Author + information
- Received November 14, 2019
- Revision received January 23, 2020
- Accepted February 13, 2020
- Published online April 13, 2020.
- Björn Redfors, MD, PhDa,b,c,∗,
- Ariel Furer, MDa,d,e,∗,
- Harry P. Selker, MD, MSPHf,
- Holger Thiele, MDg,
- Manesh R. Patel, MDh,
- Shmuel Chen, MD, PhDa,b,
- James E. Udelson, MDi,
- E. Magnus Ohman, MDh,
- Ingo Eitel, MDj,k,
- Christopher B. Granger, MDh,
- Akiko Maehara, MDa,b,
- Ajay J. Kirtane, MD, SMa,b,
- Philippe Généreux, MDa,l,m,
- Paul L. Jenkins, PhDn,
- Ori Ben-Yehuda, MDa,b and
- Gregg W. Stone, MDa,o,∗ (, )@GreggWStone
- aClinical Trials Center, Cardiovascular Research Foundation, New York, New York
- bDepartment of Cardiology, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York
- cDepartment of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- dMedical Corps, Israel Defense Forces, Tel Hashomer, Israel
- eDepartment of Military Medicine, Hebrew University Hadassah School of Medicine, Jerusalem, Israel
- fInstitute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
- gHeart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
- hDivision of Cardiology, Duke University Medical Center, Durham, North Carolina
- iDivision of Cardiology, Tufts Medical Center, Boston, Massachusetts
- jUniversity Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Hospital Schleswig-Holstein, Lübeck, Germany
- kGerman Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Lübeck, Germany
- lGagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey
- mHôpital du Sacré-Coeur de Montréal, Montréal, Québec, Canada
- nMary Imogene Bassett Hospital, Cooperstown, New York
- oThe Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
- ↵∗Address for correspondence:
Dr. Gregg W. Stone, Mount Sinai Medical Center, Cardiovascular Research Foundation, 1700 Broadway, 9th Floor, New York, New York 10019.
Background Smoking is a well-established risk factor for ST-segment elevation myocardial infarction (STEMI); however, once STEMI occurs, smoking has been associated with favorable short-term outcomes, an observation termed the “smoker’s paradox.” It has been postulated that smoking might exert protective effects that could reduce infarct size, a strong independent predictor of worse outcomes after STEMI.
Objectives The purpose of this study was to determine the relationship among smoking, infarct size, microvascular obstruction (MVO), and adverse outcomes after STEMI.
Methods Individual patient-data were pooled from 10 randomized trials of patients with STEMI undergoing primary percutaneous coronary intervention. Infarct size was assessed at median 4 days by either cardiac magnetic resonance imaging or technetium-99m sestamibi single-photon emission computed tomography. Multivariable analysis was used to assess the relationship between smoking, infarct size, and the 1-year rates of death or heart failure (HF) hospitalization and reinfarction.
Results Among 2,564 patients with STEMI, 1,093 (42.6%) were recent smokers. Smokers were 10 years younger and had fewer comorbidities. Infarct size was similar in smokers and nonsmokers (adjusted difference: 0.0%; 95% confidence interval [CI]: −3.3% to 3.3%; p = 0.99). Nor was the extent of MVO different between smokers and nonsmokers. Smokers had lower crude 1-year rates of all-cause death (1.0% vs. 2.9%; p < 0.001) and death or HF hospitalization (3.3% vs. 5.1%; p = 0.009) with similar rates of reinfarction. After adjustment for age and other risk factors, smokers had a similar 1-year risk of death (adjusted hazard ratio [adjHR]: 0.92; 95% CI: 0.46 to 1.84) and higher risks of death or HF hospitalization (adjHR: 1.49; 95% CI: 1.09 to 2.02) as well as reinfarction (adjHR: 1.97; 95% CI: 1.17 to 3.33).
Conclusions In the present large-scale individual patient-data pooled analysis, recent smoking was unrelated to infarct size or MVO, but was associated with a worse prognosis after primary PCI in STEMI. The smoker’s paradox may be explained by the younger age and fewer cardiovascular risk factors in smokers compared with nonsmokers.
- infarct size
- percutaneous coronary intervention (PCI)
- ST-segment elevation myocardial infarction (STEMI)
↵∗ Drs. Redfors and Furer contributed equally to this work.
Dr. Patel has received grants from Bayer, Janssen, HeartFlow, and the National Heart, Lung, and Blood Institute; and has served as an advisor/consultant for AstraZeneca, Bayer, Janssen, and HeartFlow. Dr. Udelson has served on a trial steering committee for Abiomed; and has served as a consultant for Imbria Pharmaceuticals. Dr. Ohman has received research grants from Abiomed, Chiesi, and Portola; and has served as a consultant for Abiomed, Cara Therapeutics, Genentech, Imbria Pharmaceuticals, Impulse Dynamics, Janssen Pharmaceuticals, Medtronic, Medscape, Milestone Pharmaceuticals, and XyloCor Therapeutics. Dr. Granger has received research grants from AstraZeneca, the U.S. Food and Drug Administration, National Institutes of Health, GlaxoSmithKline, Medtronic, Novartis, Apple, Boehringer Ingelheim, Bristol-Myers Squibb/Pfizer, and Janssen; has served as a consultant for AstraZeneca, Espero, GlaxoSmithKline, Medtronic, Novartis, Boehringer Ingelheim, Boston Scientific, Bristol-Myers Squibb/Pfizer, Daiichi-Sankyo, Merck, Roche, Eli Lilly, The Medicines Company, and Janssen. Dr. Maehara has received grant support from and served as a consultant for Abbott Vascular and Boston Scientific; and has served as a consultant for Conavi Medical Inc. Dr. Kirtane has received institutional funding to Columbia University and/or Cardiovascular Research Foundation from Medtronic, Boston Scientific, Abbott Vascular, Abiomed, CSI, CathWorks, Siemens, Philips, and ReCor Medical. Dr, Généreux has received speaker fees from Abbott Vascular, Edwards Lifesciences, Medtronic, Tryton Medical Inc., Cardinal Health, and Cardiovascular Systems Inc.; has received consulting fees from Abbott Vascular, Boston Scientific, Cardiovascular Systems Inc., and Pi-Cardia; has received an institutional research grant from Boston Scientific; and has equity in SIG.NUM, SoundBite Medical Solutions Inc., Saranas, and Pi-Cardia. Dr. Stone has served as a consultant to Miracor, TherOx, and Abiomed. All other authors have reported that they have no relationships relevant to the contents of this paper. Harvey D. White, DSC, FACC, served as Guest Associate Editor for this paper.
- Received November 14, 2019.
- Revision received January 23, 2020.
- Accepted February 13, 2020.
- 2020 American College of Cardiology Foundation
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