Changes in personal characteristics of men, over five years, following first diagnosis of coronary heart disease

Smoking cessation following admission to a coronary care unit

OBJECTIVE

To determine the impact of an episode of serious cardiovascular disease on smoking behavior and to identify factors associated with smoking cessation in this setting.

DESIGN

Prospective observational study in which smokers admitted to a coronary care unit (CCU) were followed for one year after hospital discharge to determine subsequent smoking behavior.

SETTING

Coronary care unit of a teaching hospital.

PATIENTS

Preadmission smoking status was assessed in all 828 patients admitted to the CCU during one year. The 310 smokers surviving to hospital discharge were followed and their smoking behaviors assessed by self-report at six and 12 months.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Six months after discharge, 32% of survivors were not smoking; the rate of sustained cessation at one year was 25%. Smokers with a new diagnosis of coronary heart disease (CHD) made during hospitalization had the highest cessation rate (53% vs. 31%, p = 0.01). On multivariate analysis, smoking cessation was more likely if patients were discharged with a diagnosis of CHD, had no prior history of CHD, were lighter smokers (less than 1 pack/day), and had congestive heart failure during hospitalization. Among smokers admitted because of suspected myocardial infarction (MI), cessation was more likely if the diagnosis was CHD than if it was noncoronary (37% vs. 19%, p less than 0.05), but a diagnosis of MI led to no more smoking cessation than did coronary insufficiency.

CONCLUSION

Hospitalization in a CCU is a stimulus to long-term smoking cessation, especially for lighter smokers and those with a new diagnosis of CHD. Admission to a CCU may represent a time when smoking habits are particularly susceptible to intervention. Smoking cessation in this setting should improve patient outcomes because cessation reduces cardiovascular mortality, even when quitting occurs after the onset of CHD.

Late outcome of survivors of out-of-hospital cardiac arrest with left ventricular ejection fractions greater than or equal to 50% and without significant coronary arterial narrowing

In a retrospective survey of 1,195 survivors of out-of-hospital ventricular fibrillation, 43 patients were identified in whom left ventricular ejection fraction was greater than or equal to 0.50 and in whom no coronary artery stenosis of greater than or equal to 50% luminal diameter were present. Thirteen (30%) of these patients had hypokinesia on left ventriculography, and 20 patients (47%) had a persistently abnormal electrocardiogram. Seven patients (16%) had recurrent out-of-hospital cardiac arrest during an average follow-up of 86 +/- 54 months. The presence of either wall motion or electrocardiographic abnormalities defined patients with a several-fold higher risk of recurrent cardiac arrest than those without such abnormalities. The risk for recurrent cardiac arrest within 5 years was 30% in those with abnormal electrocardiograms versus 5% in the others (p less than 0.03). Age was an independent predictor of recurrent cardiac arrest in this group (p less than 0.01); surprisingly, recurrent cardiac arrest was occurring more often among younger patients. Although cardiac arrest is unusual in patients without major structural heart disease, its recurrence in such survivors is common. Patients at relatively high risk for recurrent ventricular fibrillation can be identified by their youth and by abnormalities detected on the surface 12-lead electrocardiogram or by contrast left ventriculography.

Use of health services after a myocardial infarction

Short-term and long-term use of physician consultations and rehospitalizations were studied in 383 myocardial infarction (MI) patients in relation to demographic, medical, and psychological factors. Short-term (i.e. within 6 months post-MI) utilization of physicians was only related to patients' health locus of control. In comparison, a higher number of physician consultations 3-5 years after the MI was independently related to female sex, more non-cardiac limitations before the MI, more complications during hospitalization, less cardiac lifestyle knowledge, and higher levels of anxiety and depression short time after the MI. Every second patient was readmitted to the hospital before the 3-5 years follow-up but only 14% suffered a non-fatal reinfarction. More rehospitalizations were independently related to a higher number of previous hospitalizations for heart disease, more pre-MI cardiac limitations, less cardiac lifestyle knowledge, and higher initial level of emotional distress. Discriminant analysis identified female sex and patients' initial expectations of reduced emotional control as the best predictor variables for a rehospitalization caused by chest pain without a new infarction, whereas a reinfarction was best discriminated by the number of previous hospitalizations for heart disease. We conclude that psychological factors influence health services utilization to a comparable extent as medical factors. These findings may indicate a greater need for long-term professional support in patients with less initial cognitive and emotional control.

Maintaining smoking abstinence after myocardial infarction

Maintaining smoking abstinence after a myocardial infarction (MI) greatly reduces risks of recurrent disease morbidity and of mortality. Although post-MI patients appear to have better long-term rates of smoking abstinence compared with healthy groups, studies employing biochemical verification of smoking status generally indicate that only about one third of previously smoking post-MI patients remain abstinent at follow-up. Factors which may accompany the occurrence of a MI and which may be associated with maintenance of smoking abstinence include environmental changes aiding cessation (e.g., decreased exposure to smoking cues), increased social support from family, and stronger belief in the harmful effects of continued smoking. The usefulness of these factors in developing new treatments for maintaining abstinence in post-MI patients is discussed, and commonalities between efforts to maintain smoking abstinence in post-MI patients and avoidance of substance abuse in other groups at risk for serious health consequences are briefly noted.

