(Circulation. 1996;93:42-47.)
© 1996 American Heart Association, Inc.
Articles |
Smoking and Cardiac Events After Venous Coronary Bypass Surgery
A 15-Year Follow-up Study
From Cardiology R&D Department (A.A.V.), Department of Cardiology (H.W.T.P., S.M.P.G.E., N.M.E.), and Department of Cardiothoracic Surgery (F.E.E.V.), St Antonius Hospital, Nieuwegein; Department of Cardiology (B.L. van B.), Diaconessenhuis, Eindhoven; and Department of Clinical Epidemiology (E.M.K., J.G.P.T.), Academic Medical Center, Amsterdam, the Netherlands.
Correspondence to H.W.T. Plokker, Department of Cardiology, St Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, the Netherlands.
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Abstract |
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 Top Abstract IntroductionMethods Results Discussion References |
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Background The long-term clinical effects of smoking and smoking cessation after venous coronary bypass surgery have not been well established.
Methods and Results Four hundred fifteen patients who underwent venous coronary bypass surgery between April 1976 and April 1977 were followed up prospectively for 15 years. Multivariate Cox survival analysis revealed that patients who smoked at the time of surgery had no elevated risks for clinical events compared with nonsmokers. However, smoking behavior at 1 and 5 years after surgery appeared to be an important predictor of clinical events during the subsequent follow-up period. Compared with patients who stopped smoking since surgery, smokers at 1 year after surgery had more than twice the risk for myocardial infarction and reoperation. Patients who were still smoking at 5 years after surgery had even more elevated risks for myocardial infarction and reoperation and a significantly increased risk for angina pectoris compared with patients who stopped smoking since surgery and patients who never smoked. Patients who started to smoke again within 5 years after surgery had increased risks for reoperation and angina pectoris. No differences in outcome were found between patients who stopped smoking since surgery and nonsmokers.
Conclusions Our results show that smoking cessation after coronary bypass surgery may have important beneficial effects on clinical events during long-term follow-up.
Key Words: smoking • bypass • follow-up studies
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Introduction |
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TopAbstractIntroductionMethods Results Discussion References |
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The adverse effects of smoking on coronary artery disease have been well described in the past. Previous studies showed that smoking is strongly related to the progression of coronary artery disease1 2 3 as well as to the incidence of cardiac death4 5 and myocardial infarction.6 7 8 9 Other studies showed improved survival10 11 12 13 14 and a lower incidence of myocardial infarction15 16 after smoking cessation. Because of these results and the present restricted resources, there has been controversy recently about whether smokers should have the same opportunities for coronary bypass surgery as nonsmokers.17 18 However, effects of smoking and smoking cessation after coronary bypass surgery on the need for reoperation and coronary angioplasty and on the return of angina pectoris have not been well described.
To determine the influence of smoking and smoking cessation not only on the incidence of death and myocardial infarction but also on reintervention and angina pectoris, we analyzed a group of 446 consecutive patients who underwent venous coronary bypass surgery in 1976 or 1977 and were followed up prospectively for 15 years.
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Methods |
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TopAbstractIntroductionMethods Results Discussion References |
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Patients
A series of 446 consecutive patients underwent isolated aortocoronary saphenous vein bypass surgery with or without resection of a left ventricular aneurysm at St Antonius Hospital, formerly in Utrecht and now in Nieuwegein, Netherlands, between April 1, 1976, and April 1, 1977. Eighteen patients in whom the operation was combined with a valve replacement were excluded from analysis. Thirteen patients died within 30 days after the procedure. The study group of the 415 remaining patients consisted of 372 men and 43 women with a mean age of 52.5 years (range, 20 to 73 years). Other characteristics of the smokers and nonsmokers at baseline are presented in Table 1
.
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Follow-up and Data Collection
Several follow-up methodologies
were used
simultaneously to obtain the most complete information
possible. All patients were followed up by use of the anniversary
method at our outpatient clinic or the outpatient clinic of the
referring cardiologists. All patients except one, who went abroad and
was lost to follow-up 7 years after surgery, were traced at the
common closing date of April 1, 1992.
