fatal stroke and myocardial infarction (MI) during a follow-up period of 13.4+/-3.6 years after adjusting for differences in age, gender, and ethnicity in a national cohort of 9252 adults who participated in the Second National Health and Nutrition Examination Survey (NHANES) Mortality Follow-up Study. Inadequate risk factor modification was defined by presence of either blood pressure >140/90 mm Hg, serum cholesterol >200 mg/dL, or active cigarette smoking. Using the data from 4115 adults screened in the NHANES 1999 to 2000, population attributable risk (PAR) percent and associated cost incurred (expressed as proportion of total 1-year cost incurred for CVD mortality in year 2001) was estimated.

RESULTS

CVD mortality risk increased in a stepwise manner for persons with no previous MI or stroke and > or =2 inadequately controlled risk factors (2x); and previous history of MI and stroke and adequately controlled risk factors (2.6x), 1 inadequately controlled risk factor (4.3x), and > or =2 inadequately controlled risk factors (5.7x). The PAR was 14% (estimated cost incurred 13.2 billion dollars) among persons with > or =2 inadequately controlled risk factors without previous MI or stroke (estimated 17% of total US population). Among persons with previous MI or stroke, the PAR was 7% (cost incurred 6.2 billion dollars) and 8% (cost incurred 7.4 billion dollars) for 1 inadequately controlled risk factor and > or =2 inadequately controlled risk factors, respectively. An excess of cost of 13.6 billion dollars was spent on 4% of the total population (persons with inadequate secondary prevention).

CONCLUSIONS

The model demonstrates the differential risk of mortality from inadequately controlled cardiovascular risk factors in primary and secondary prevention settings. The large financial cost incurred by inadequate primary and secondary prevention justifies intensive efforts directed toward detection and treatment of cardiovascular risk factors.

Use of smoking cessation interventions and aspirin for secondary prevention: are there racial disparities?

We examined whether racial differences exist in the use of aspirin and smoking cessation interventions for secondary prevention in veterans with coronary artery disease (CAD). We enrolled a total of 1045 African-American and white patients with CAD at 5 Veterans Administration hospitals between 1999 and 2001. Data were obtained by chart review. Among current smokers, African-American and white patients were equally likely to receive smoking cessation interventions (55.8% versus 56.1%; P = .97). Similarly, among ideal candidates for aspirin therapy, there was no difference in overall treatment rates between the 2 groups (74.1% versus 73.4%; P = .85). However, in the subsets of ideal candidates with hypercholesterolemia and previous stroke, African-Americans were less likely than whites to receive aspirin (P < .05). In contrast, African-Americans with hypertension were more likely than whites to receive aspirin (P = .05). Our findings highlight the need for improvement in use of smoking cessation interventions and aspirin among all patients with CAD and indicate an area where future quality improvement efforts may be warranted.

Inpatient smoking-cessation counseling and all-cause mortality among the elderly

BACKGROUND

Although smoking cessation is essential to the management of acute myocardial infarction (AMI), prevalence and benefits of smoking-cessation counseling in the inpatient setting are not well described among older adults. The objective of this study was to evaluate associations between inpatient smoking-cessation counseling and 5-year all-cause mortality among older adults hospitalized with AMI.

METHODS

The Cooperative Cardiovascular Project (January 1994-July 1995) included 788 Medicare beneficiaries aged >/=65 years who were current smokers, admitted to acute care facilities in North Carolina with confirmed AMI, and discharged alive. Information on smoking-cessation advice or counseling prior to discharge was abstracted from medical records. Associations of counseling with 5-year risk of death were assessed with multivariate Cox proportional hazards regression.

RESULTS

Smoking-cessation counseling was provided to 40% of AMI patients before discharge. Women (p =0.06) and blacks (p =0.02) were less likely to receive counseling. Counseling was associated with a history of chronic obstructive pulmonary disease (p =0.01). Increasing age, discharge to a skilled nursing facility, and histories of hypertension, heart failure, or stroke were associated with no counseling (p <0.05, all cause). Age-adjusted mortality rates (per 1000 enrollees) at 5 years were 488.3 for patients who were given counseling compared to 579.3 for patients without counseling. After adjustment for age, race, gender, prior histories of hypertension, cardiovascular diseases, diabetes, and chronic obstructive pulmonary disease, Killip class III or IV, and discharge to a skilled nursing facility; inpatient counseling remained associated with improved survival (relative hazard, 0.78; 95% confidence interval, 0.63-0.97).

CONCLUSIONS

Inpatient counseling on smoking cessation is suboptimal among older smokers hospitalized with AMI. Even without confirmation of actual cessation, these data suggest that provision of smoking-cessation advice or counseling has a major impact on survival of older adults.

