Smoking and Cardiovascular Outcomes | Journal Scan

Study Questions:

Is smoking associated with adverse outcomes among patients with complex coronary artery disease (CAD)?


Data from SYNTAX (SYNergy Between PCI With TAXUS and Cardiac Surgery), a prospective multicenter trial, were used for the present analysis. The original trial compared percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) among patients with complex CAD (defined as left main and/or three-vessel disease). Smoking history was collected at baseline, 6 months, and 1, 3, and 5 years into follow-up. The composite endpoint included cardiac and cerebrovascular events including myocardial infarction, stroke, and revascularization. Smoking was examined as a time-varying covariate.


A total of 1,800 patients who had available data on smoking status were included in the present analysis. Smokers were younger, mostly male, and had a higher burden of CAD compared to nonsmokers. Smokers were also less likely to have additional cardiovascular risk factors. Almost one fifth of patients (17.9%) modified their smoking patterns during follow-up. At baseline, 20% of patients were smoking. After revascularization, approximately 60% stopped smoking. Baseline smoking status was observed to have no impact on adverse outcomes at 5 years. Smoking during follow-up was associated with adverse outcomes. Continued smoking was associated with increased risk for myocardial infarction, stent thrombosis, or graft occlusion compared to never-smokers. Smoking was a significant predictor of the composite endpoint, which included death, myocardial infarction, and stroke (hazard ratio [HR], 1.8; 95% confidence interval [CI], 1.3-2.5). Risk for subsequent myocardial infarction was one of the strongest relationships observed (HR, 1.96; 95% CI, 1.21-2.86).


The investigators concluded that smoking is associated with worse clinical outcomes among patients with complex CAD.


These data suggest that the smoking paradox observed in prior studies may not be accurate. Needless to say, clinicians should strongly advise smokers to stop smoking. These data also suggest that quit rates are high after a patient is diagnosed with CAD. This may represent an optimal time for smoking cessation interventions.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and Coronary Artery Disease, Smoking

Keywords: Coronary Artery Disease, Coronary Disease, Smoking, Smoking Cessation, Coronary Artery Bypass, Cardiac Surgical Procedures, Percutaneous Coronary Intervention, Myocardial Revascularization, Stents, Myocardial Infarction, Stroke, Secondary Prevention, Risk Factors, Cost of Illness, Prospective Studies, Mortality

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