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Gender, Smoking, and STEMI Risk
Study Questions:
Is there differential risk of smoking between men and women presenting with ST-segment elevation myocardial infarction (STEMI)?
Methods:
This was a retrospective ecological cohort study from the United Kingdom. All patients presenting with STEMI between 2004 and 2014 were combined with population data to generate incidence rates of STEMI. Age-standardized incidence rate ratios (IRRs) were calculated comparing STEMI rates between smokers and nonsmokers stratified by age and sex.
Results:
A total of 3,343 patients presented over 5,639,328 person-years. Peak STEMI rate for current smokers was in the age range of 70-79 years for women (235 per 100,000 patient-years) and 50-59 years (425 per 100,000 patient-years) in men. Smoking was associated with a significantly greater increase in STEMI rate for women than men (IRR, 6.62; 95% confidence interval [CI], 5.98-7.31 vs. IRR, 4.40; 95% CI, 4.15-4.67). The greatest increased risk was in women ages 18-49 years (IRR, 13.22; 95% CI, 10.33-16.66 vs. IRR, 8.60; 95% CI, 7.70-9.59 in men). The greatest risk difference was in the age group 50-64 years, with IRR of 9.66 (95% CI, 8.30-11.18) in women and 4.47 (95% CI, 4.10-4.86) in men.
Conclusions:
When evaluating differential risk of smoking among patients with STEMI, women who smoke may have significantly increased risk of STEMI compared to male smokers.
Perspective:
Smoking and nicotine increases risk of endothelial dysfunction, thrombosis, and inflammation. Prior studies have suggested that there may be a differential risk attributed to smoking among women compared to men. The extent of this risk has not been studied before. Authors of this study used innovative statistical methods to show increased risk in female smokers compared to male smokers, with the largest risk difference among middle-aged patients and highest risk difference in the youngest patients (18-49 years old). Potential mechanisms by which smoking adversely affects women remain incompletely understood. One theory relates to smoking lowering estrogen levels in premenopausal women and may explain almost twice the risk seen in younger women compared to men. Barring the retrospective nature of the study and self-reported smoking status, all patients, especially young women, should be counseled for smoking cessation.
Clinical Topics: Cardiovascular Care Team, Prevention, Smoking
Keywords: Estrogens, Incidence, Inflammation, Middle Aged, Myocardial Infarction, Primary Prevention, Risk, Smoking, Smoking Cessation, Thrombosis, Tobacco, Women
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