Smoking cessation for the secondary prevention of coronary heart disease

BACKGROUND

Although the importance of smoking as a risk factor for coronary heart disease is beyond doubt, the speed and magnitude of risk reduction when a smoker with coronary heart disease quits are still subjects of debate.

OBJECTIVES

To estimate the magnitude of risk reduction when a patient with CHD stops smoking.

SEARCH STRATEGY

We searched the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Science Citation Index, CINAHL, PsychLit, Dissertation Abstracts, BIDS ISI Index to Scientific and Technical Proceedings, UK National Research Register from the start of each database. Sixty-one large international cohort studies of cardiovascular disease were identified, and contact made with authors to search for any unpublished results. The search was supplemented by cross-checking references and contact with various experts. Date of last search was April 2003.

SELECTION CRITERIA

Any prospective cohort studies of patients with a diagnosis of CHD, which include all-cause mortality as an outcome measure. Smoking status must be measured on at least two occasions to ascertain which smokers have quit, and followed-up for at least two years.

DATA COLLECTION AND ANALYSIS

Eligibility and trial quality were assessed independently by two reviewers.

MAIN RESULTS

Twenty studies were included. There was a 36% reduction in crude relative risk (RR) of mortality for those who quit smoking compared with those who continued to smoke (RR 0.64, 95% confidence interval 0.58 to 0.71). There was also a reduction in non-fatal myocardial infarctions (crude RR 0.68, 95% confidence interval 0.57 to 0.82). Many studies did not adequately address quality issues, such as control of confounding, and misclassification of smoking status. However, there was little difference in the results for the six 'higher quality' studies, and little heterogeneity between these studies. This review was not able to assess how quickly the risk of mortality was reduced.

REVIEWER'S CONCLUSIONS

Quitting smoking is associated with a substantial reduction in risk of all-cause mortality among patients with CHD. The pooled crude RR was 0.64 (95% CI 0.58 to 0.71). This 36% risk reduction appears substantial compared with other secondary preventive therapies such as cholesterol lowering which have received greater attention in recent years. The risk reduction associated with quitting smoking seems consistent regardless of differences between the studies in terms of index cardiac events, age, sex, country, and time period. However, relatively few studies have included large numbers of older people, women, or people of non-European descent, and most were carried out in Western countries.

Home-based versus hospital-based cardiac rehabilitation after myocardial infarction or revascularisation: design and rationale of the Birmingham Rehabilitation Uptake Maximisation Study (BRUM): a randomised controlled trial [ISRCTN72884263]

BACKGROUND

Cardiac rehabilitation following myocardial infarction reduces subsequent mortality, but uptake and adherence to rehabilitation programmes remains poor, particularly among women, the elderly and ethnic minority groups. Evidence of the effectiveness of home-based cardiac rehabilitation remains limited. This trial evaluates the effectiveness and cost-effectiveness of home-based compared to hospital-based cardiac rehabilitation.

METHODS/DESIGN

A pragmatic randomised controlled trial of home-based compared with hospital-based cardiac rehabilitation in four hospitals serving a multi-ethnic inner city population in the United Kingdom was designed. The home programme is nurse-facilitated, manual-based using the Heart Manual. The hospital programmes offer comprehensive cardiac rehabilitation in an out-patient setting.

PATIENTS

We will randomise 650 adult, English or Punjabi-speaking patients of low-medium risk following myocardial infarction, coronary angioplasty or coronary artery bypass graft who have been referred for cardiac rehabilitation.

MAIN OUTCOME MEASURES

Serum cholesterol, smoking cessation, blood pressure, Hospital Anxiety and Depression Score, distance walked on Shuttle walk-test measured at 6, 12 and 24 months. Adherence to the programmes will be estimated using patient self-reports of activity.In-depth interviews with non-attendees and non-adherers will ascertain patient views and the acceptability of the programmes and provide insights about non-attendance and aims to generate a theory of attendance at cardiac rehabilitation. The economic analysis will measure National Health Service costs using resource inputs. Patient costs will be established from the qualitative research, in particular how they affect adherence.

DISCUSSION

More data are needed on the role of home-based versus hospital-based cardiac rehabilitation for patients following myocardial infarction and revascularisation, which would be provided by the Birmingham Rehabilitation Uptake Maximisation Study (BRUM) study and has implications for the clinical management of these patients. A novel feature of this study is the inclusion of non-English Punjabi speakers.

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

CONTEXT

As more interventions become available for the treatment of coronary heart disease (CHD), policy makers and health practitioners need to understand the benefits of each intervention, to better determine where to focus resources. This is particularly true when a patient with CHD quits smoking.

OBJECTIVE

To conduct a systematic review to determine the magnitude of risk reduction achieved by smoking cessation in patients with CHD.