Definitions
Smoking Behavior
A smoker was
defined as a patient who smoked at the time of
surgery and/or smoked at 1 year after surgery. A permanent smoker was
defined as a patient who smoked at surgery, at 1 year after surgery,
and at 5 years after surgery. A nonsmoker was a patient who never
smoked or who smoked in the past but did not smoke at the time of
surgery or afterward. We defined a quitter since surgery as being a
patient who stopped smoking since surgery and who did not smoke at
either 1 year or 5 years after surgery. A recidivist smoker was a
patient who stopped smoking but resumed smoking within 5 years after
surgery.
Angina Pectoris
The severity of angina
pectoris was scored according to the
guidelines of the Canadian Cardiovascular
Society,19 and left ventricular function was
graded according to the Coronary Artery Surgery Study (CASS)
registry.20
Myocardial Infarction
A
myocardial infarction was diagnosed by the presence of (1)
large Q waves associated with changes in ST segments and T waves in
specific and appropriate leads that indicate the location of the
infarct or (2) specific enzyme alterations in combination with
localized serial T wave changes.
End Points
Death, myocardial infarction, coronary bypass
surgery,
coronary angioplasty, and recurrence of angina pectoris
were considered clinical end points.
End points were scored in a hierarchical manner. Angina pectoris was scored as an end point only if until that moment, no other end point had been reached. Myocardial infarction was scored only if a patient had not already undergone a reintervention procedure, and coronary bypass surgery and coronary angioplasty were scored only when they were the first postoperative reintervention procedure performed. In all other situations, these events were considered censored. This was done to avoid the confounding effect of one event causing another, for example, a coronary angioplasty procedure causing a myocardial infarction.
Comparisons
Event rates were analyzed multivariately
at three different time intervals for the indicated groups: (1) from
surgery to 15 years after surgery—smokers compared with
nonsmokers; (2) from 1 to 15 years after surgery—smokers compared
with quitters since surgery; (3) from 5 to 15 years after
surgery—permanent smokers and recidivist smokers compared with
quitters since surgery; permanent smokers, recidivist smokers, and
quitters since surgery compared with nonsmokers.
When groups were compared from 1 to 15 years and from 5 to 15 years, events that occurred before 1 or 5 years, respectively, were censored.
Statistical Analysis
To identify prognostic covariates that
might have
"explained" a difference in survival time between smokers and
nonsmokers, we estimated survival curves by the method described by
Kaplan and Meier21 from the following variables: age,
sex, obesity (body mass index), diabetes mellitus, elevated levels of
serum cholesterol and triglycerides,
hypertension, history of heart failure, preoperative angina pectoris,
family history of coronary artery disease, number of vessels
diseased, completeness of revascularization, number
of distal anastomoses, left ventricular function, history
of myocardial infarction, operation indication, the presence of
collateral arteries, left main coronary artery disease, and
proximal left anterior descending artery disease. Differences in
survival times between groups were calculated using the log-rank
and Wilcoxon tests. All variables with a significance level
of P<.10 in at least one of these univariate
tests were introduced into a multivariate model as
proposed by Cox.22 Age and sex were always included.
Finally, smoking behavior was added to the model. We checked the
assumption of proportional hazards for each predictor variable by
estimating the plots of the logarithm of the cumulative hazard. By
using this analysis, we could predict the independent influence
of smoking on different cardiac events in this population. The risk of
having a cardiac event for a smoker in relation to a nonsmoker is
reflected by the hazard ratio.
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Results |
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Follow-up was complete in 99.8% of the patients and averaged 15.4 years for the survivors. Thirteen patients (3%) died within 30 days after surgery. These patients were not included for analysis. Long-term results for this study group have been described elsewhere.23 The distribution of smokers, nonsmokers, quitters since surgery, permanent smokers, and recidivist smokers at the time of surgery and at 1 and 5 years after surgery is presented in Table 2
.