Smoking behavior among participants in the nurses' health study

We analyzed smoking behavior of 91,651 married female nurses, aged 30-55 years in 1976. The prevalence of smoking was similar among all birth cohorts. The largest percentage increase in starting to smoke occurred between ages 15 and 25 years; by age 25, 50 per cent had started smoking. The cessation rate was lowest in earlier birth cohorts and among nurses starting to smoke at earlier ages. The cessation rate increased substantially between 1963-73 compared with the period 1948-58.

Factors related to patient smoking status

To investigate those factors associated with patients' cigarette smoking status, 455 consecutive patients seen in two specialty clinics and one general medicine clinic at a university medical center were studied. Patient's age, sex, health status, and number of previous cessation attempts discriminated current from ex-smokers. A strong interaction was observed between sex and disease status with females showing a greater impact of smoking-related disease on smoking behavior than males.

Smoking behavior, cessation techniques, and the health decision model

The magnitude of the problem of smoking challenges health providers to persuade patients of the importance of trying to quit. Smoking behavior and cessation techniques are discussed in terms of the health decision model, a third-generation model combining health beliefs, decision analysis, and behavioral decision theory. This review suggests the need for physicians to emphasize factors such as health beliefs, self-efficacy, social support, and reduction of stress in smoking cessation efforts. Patients experiencing symptoms, particularly relating to the lungs or heart, may have stronger health beliefs and are clearly more likely to quit smoking. In the absence of a clear-cut advantage for any particular smoking cessation technique, physicians should provide advice about smoking as a regular part of every patient visit.

Variables related to long-term smoking status following cardiac events

Abstinence rates for smokers following a myocardial infarction (MI) or coronary by-pass surgery (CABG) are far superior to those for persons attending formal cessation programs. However, only two studies have used any biochemical verification of self-report in this population, and it is unclear what variables are associated with successful cessation post-MI or -CABG. The present study used alveolar carbon monoxide levels to verify self-report of post-MI and -CABG veterans and obtained only a 29% abstinence rate. Most abstinent veterans quit immediately after their first cardiac event, and only the belief that smoking contributed to their cardiac problems predicted long-term smoking status.

Factors which differentiate smokers from ex-smokers among cardiovascular patients: a discriminant analysis

A retrospective analysis of smoking behavior among hospitalized, cardiovascular patients was conducted in order to describe factors which differentiate smokers from ex-smokers. Ex-smokers were defined as smokers who abstained from smoking for at least 6 months prior to admission to the hospital. A multifactor model of variables related to smoking cessation was tested utilizing a survey instrument which measured health beliefs, health locus of control, a standardized measure of stress (habits of nervous tension), social supports and tendency to utilize social and over-the-counter medication. Social support for cessation measured as the degree of disapproval of smoking by the respondents social network and belief in susceptibility to the smoking--disease linkage were the factors which most highly differentiated smokers and ex-smokers among the respondents. The standardized measure of stress did not differentiate the groups. The efficacy of routine health counselling concerning negative effects of smoking by health professionals and the encouragement and structuring of social supports for smoking cessation among high risk populations should be further investigated as an alternative or adjunct to more elaborate and formal programs of smoking cessation.

Factors affecting cigarette smoking status in patients with ischemic heart disease

To determine the factors affecting cigarette smoking status after the development of ischemic heart disease, 200 patients were studied who were hospitalized with a coronary event and enrolled in a cardiac rehabilitation program. There were significantly more current smokers (55%) among the 96 patients hospitalized with an initial presentation of a coronary event as compared to the percent of current-smokers (34%) among the 104 patients hospitalized with a recurrent coronary event (p less than 0.01). In addition to the occurrence of a prior event, increasing age also significantly discriminated ex-cigarette smokers from current smokers. Among the patients with a recurrent event ex-smokers (44%) and current smokers (34%) differed significantly with respect to age, education, occupation, negative attitudes towards smoking and peak number of cigarettes smoked. Two models were developed which were able to correctly classify 61.7 and 69.1% of the patients with regard to smoking status.

Smoking cessation in a prospective study of healthy adult males: effects of age, time period, and amount smoked

The present study examined effects on smoking cessation of three variables-chronological age, time period, and amount smoked-in 637 healthy male smokers aged 22-69 at baseline. Subjects were followed from 1962-1975 using life table procedures. Age was not significantly related to quitting rates (p = .150). The amount smoked effect approached significance (p = .096) with rates of quitting progressively lower at higher consumption levels. Powerful time-period effects were found (p = .008). Incidence rates of quitting increased from 1962-1970, after which a marked decline occurred. (Am J Public Health 1983; 73:446-450.)