DATA SOURCES

Nine electronic databases were searched from start of database to April 2003, supplemented by cross-checking references, contact with experts, and with large international cohort studies (identified by the Prospective Studies Collaboration).

STUDY SELECTION

Prospective cohort studies of patients who were diagnosed with CHD were included if they reported all-cause mortality and had at least 2 years of follow-up. Smoking status had to be measured after CHD diagnosis to ascertain quitting.

DATA EXTRACTION

Two reviewers independently assessed studies to determine eligibility, quality assessment of studies, and results, and independently carried out data extraction using a prepiloted, standardized form.

DATA SYNTHESIS

From the literature search, 665 publications were screened and 20 studies were included. Results showed a 36% reduction in crude relative risk (RR) of mortality for patients with CHD who quit compared with those who continued smoking (RR, 0.64; 95% confidence interval [CI], 0.58-0.71). Results from individual studies did not vary greatly despite many differences in patient characteristics, such as age, sex, type of CHD, and the years in which studies took place. Adjusted risk estimates did not differ substantially from crude estimates. Many studies did not adequately address quality issues, such as control of confounding, and misclassification of smoking status. However, restriction to 6 higher-quality studies had little effect on the estimate (RR, 0.71; 95% CI, 0.65-0.77). Few studies included large numbers of elderly persons, women, ethnic minorities, or patients from developing countries.

CONCLUSIONS

Quitting smoking is associated with a substantial reduction in risk of all-cause mortality among patients with CHD. This risk reduction appears to be consistent regardless of age, sex, index cardiac event, country, and year of study commencement.

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.

Hospital- and clinic-based smoking cessation interventions for smokers with cardiovascular disease

Cigarette smoking is the leading preventable cause of death in the United States and a major risk factor for cardiovascular disease (CVD). Large observational epidemiologic studies conducted in diverse populations have demonstrated a strong association between smoking and CVD morbidity and mortality. Observational epidemiologic studies have also demonstrated a substantial benefit of smoking cessation on cardiovascular morbidity and mortality. Smoking cessation after myocardial infarction reduces subsequent cardiovascular mortality by nearly 50%. Therefore, the use of effective strategies to reduce the prevalence of tobacco use is a high priority for both the primary and secondary prevention of CVD. Effective smoking cessation interventions have been identified in randomized controlled trials in the general population of smokers. These methods, which include behavioral counseling and pharmacotherapy, are incorporated into clinical practice guidelines for physicians in the United States and Great Britain. A smaller but still substantial body of evidence demonstrates the efficacy of these interventions in hospital- and clinic-based settings for smokers with CVD. This evidence is sufficient to support the routine implementation of these smoking cessation methods in inpatient and outpatient settings for smokers with CVD.

[Smoking cessation and risk of myocardial reinfarction in coronary patients: a nested case-control study]

INTRODUCTION AND OBJECTIVES

Smoking cessation reduces mortality in coronary patients. The aim of this study was to estimate association measures between the risk of occurrence of fatal or non-fatal reinfarction in patients who either continue to smoke or stop after a first infarction and are treated with secondary prevention measures.

PATIENTS AND METHOD

The study was a case-control (1:1) design nested in a cohort of 985 coronary patients under the age of 76 years who were not treated with invasive procedures and survived more than 6 months after the first acute myocardial infarction. Cases were all patients who suffered reinfarction (n = 137) between 1997 and 2000. A control patient was matched with each case by gender, age, hospital, interviewer, and the secondary prevention timeframe.

RESULTS

Patients who smoke after the first acute myocardial infarction had an Odds ratio (OR) of 2.83 (95% CI, 1.47-5.47) for a new acute myocardial infarction. Adjustment for lifestyle, drug treatment, and risk factors (family history of coronary disease, high blood pressure, hypercholesterolemia, and diabetes mellitus) did not change the OR (2.80 [95% CI, 1.35-5.80]). Patients who quit smoking had an adjusted OR of 0.90 (95% CI, 0.47-1.71) compared with non-smokers before the first acute myocardial infarction. Continued smoking had an adjusted OR of 2.90 (95% CI, 1.35-6.20) compared to quitting after the first acute myocardial infarction.

CONCLUSION

The risk of acute myocardial infarctions is three times higher in patients who continue to smoke after an acute coronary event compared with patients who quit. The risk of reinfarction in patients who stop smoking is similar to the risk of non-smokers before the first infarction.

Smoking and endothelial function

The arterial endothelium is a vital homeostatic cell layer responsible for a variety of functions such as thromboresistance, control of vessel tone, and vessel growth. Recent evidence has indicated that both active and passive cigarette smoking are associated with dysfunction of normal endothelial physiology, in a dose dependent and potentially reversible way. Endothelial abnormalities may predispose to the atherogenic and thrombotic problems associated with cigarette smoking.

