Circulation, Vol 87, 53-58, Copyright © 1993 by American Heart Association
GI Barbash, HD White, M Modan, R Diaz, JR Hampton, J Heikkila, A Kristinsson, S Moulopoulos, EA Paolasso and T Van der Werf
BACKGROUND. Despite the fact that smoking is a well-established risk factor
for the development of coronary artery disease, some investigators have
noted that hospital mortality after acute myocardial infarction is lower in
patients who smoke than in nonsmoking patients. To evaluate the association
of smoking with mortality during hospitalization after thrombolytic therapy
and 6 months afterward, we analyzed the results of the International Tissue
Plasminogen Activator/Streptokinase Mortality Trial. METHODS AND RESULTS.
Patients were divided into three groups: nonsmokers (those who never
smoked), ex- smokers, and active smokers. Multivariate and univariate
comparisons were made with respect to baseline characteristics and clinical
outcome. There were 2,366 nonsmokers, 2,244 ex-smokers, and 3,649 active
smokers. The baseline characteristics of nonsmoking patients differed
significantly from the ex-smokers and active smokers. The nonsmoking group
included more women than the ex-smokers or active smokers (45% versus 10.6%
and 17.6%, respectively), was older (67 +/- 10 years versus 64 +/- 10 years
and 58 +/- 11 years), had a higher rate of diabetes mellitus (16.3% versus
11.1% and 7.5%), and had a worse Killip class at admission. Nonsmoking
patients and ex-smokers experienced more in-hospital reinfarction than
active smokers (4.7% and 5% versus 2.7%, p < 0.0001, respectively).
Nonsmokers experienced more in-hospital shock than the ex-smokers or active
smokers (9.2% versus 6.4% and 5.8%, p < 0.0001), stroke (1.9% versus
1.8% and 0.8%, p < 0.0001), and bleeding (7.2% versus 6.5% and 4.4%, p
< 0.0001). They also experienced a higher in-hospital and 6-month
mortality (12.8% and 17.6%) than ex-smokers (8.2% and 12.1%) or active
smokers (5.4% and 7.8%) (p < 0.0001). A multivariate analysis accounting
for all baseline characteristics demonstrated a significant association
between nonsmoking and increased hospital mortality, with an odds ratio of
1.42 (confidence limits, 1.15-1.72). Among active smokers, there was a
nonsignificant trend for mortality rates to decrease with increasing
numbers of cigarettes smoked per day. CONCLUSIONS. This retrospective
analysis indicates that smokers receiving thrombolytic therapy after acute
myocardial infarction have significantly better hospital and 6- month
outcome than nonsmokers or ex-smokers. However, smokers sustained their
infarction at a significantly earlier age than nonsmokers, and strenuous
efforts should continue to be made to decrease the incidence of new and
continued smoking.
ARTICLES
Significance of smoking in patients receiving thrombolytic therapy for acute myocardial infarction. Experience gleaned from the International Tissue Plasminogen Activator/Streptokinase Mortality Trial
Cardiovascular Research Unit, Green Lane/National Women's Hospital, Auckland, New Zealand.
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