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Death
Of the 169 smokers at the time of surgery, 66 (39%)
died within
15 years; 23% of these deaths were due to cardiac causes. Death
occurred in 91 (37%) of the 244 patients who were nonsmokers at the
time of surgery; over half of these deaths (56 deaths; 62%) were due
to cardiac causes.. From surgery to 15 years afterward,
multivariate Cox survival analysis revealed no
significantly increased mortality for smokers compared with nonsmokers
(Table 3), and analysis from 1 to 5 years after
surgery did not reveal significant differences in mortality between
smokers, quitters since surgery, and nonsmokers (Table 4).
Although analysis from 5 to 15 years after
surgery yielded an elevated mortality risk of 1.7 times for permanent
smokers compared with quitters since surgery, mortality risk was not
significantly increased (Table 5). Also, mortality rates
between recidivist smokers, quitters since surgery, and permanent
smokers compared with nonsmokers from 5 to 15 years after surgery did
not differ significantly (Table 6). Death due to cardiac
causes was also comparable between groups at all three time
intervals.
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Myocardial Infarction
From surgery to 15 years afterward, no
significant differences in
myocardial infarction rate were found between smokers and nonsmokers
(Table 3
; the Figure). However, from 1 to 15
years after
surgery, the myocardial infarction rate for smokers was 29% compared
with 17% for patients who stopped smoking since surgery.
Multivariate analysis revealed that at 1 year
after surgery, smokers had an elevated risk for myocardial infarction
that was 2.3 times the risk for quitters since surgery
(P=.04) in the subsequent follow-up period (Table
4).
From 5 to 15 years after surgery, permanent smokers had a 2.5 times
increased risk for myocardial infarction compared with quitters since
surgery (P=.04, Table 6) and a 2.4 times
increased risk
compared with nonsmokers (P=.008, Table 6). The
risk for
myocardial infarction for recidivist smokers from 5 to 15 years after
surgery was not significantly increased (1.9 and 1.8 times) compared
with quitters since surgery and nonsmokers, respectively. Myocardial
infarction rate from 5 to 15 years after surgery was comparable for
quitters since surgery and nonsmokers (Table 6).
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Coronary Bypass Surgery
From baseline coronary bypass surgery
to 15 years
afterward, 28 of the 164 patients who smoked at the time of surgery
underwent reoperation compared with 42 of the 244 baseline nonsmokers
(P=NS, Table 3). Perioperative mortality of
this reoperation procedure was 7.1% in both groups. Most patients were
reoperated on because of recurrence of angina pectoris.
Emergency bypass surgery because of an unsuccessful coronary
angioplasty was censored in our analysis. In the baseline
smokers group, 3 patients (7%) had a recent myocardial infarction
before surgery, compared with two baseline nonsmokers (7%). Patients
who smoked at 1 year after surgery had a 2.5 times elevated risk of
undergoing a reoperation compared with patients who quit smoking since
surgery (P=.03, Table 4). Moreover, the risk
for reoperation
for patients who were still smoking at 5 years after surgery (permanent
smokers) was 3.3 times (P=.03) the risk for quitters since
surgery. Also, patients who started to smoke again within 5 years
(recidivist smokers) had an elevated risk for reoperation of 3.4 times
(P=.04) the risk for quitters since surgery (Table
6).
Compared with nonsmokers, risks for permanent smokers and recidivist
smokers were significantly increased, whereas quitters since surgery
had outcomes comparable to nonsmokers (Table 6).
Coronary Angioplasty
Fifty-seven patients underwent a
coronary angioplasty
as a first reintervention procedure after their coronary bypass
surgery. Total periprocedural mortality was 2% and did not differ
between smokers and nonsmokers. Most patients underwent
coronary angioplasty because of recurrence of angina
pectoris. A recent myocardial infarction (<1 month before
coronary angioplasty) was found in 12% of the patients.
Comparisons between smokers, nonsmokers, quitters since surgery,
permanent smokers, and recidivist smokers did not reveal significant
differences in coronary angioplasty rate. However, there was a
trend for an increased risk for the need for coronary
angioplasty for recidivist smokers and permanent smokers compared with
nonsmokers, whereas event rates between quitters since surgery and
nonsmokers were comparable (Table 6).