Smoking cessation for the secondary prevention of coronary heart disease

BACKGROUND

Although the importance of smoking as a risk factor for coronary heart disease is beyond doubt, the speed and magnitude of risk reduction when a smoker with coronary heart disease quits are still subjects of debate.

OBJECTIVES

To estimate the magnitude of risk reduction when a patient with CHD stops smoking.

SEARCH STRATEGY

We searched the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Science Citation Index, CINAHL, PsychLit, Dissertation Abstracts, BIDS ISI Index to Scientific and Technical Proceedings, UK National Research Register from the start of each database. Sixty-one large international cohort studies of cardiovascular disease were identified, and contact made with authors to search for any unpublished results. The search was supplemented by cross-checking references and contact with various experts. Date of last search was April 2003.

SELECTION CRITERIA

Any prospective cohort studies of patients with a diagnosis of CHD, which include all-cause mortality as an outcome measure. Smoking status must be measured on at least two occasions to ascertain which smokers have quit, and followed-up for at least two years.

DATA COLLECTION AND ANALYSIS

Eligibility and trial quality were assessed independently by two reviewers.

MAIN RESULTS

Twenty studies were included. There was a 36% reduction in crude relative risk (RR) of mortality for those who quit smoking compared with those who continued to smoke (RR 0.64, 95% confidence interval 0.58 to 0.71). There was also a reduction in non-fatal myocardial infarctions (crude RR 0.68, 95% confidence interval 0.57 to 0.82). Many studies did not adequately address quality issues, such as control of confounding, and misclassification of smoking status. However, there was little difference in the results for the six 'higher quality' studies, and little heterogeneity between these studies. This review was not able to assess how quickly the risk of mortality was reduced.

REVIEWER'S CONCLUSIONS

Quitting smoking is associated with a substantial reduction in risk of all-cause mortality among patients with CHD. The pooled crude RR was 0.64 (95% CI 0.58 to 0.71). This 36% risk reduction appears substantial compared with other secondary preventive therapies such as cholesterol lowering which have received greater attention in recent years. The risk reduction associated with quitting smoking seems consistent regardless of differences between the studies in terms of index cardiac events, age, sex, country, and time period. However, relatively few studies have included large numbers of older people, women, or people of non-European descent, and most were carried out in Western countries.

Smoking behaviour of patients undergoing cardiac surgery

OBJECTIVES

Investigate smoking behaviour and opinions on tobacco use in patients undergoing cardiac surgery.

METHODS

In this descriptive study, 200 patients were preoperatively asked to complete a questionnaire on their 'smoking habits'. Smoking behaviour, smoking cessation, tobacco and health, smoking in hospital and smoking after the operation were the main subjects. Eighty percent of the questionnaires (161 patients) could be used in the study. The total group was divided into three groups: group A: patients smoking at the moment of hospitalisation, group B: patients who had stopped smoking and group C: patients who had never smoked.

RESULTS

There is a difference in the answers between the three groups. For most patients the relation between tobacco use and cardiovascular disease is not clear; there is obviously an information gap. More than 50% of the patients do not agree with smoking in hospital, not even in 'smokers rooms'. Most patients have the intention of stopping smoking after their heart operation. This is an individual decision and support seems minimal.

CONCLUSION

This study confirms that the relation between smoking and cardiovascular diseases is not clear for many cardiac patients. Hospitalisation can be a good moment for smoking cessation, but support is necessary.

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.

New recommendations from the 1999 American College of Cardiology/American Heart Association acute myocardial infarction guidelines

OBJECTIVE

To review literature relating to significant changes in drug therapy recommendations in the 1999 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for treating patients with acute myocardial infarction (AMI).

DATA SOURCES

1999 ACC/AHA AMI guidelines, English-language clinical trials, reviews, and editorials researching the role of drug therapy and primary angioplasty for AMI that were referenced in the guidelines were included. Additional data published in 2000 or unpublished were also included if relevant to interpretation of the guidelines.

STUDY SELECTION

The articles selected influence AMI treatment recommendations.

DATA SYNTHESIS

Many clinicians and health systems use the ACC/AHA AMI guidelines to develop treatment plans for AMI patients. This review highlights important changes in AMI drug therapy recommendations by reviewing the results of recent clinical trials. Insights into evolving drug therapy strategies that may impact future guideline development are also described.