Relation of education to sudden death after myocardial infarction

We studied the influence of social and personal characteristics on prognosis among 1739 male survivors of myocardial infarction who had been monitored for one hour at a standard examination and subsequently followed for mortality. Over a three-year period men with little education (eight years of schooling or less) who had complex ventricular premature beats in the monitoring hour had over three times the risk of sudden coronary death found among better educated men with the same arrhythmia (cumulative mortality of 33 per cent and 9 per cent, respectively). No such differential appeared in the absence of complex ventricular premature beats. Neither risk factors for incidence of coronary heart disease nor clinical characteristics affecting prognosis accounted for the differences observed. There was no relation between education level and risk of recurrent infarction.

Health beliefs and smoking patterns in heart patients and their wives: a longitudinal study

Smoking patterns of 205 male patients were examined over a period of eight years after a primary myocardial infarction. Smoking data from their wives at one year after the heart attack were also examined. A marked, persistent reduction in smoking was found among the men. Smoking patterns of wives remained essentially unchanged. Smoking patterns before the heart attack were not related to demographic variables, except for the associated between smoker-nonsmoker status and social measures. Conceptions of susceptibility, threat, and power of prevention drawn from theoretical models on preventive health behavior were employed for analysis. High proportions of husbands and wives reported belief in smoking as important in the etiology of the heart attack, and in possibilities of prevention. Specific beliefs concerning threat, susceptibility, and prevention were not found to be related to the massive drop in smoking behavior among the men nor to stability in pattern among the wives. Alternative explanations are reviewed.

Repetitive health examinations as an intervention measure

A cohort of 107 men aged 51-53 years with borderline levels of blood pressure, serum cholesterol, or glucose tolerance was recruited from a general population in central Zagreb, Yugoslavia, and randomized into two groups; one was treated with drugs and the other observed in a similar fashion but not treated. Ninety-five men appeared regularly for the check-ups over a 2-year period. Levels of systolic blood pressure, cholesterol, and glucose showed a substantial decrease over a period of 2 years in both treated and control groups. The possible effect of repeated check-ups and their implications are discussed.

Ischaemic heart disease: a secondary prevention trial using clofibrate. Report by a research committee of the Scottish Society of Physicians

A trial is reported of the effects of giving clofibrate to prevent progression of pre-existing ischaemic heart disease. There were two groups randomly distributed between clofibrate (350 patients) and placebo (367 patients) regimens. The trial lasted about six years and was conducted in 19 hospitals in Scotland. The criteria of acceptance into the trial were precise and were monitored by one observer. The standards of diagnosis of events were defined and all protocols and electrocardiograms were read blind by one observer.THREE CATEGORIES OF PATIENTS WERE ADMISSIBLE TO THE TRIAL: (1) patients with one myocardial infarction (W.H.O. E.C.G. criteria) between 8 and 16 weeks before the start of the trial; (2) patients with angina of a duration of 3 to 24 months, provided their E.C.G. showed signs of myocardial ischaemia at rest or after exercise; and (3) patients with one recent myocardial infarction and pre-existing angina as defined above.There were fewer deaths in patients with angina (categories 2 and 3 above) treated with clofibrate than in those on placebo. The mortality in the former group was reduced by 62%, and this is a statistically significant difference. Clofibrate did not have any statistically significant effect in reducing the rate of non-fatal infarction in patients with angina or in those with myocardial infarction and pre-existing angina, though a beneficial trend was evident when both subgroups were combined (a 44% reduction compared with the placebo group). There was a significant reduction in all events (fatal and non-fatal) in patients with angina ("all anginas") in the clofibrate-treated group; the rate was reduced by 53%.Clofibrate did not alter the overall mortality or morbidity rates in patients admitted to the trial with recent myocardial infarction without preceding angina of more than three months' duration. In one subgroup there was a statistically significant adverse effect in the clofibrate-treated group. The lack of any overall effect in patients with myocardial infarction might be related to the unexpectedly low mortality rate (2.97%) in the placebo group; it is usually in the region of 4-9% per annum after first myocardial infarction.In patients categorized as "all anginas" there was significant reduction in events whether the initial serum cholesterol level was high (greater than 260 mg/100 ml) or normal. Clofibrate seemed to have a small but not significant beneficial effect in patients with myocardial infarction with initially high serum cholesterol levels, but was of no value in those with initially normal serum cholesterol levels. There was no significant relationship between the response or lack of response of serum cholesterol to clofibrate and the incidence of events either in patients with angina or in those with infarction.The main conclusion of this trial is that clofibrate had a beneficial effect in reducing mortality and, to a lesser extent, morbidity in patients who presented with angina ("all anginas"). This effect was independent of initial serum cholesterol levels or the extent to which serum cholesterol was lowered. The drug had no significant overall effect on prognosis in patients with myocardial infarction alone.