Angina Pectoris
After 15 years, only 27% of the patients from
the entire study
population were still free from angina pectoris. From surgery to 15
years afterward and from 1 to 15 years after surgery, event rates for
the return of angina pectoris between smokers, nonsmokers, and quitters
since surgery were not significantly different. However, patients who
were still smoking at 5 years after surgery or who started to smoke
within 5 years after surgery had a more than twofold increased risk for
the return of angina pectoris compared with patients who quit smoking
since surgery (Table 6). Again, the return of angina pectoris
was
comparable between quitters since surgery and nonsmokers (Table
6).
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Discussion |
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TopAbstractIntroductionMethods Results Discussion References |
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Recently, there has been much controversy about whether smokers should receive the same opportunities for coronary bypass surgery as nonsmokers,17 18 and proposals have been made to hold smokers accountable for heart disease costs.24 Discussion about this subject was based mainly on the consistent finding that continued smoking after coronary bypass surgery increases mortality and myocardial infarction rate. However, to the best of our knowledge, no data are available on the risks for death and myocardial infarction after coronary bypass for patients who continued to smoke or who started to smoke again after surgery compared with patients who stopped smoking since surgery. Moreover, questions about the risk for reoperation and coronary angioplasty after coronary bypass surgery for smokers also have remained unanswered.
The results of this study showed that patients who continued to smoke or patients who started to smoke again after coronary bypass surgery had increased risks not only for myocardial infarction but also for coronary bypass surgery and recurrence of angina pectoris compared with patients who stopped smoking since surgery and patients who did not smoke. Moreover, clinical outcome after surgery for patients who stopped smoking since surgery was similar to nonsmokers.
In contrast with other studies, we did not find a strong relation between smoking behavior and survival. A possible explanation could be not only that the deleterious effects of smoking may be mediated by the chronic process of atherosclerotic progression in the grafts and the native system but also that smoking is positively correlated with immediate perioperative morbidity and mortality, mainly due to pulmonary infections.25 Because we aimed to describe the long-term effects of smoking and smoking cessation, we did not include patients who died within 30 days after surgery, which could have biased the results.
The association between smoking behavior and myocardial infarction is already recognized. Hartz et al8 found a significant association between smoking and myocardial infarction for men >50 years old. In a study from Rosenberg et al,7 smoking was found to increase the risk for a second myocardial infarction in women, and the risk increased with the number of cigarettes smoked. In another study in men <55 years old, Rosenberg et al15 showed that the estimated relative risk for myocardial infarction for smokers compared with those who never smoked was 2.9. Hermanson et al13 concluded that, in older and in younger patients, patients with coronary artery disease who continued to smoke had a relative risk of 1.5 for myocardial infarction compared with quitters. Wilhelmsson et al6 found that patients who stopped smoking after their first myocardial infarction had only half the rate of nonfatal recurrences as those who continued to smoke. Åberg et al16 also found a lower frequency of reinfarction in a 10-year follow-up study. Thus, although there is a large body of evidence that smoking is related to myocardial infarction and that smoking cessation lessens the risk of this event, there are few multivariately analyzed data about its effects after coronary bypass surgery.
Our findings that smoking has an increased risk for the return of angina pectoris support the results from the CASS study,14 in which it was found that smokers, in comparison with nonsmokers, were less likely to remain free from angina pectoris after 10 years in both the patient groups randomized to medical treatment and the coronary bypass surgery group. There are few other studies that examine the influence of smoking after coronary bypass surgery on angina pectoris. Moreover, hardly any data are available about the effects of smoking behavior on the need for reintervention, either operative or by angioplasty.
We report on the effects of smoking behavior on clinical events after venous coronary bypass surgery. At present, it has been shown that arterial grafts might have an improved outcome over venous grafts.26 27 However, for a variety of reasons, venous grafts continue to be used in the majority of coronary bypass surgery patients, mostly in combination with arterial grafts.28 29 30 Since it is conceivable that venous conduits will be the first to cause clinical events, factors that influence the clinical outcome of patients with venous grafts remain important.