CONCLUSIONS

Several changes in drug therapy recommendations were included in the 1999 AMI ACC/AHA guidelines. There is emphasis on administering fibrin-specific thrombolytics secondary to enhanced efficacy. Selection between fibrin-specific agents is unclear at this time. Low response rates to thrombolytics have been noted in the elderly, women, patients with heart failure, and those showing left bundle-branch block on the electrocardiogram. These patient groups should be targeted for improved utilization programs. The use of glycoprotein (GP) IIb/IIIa receptor inhibitors in non-ST-segment elevation MI was emphasized. Small trials combining reduced doses of thrombolytics with GP IIb/IIIa receptor inhibitors have shown promise by increasing reperfusion rates without increasing bleeding risk, but firm conclusions cannot be made until the results of larger trials are known. Primary percutaneous coronary intervention (PCI) trials suggest lower mortality rates for primary PCI when compared with thrombolysis alone. However, primary PCI, including coronary angioplasty, is only available at approximately 13% of US hospitals, making thrombolysis the preferred strategy for most patients. Clopidogrel has supplanted ticlopidine as the recommended antiplatelet agent for patients with aspirin allergy or intolerance following reports of a better safety profile. The recommended dose of unfractionated heparin is lower than previously recommended, necessitating a separate nomogram for patients with acute coronary syndromes. Routine use of warfarin, either alone or in combination with aspirin, is not supported by clinical trials; however, warfarin remains a choice for antithrombotic therapy in patients intolerant to aspirin. Beta-adrenergic receptor blockers continue to be recommended, and emphasis is placed on improving rates of early administration (during hospitalization), even in patients with moderate left ventricular dysfunction. New recommendations for drug treatment of post-AMI patients with low high-density lipoprotein cholesterol and/or elevated triglycerides are included, with either niacin or gemfibrozil recommended as an option. Supplementary antioxidants are not recommended for either primary or secondary prevention of AMI, with new data demonstrating lack of efficacy vitamin E in primary prevention. Estrogen replacement therapy or hormonal replacement therapy should not be initiated solely for prevention of cardiovascular disease, but can be continued in cardiovascular patients already taking long-term therapy for other reasons. Bupropion has been added as a new treatment option for smoking cessation. As drug therapy continues to evolve in treating AMI, more frequent updates of therapy guidelines will be necessary.

Gender difference in the influence of smoking on arterial wall thickness

BACKGROUND

We hypothesized that arterial wall thickening, an early atherogenic alteration, might be associated with smoking differently according to gender, considering the cardiovascular protection of female sex hormones.

METHODS AND RESULTS

We measured ultrasonographically carotid and femoral intima-media thickness (IMT) in 194 men and 330 women without risk factors other than smoking. In men: (i) current smokers had greater carotid and femoral IMT (P<0.01, P<0.001) and former smokers had greater femoral IMT (P<0.01) than never smokers; (ii) in pooled never, current and former smokers carotid and femoral IMT correlated to current daily smoking (P<0.01) and lifelong smoking (P<0.001); and (iii) carotid and femoral IMT correlated to age in never smokers (P<0.001), current smokers (P<0.01, P<0.001) and former smokers (P<0.01), with greater slopes in current than in former smokers at carotid site (P<0.05) and in current than in never smokers at femoral site (P<0.05). In women: (i) IMT did not differ by smoking status; (ii) in pooled smokers and non smokers femoral IMT correlated to current daily smoking (P=0.01) and to lifelong smoking (P<0.01) with a lower slope than in men (P<0.001), while carotid IMT did not; and (iii) carotid and femoral IMT correlated to age in never smokers (P<0.001), current smokers (P<0.001, P<0.05) and former smokers (P<0.001, P<0.01) with no different slopes.

CONCLUSION

Smoking-related increase in IMT existed in men but not in women, suggesting a possible protection of female gender from early structural arterial alteration of smoking.

Mortality, mode of death and risk indicators for death during 5 years after coronary artery bypass grafting among patients with and without a history of diabetes mellitus

OBJECTIVE

To describe mortality, mode of death, risk indicators for death and symptoms of angina pectoris among survivors during 5 years after coronary artery bypass grafting (CABG) among patients with and without a history of diabetes mellitus.

METHODS

All patients in western Sweden who underwent CABG without concomitant valve surgery and who had no previous CABG between June 1988 and June 1991 were entered prospectively in this study. After 5 years, information on deaths that had occurred was obtained for the analysis.

RESULTS

In all, 1998 patients were included in the analysis; 242 (12%) had a history of diabetes. Among the non-diabetic patients, 5-year mortality was 12.5%; the corresponding relative risk for diabetic patients was 2.1 (95% confidence interval 1.6 to 2.9). A history of diabetes was an independent risk indicator of death; there was no significant interaction between any other risk indicator and diabetes. Independent risk indicators for death among diabetic patients were: current smoking, renal dysfunction and left ventricular ejection fraction < 0.40. Compared with non-diabetic patients, those with diabetes more frequently died in hospital, died a cardiac death, or had death associated with the development of acute myocardial infarction and with symptoms of congestive heart failure. Among survivors, diabetic patients tended to have more angina pectoris 5 years after CABG than did those without diabetes.

CONCLUSION

During a period of 5 years after CABG, diabetic patients had a mortality twice that of non-diabetic patients. The increased risk included death in hospital, cardiac death and death associated with development of acute myocardial infarction and with symptoms of congestive heart failure.

Risk factor modification through nonpharmacological interventions in patients with coronary heart disease

Coronary heart disease (CHD) is still the main cause of death in developed countries. Because of improved treatment, many patients survive the acute phase of a myocardial infarction, which makes secondary prevention of CHD of major importance. Most risk factors responsible for the development and progression of CHD are associated with behavior. Therefore, interventions aimed at behavior change may contribute to risk factor modification and secondary prevention of CHD. The effects of separate risk factor modification efforts by means of randomized, controlled clinical trials of nonpharmacological interventions in patients suffering from CHD are reviewed. Interventions aimed at healthy lifestyles may stimulate smoking cessation rates, reduce elevated serum total and low-density lipoprotein (LDL)-cholesterol concentrations, and favorably modify type A behavior in CHD patients. Moreover, reduction of coronary atherosclerosis has been reported after intensive lifestyle and exercise interventions, whereas exercise and type A interventions may also lead to reduced CHD morbidity and mortality. As for hypertension and obesity, studies aimed at secondary prevention are lacking.

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.

Five-year mortality in patients with acute chest pain in relation to smoking habits

BACKGROUND

Smoking is one of the major risk indicators for development of coronary artery disease, and smokers develop acute myocardial infarction (AMI) approximately a decade earlier than nonsmokers. In smokers with established coronary artery disease, quitting smoking has been associated with a more favorable prognosis. However, most of these studies comprised younger patients, the majority of whom were males.

HYPOTHESIS

The purpose of the study was to determine mortality, mode of death, and risk indicators of death in relation to smoking habits among consecutive patients admitted to the emergency department with acute chest pain.

METHODS

In all, 4,553 patients admitted with acute chest pain to the emergency department at Sahlgrenska University Hospital during a period of 21 months were included in the analyses and were prospectively followed for 5 years.

RESULTS

Of these patients, 36% admitted current smoking. They were younger and had a lower prevalence of previous cardiovascular diseases than did nonsmokers. The 5-year mortality was 19.4% among smokers and 24.9% among non-smokers (p < 0.0001). However, when adjusting for difference in age, smoking was associated with an increased risk [relative risk (RR) 1.51; 95% confidence interval (CI) 1.32-1.74; p < 0.0001]. Among patients presenting originally with chest pain, the increased mortality for smokers was more pronounced in patients with non-acute than acute myocardial infarction (AMI). Among patients who died, death in smokers was less frequently associated with new-onset myocardial infarction (MI) and congestive heart failure. Among those who smoked at onset of symptoms and were alive 1 year later, 25% had stopped smoking. Patients with a confirmed AMI who continued smoking 1 year after onset of symptoms had a higher mortality (28.4%) during the subsequent 4 years than patients who stopped smoking (15.2%; p = 0.049).

CONCLUSION

In consecutive patients admitted to the emergency department with acute chest pain, current smoking was significantly associated with an increased risk of death during 5 years of follow-up. Among patients who died, death in smokers was less frequently associated with new-onset MI and congestive heart failure than was death in nonsmokers.

[Ambulatory cardiac phase II rehabilitation--"the Cologne model"--including 3-year-outcome after termination of rehabilitation]