The present study has some shortcomings. First, we did not assess the total life consumption of cigarettes, and although we recorded number of cigarettes smoked, groups became too small to detect any significant differences. Second, there may have been other factors intercorrelating with smoking behavior that we did not record. For example, social status was not recorded, although differences in social status in the Netherlands are very small. Finally, smoking status was assessed by asking patients about their smoking behavior. We were not able to check the expressed smoking behavior by biochemical validation, and this remains a possible source of bias.
Despite these imperfections, on the basis of our prospective, multivariate analysis, there is a strong indication that patients who continue to smoke or who start smoking again after coronary bypass surgery have an elevated risk not only for myocardial infarction but also for the return of angina pectoris and the need for coronary bypass surgery. Therefore, we conclude that smoking cessation after coronary bypass surgery may have important beneficial effects on long-term cardiac morbidity.
Received January 30, 1995; revision received May 8, 1995; accepted August 24, 1995.
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K. Wilson, N. Gibson, A. Willan, and D. Cook Effect of Smoking Cessation on Mortality After Myocardial Infarction: Meta-analysis of Cohort Studies Arch Intern Med, April 10, 2000; 160(7): 939 - 944. [Abstract] [Full Text] [PDF]
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T.F.M. Van Berkel, H. Boersma, J.W. Roos-Hesselink, R.A.M. Erdman, and M.L. Simoons Impact of smoking cessation and smoking interventions in patients with coronary heart disease Eur. Heart J., December 2, 1999; 20(24): 1773 - 1782. [PDF]
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E.-S. Tan, J. van der Meer, P. Jan de Kam, P. H. J. M. Dunselman, B. J. M. Mulder, C. A. P. L. Ascoop, M. Pfisterer, K. I. Lie, and for CABADAS Research Group of the Interuniversity Worse clinical outcome but similar graft patency in women versus men one year after coronary artery bypass graft surgery owing to an excess of exposed risk factors in women J. Am. Coll. Cardiol., November 15, 1999; 34(6): 1760 - 1768. [Abstract] [Full Text] [PDF]
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T.F.M. Van Berkel, H. Boersma, D. De Baquer, J.W. Deckers, and D. Wood Registration and management of smoking behaviour in patients with coronary heart disease. The EUROASPIRE survey Eur. Heart J., November 2, 1999; 20(22): 1630 - 1637. [Abstract] [PDF]
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K. A. Eagle, R. A. Guyton, R. Davidoff, G. A. Ewy, J. Fonger, T. J. Gardner, J. P. Gott, H. C. Herrmann, R. A. Marlow, W. C. Nugent, et al. ACC/AHA guidelines for coronary artery bypass graft surgery: A report of the American College of Cardiology/ American Heart Association task force on Practice Guidelines (Committee to revise the 1991 Guidelines for Coronary Artery Bypass Graft Surgery) J. Am. Coll. Cardiol., October 1, 1999; 34(4): 1262 - 1347. [Full Text] [PDF]
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J. G. Motwani and E. J. Topol Aortocoronary Saphenous Vein Graft Disease : Pathogenesis, Predisposition, and Prevention Circulation, March 10, 1998; 97(9): 916 - 931. [Abstract] [Full Text] [PDF]
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J. M. Murabito, R. B. D'Agostino, H. Silbershatz, and P. W. F. Wilson Intermittent Claudication : A Risk Profile From The Framingham Heart Study Circulation, July 1, 1997; 96(1): 44 - 49. [Abstract] [Full Text]
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D. Hasdai, K. N. Garratt, D. E. Grill, A. Lerman, and D. R. Holmes Effect of Smoking Status on the Long-Term Outcome after Successful Percutaneous Coronary Revascularization N. Engl. J. Med., March 13, 1997; 336(11): 755 - 761. [Abstract] [Full Text] [PDF]
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