From January 1992 until December 1994 the Cologne model of ambulant cardiac rehabilitation (ACR) in the greater area of Cologne, Germany, was performed and is still in progress. In Germany until 1992 the cardiac rehabilitation was exclusively performed stationary. The objective of the "Cologne model" was to evaluate, whether the transfer of the stationary cardiac rehabilitation programs into the ambulatory setting is achievable without deficits in efficiency, safety and overall quality. The results obtained are intended to serve for standardization and quality control of future ambulatory cardiac rehabilitation programs in Germany. From 1992 to 1994 108 patients (94 men, 14 women; 52.3 +/- 8.0 years old) with coronary artery disease (CAD) which were compatible with the criteria of the "Cologne model" (Table 1) participated in the 4-week ACR. The indications for inclusion into the ACR were in 74 cases a myocardial infarction (MI), in 34 cases CAD without MI, but with PTCA/stent-procedure (Table 3). Seven patients discontinued the ACR prematurely, 2 patients because of cardiovascular reasons. Reasons for the preference of the ambulatory over a stationary cardiac rehabilitation program were in 40.6% of the patients refusal of "hospital ambience", in 43.6% familiar or in 12.9% professional reasons. During the 4-week ACR patients participated in a mean of 72.9 +/- 6.7 hours of therapy (Table 4). As a result of the ACR exercise tolerance increased highly significantly (**) from 116.4 +/- 28.8 to 129.9 +/- 34.6 watt). This improvement was maintained at the 1- and 3-year control (128.7 +/- 35.8**) examinations (Tables 5 and 7). One year after ACR 77% of the patients stated to be physically active in ambulatory heart groups (AHG) (27.6%) or on their own (49.4%). Three years after ACR the rate of regularly physically active patients still was 59.2%. Furthermore, as a result of ACR the dietary behavior was changed significantly. There was a reduction in the consumption of lipids by 20.8%, saturated fatty acids by 30.7% and of cholesterol by 30.5%. The plasma concentrations of cholesterol decreased from 231 +/- 49.8 to 213.2 +/- 35.9 mg%**. Six (and 12) months after ACR they increased again to 225.6 +/- 39.4 mg%. Three years after ACR the mean cholesterol level was 219.1 +/- 39.3 mg%. In the high risk group (cholesterol at the initial visit > 220 mg%) cholesterol levels were reduced from 266 +/- 44 to 232 +/- 31.9 mg%**. Six and 12 months after ACR they were 239.7 +/- 35.8 mg% and 245.8 +/- 32.6 mg%, respectively, (Tables 6 and 7) and still significantly lower than before ACR, though only 19% of the patients were treated with lipid lowering agents. Three years after ACR cholesterol were 234.6 +/- 37.7 mg%** in the high-risk group. 34.2% of the patients received lipid lowering agents. Mean body weight remained unaltered over the 3-year period. Smoking behavior was not altered significantly during the 4-week ACR. However, before the cardiovascular event 67.3% of the patients had smoked cigarettes. At the beginning and at the end of ACR 20.8% of the patients still smoked. During the ACR the number of smoked cigarettes was reduced significantly from 32.4 +/- 15.2 to 6.9 +/- 5.2 cigarettes per day. One year after ACR 23% of the patients were smokers, 3 years after ACR the percentage of smokers increased to 30.3%. Before ACR 73.3% of the patients were still working. During the first 6 months after ACR 68.2% returned to work and the percentage increased to 73% in the following 6 months. The results demonstrate that it is achievable to transfer the contents of the established stationary cardiac rehabilitation programs into the ambulatory setting without loss of efficiency, safety and overall quality. It is further confirmed, that it is necessary to continuously evaluate the results of the cardiac rehabilitation program on a long-term basis. (ABSTRACT TRUNCATED)

Evaluation of a nurse-delivered smoking cessation intervention for hospitalized patients with cardiac disease

OBJECTIVE

To determine the effect of a nurse-delivered smoking cessation intervention for hospitalized smokers on smoking cessation rates and smoking cessation self-efficacy at 6 months after enrollment.

DESIGN

A quasi-experimental design was used; specifically, a nonequivalent control group design was implemented.

SETTING

A 450-bed major teaching and research tertiary care hospital, serving patients from across the province of British Columbia, Canada.

SUBJECTS

Smokers with a cardiac diagnosis (n = 102) who were admitted to 1 of 2 inpatient cardiac units for medical or surgical treatment.

OUTCOME MEASURES

Self-reported smoking status and self-reported smoking cessation self-efficacy.

INTERVENTION

Two structured, in-hospital contacts, followed by 3 months of telephone support. The interventions focused on problem-solving and reinforcing the patient's self-efficacy.

RESULTS

Of the patients enrolled, 86 completed 6-month follow-up questionnaires. When subjects who were lost to follow-up were assumed to be smokers, 46% of the intervention group, compared with 31% of the control group, were nonsmokers. When key variables were controlled, we found that those subjects in the control group were 3 times more likely to relapse and begin smoking than those who received the intervention. There were no significant differences in follow-up smoking cessation self-efficacy scores in the treatment and control groups. When background variables were controlled, self-efficacy related to positive/social situations and habit/addictive situations were noted to be significantly higher in the intervention group.

CONCLUSION

The findings of this research are encouraging; they suggest that a nurse-delivered smoking cessation intervention improved the smoking cessation rate in patients with cardiac disease.

Natural history of myocardial infarction and angina pectoris in a general population sample of middle-aged men: a 16-year follow-up of the Primary Prevention Study, Göteborg, Sweden

OBJECTIVES

Although many studies have described prognosis in patients with coronary heart disease (CHD), few have compared outcome in men with clinical evidence of CHD with healthy men from the general population over an extended follow-up. This study aimed to compare long-term prognosis in men with a history of myocardial infarction (MI) and in men with angina pectoris (AP) without MI, with men without clinical signs of CHD.

DESIGN

Longitudinal general population study.

SETTING

City of Göteborg, Sweden.

SUBJECTS

From a general population sample, 195 men who had survived an MI for 0-19 years (median 3 years) and 314 men with AP but no MI (uncomplicated AP) at baseline in 1974-77 were identified and compared with 6591 men without clinical coronary disease. All were aged 51-59 years. Incident non-fatal and fatal cases occurring until the beginning of 1983 were also followed (n = 317).

MAIN OUTCOME MEASURES

Death from CHD, from other causes and from all causes during a follow-up of at least 16 years.

RESULTS

Overall survival was 72% amongst men without coronary disease, 53% amongst men with uncomplicated AP and 34% amongst men with past MI at baseline. In survivors of MI the risk-factor-adjusted relative risk (RR) of coronary death during follow-up was 6.67 (95% confidence interval (CI) 5.29-8.39), of dying from non-cardiovascular causes 1.35 (0.96-1.91), and of dying from any cause 3.20 (2.67-3.83). During the first 4 years after the baseline examination, the adjusted RR of CHD death was 15.96 (10. 29-24.74), and of dying from any cause 5.22 (3.68-7.41). During the last 4 years of follow-up, relative risk was still 5.87 (3.44-10.01) for CHD death and 2.93 (2.05-4.18) for death from any cause. In men with uncomplicated AP, the adjusted relative risk of CHD death during the first 4 years was 4.05 (2.27-7.22) and 3.23 (2.10-4.96) during the last 4-year period. After the first year, the incident MI cases had the same average annual mortality (about 5%) as the prevalent cases.

CONCLUSIONS

In survivors of MI, mortality risk remained high even after an extended follow-up. Men with angina had a better prognosis, but still a compromised survival compared with the general population.

Risk indicators for recurrence among patients with coronary artery disease. Problems associated with their modification

Various risk indicators associated with recurrence of a new ischemic event among patients with coronary artery disease are described and the impact of the implementation of a secondary preventive program on such risk indicators is evaluated. At Sahlgrenska Hospital in Göteborg 293 consecutive patients under the age of 70 years were followed for one to two years after an acute myocardial infarction (AMI), coronary artery bypass grafting (CABG), or percutaneous transluminal coronary angioplasty (PTCA). Enrollment and follow-up began after institution of a secondary preventive program among physicians and nurses at the hospital. A secondary preventive nurse was appointed and guidelines for risk factor modification were provided. The lipid guidelines were rather modest, with hyperlipidemia defined as cholesterol > 6.5 mmol/l or triglycerides > 3.0 mmol/l. The mean value for low density lipoprotein (LDL) cholesterol was 3.96 mmol/l at first screening and 3.94 mmol/l at second screening. Smoking was modestly reduced, from 36% at first screening to 26% at second screening (p < 0.01) It was found that 70% of all the patients had one or more of the following risk indicators at the first screening: s-cholesterol > 6.5 mmol/l (30%), s-triglycerides > 3.0 mmol/l (19%), fasting blood glucose > 6.7 mmol/l (29%), systolic blood pressure > 160 mmHg (9%), diastolic blood pressure > 90 mmHg (8%) or smoking, compared with 67% one to two years later (p > 0.2). This is a clear demonstration of the difficulty in modifying risk indicators in patients, even with the aid of health-care professionals, in order to achieve risk-factor reduction in coronary artery disease.

A new model for risk stratification and delivery of cardiovascular rehabilitation services in the long-term clinical management of patients with coronary artery disease

This model for risk stratification includes variables that classify patients for Risk of Event similar to current models of risk stratification, as well as variables that stratify patients for Risk of Progression of Atherosclerosis by established risk factors. Categories of risk are established using accepted data from the literature for each risk factor that targets regression or plaque stabilization as the goal for Low Risk. A case-rate charging system and the proposed removal of time restrictions for length of cardiovascular rehabilitation fit neatly into the present climate for health care. Health maintenance organizations will be seeking programs that use similar models to address cost issues inherent in cardiovascular rehabilitation programs under current fee-for-service models. Improved outcomes will also be targets for these programs and case-management lends itself to disease management, thus, improved outcomes. Tracking outcomes becomes even more important to both the provider and the insurer because results drive referrals. Likewise, removal of the time restriction for cardiovascular rehabilitation allows programs to individualize care and to target risk factors that are not only most deleterious, but also where patients show readiness for change. The changing environment of health care virtually mandates change in cardiovascular rehabilitation. It is imperative that programs manage the disease process, are effective in achieving outcomes that affect both patient function and the disease process, and are cost effective. This model for risk stratification and delivery of services addresses these requirements and provides a beginning for implementing these changes in cardiovascular rehabilitation.