Editorial comment
The smoker's paradox: Not an argument against quitting smoking after acute coronary syndrome
Paradoxo do tabagismo na síndrome coronária aguda - não se trata de um argumento contra deixar de fumar após a síndrome coronariana aguda!
Miguel Mendes
Hospital de Santa Cruz-CHLO, Carnaxide, Portugal
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Two endpoints were defined: in-hospital mortality and a composite endpoint including all-cause mortality, rehospitalization for cardiovascular causes, angiography, percutaneous coronary intervention and coronary artery bypass graft surgery at one year after ACS.</p><p id="par0020" class="elsevierStylePara elsevierViewall">They found that current smokers, on average 15 years younger at presentation, showed a higher rate of STEMI than non-smokers (69.8% vs. 56.3%, p<0.001), in whom NSTEMI predominated. Current smokers also had a more benign clinical, hemodynamic and angiographic profile at hospital admission and a better in-hospital course. They also appeared to have a more favorable prognosis at one year, although they were more likely to be revascularized, mainly by PCI (84.1% vs. 67.0% in non-smokers, p<0.001), during hospital stay and in follow-up.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The raw data assessed by univariate statistics suggested that the smoker's paradox would be found in this population, but after multivariate analysis with full adjustment for age, gender, heart rate, systolic blood pressure, Killip class, creatinine at admission and ACS type, all the differences disappeared, supporting the authors’ conclusions that the smoker's paradox was not observed in the study population and that the initial apparent differences in outcome could be explained simply by smokers’ lower baseline risk.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The study's data and conclusions, coming from a tertiary center with a large ACS population, managed by current state-of-the-art drug regimes and interventions, are significant. To the best of our knowledge, this is the first paper published in Portugal to study the smoker's paradox with a sufficiently large population and with sufficient statistical power to support its conclusions.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The topic addressed by the authors is important, since several articles have been published in high-ranking medical journals (although contradicted by many others<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">2,3</span></a>) that suggest the existence of a paradoxical protection afforded by smoking in patients with coronary artery disease (CAD), heart failure and stroke.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">4–6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">This is cited by many patients as an argument for not quitting smoking, losing weight or strictly controlling their other risk factors, since they believe that they would benefit from the lower residual cardiovascular risk due to the protection conferred by tobacco smoking.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Arguments are also made in favor of electronic cigarettes. There is the perception that e-cigarettes are neutral for cardiovascular health, but this is not supported by epidemiological studies, since none have yet been performed to elucidate the impact of new forms of tobacco smoking on cardiovascular health.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">7–9</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">This misperception is clearly contradicted by other trials. The Organization to Assess Strategies in Acute Ischemic Syndromes (OASIS) 5 trial, which included 18<span class="elsevierStyleHsp" style=""></span>809 ACS patients, showed that smoking cessation reduced the risk of a new ACS by 43% at six months.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The study has some limitations, most of them acknowledged by the authors: its retrospective nature, and the lack of data regarding smoking burden and on compliance with drug regimes and cardiovascular mortality after discharge. None of these should be considered a major challenge to the study's conclusions.</p><p id="par0060" class="elsevierStylePara elsevierViewall">It would also have been interesting to assess the patients’ global cardiovascular risk previous to ACS, by the EuroSCORE or another tool validated for the Portuguese population, to ascertain whether the overall risk of smokers, who also had higher rates of dyslipidemia and family history of CAD, would have been predicted to be similar to the non-smokers group, who were 15 years older and had higher rates of hypertension and diabetes.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Another interesting exercise would be to study the consequences of differences in smoking burden in terms of cardiovascular risk, considering that greater numbers of pack/years are associated with increased risk. With this information it would be possible to quantify the risk of smoking in a different way, demonstrating, according to Bradford Hill's causal criteria, a risk that increases proportionally to the smoking burden.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">If the study had included only patients in whom the index ACS was the first manifestation of CAD, its findings and conclusions would probably be even stronger. The study population would decrease by excluding patients with previously known CAD (35.8%), stroke/transient ischemic attack (5.9%) and peripheral arterial disease (3.1%), but this would probably would strengthen the study's conclusions.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0060" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The smoker's paradox in acute coronary syndrome: is it real?" 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 3 | 12 |
| 2024 October | 46 | 31 | 77 |
| 2024 September | 59 | 27 | 86 |
| 2024 August | 48 | 32 | 80 |
| 2024 July | 29 | 20 | 49 |
| 2024 June | 25 | 16 | 41 |
| 2024 May | 31 | 25 | 56 |
| 2024 April | 29 | 21 | 50 |
| 2024 March | 28 | 28 | 56 |
| 2024 February | 32 | 24 | 56 |
| 2024 January | 23 | 18 | 41 |
| 2023 December | 20 | 30 | 50 |
| 2023 November | 34 | 20 | 54 |
| 2023 October | 21 | 15 | 36 |
| 2023 September | 24 | 16 | 40 |
| 2023 August | 36 | 17 | 53 |
| 2023 July | 40 | 14 | 54 |
| 2023 June | 30 | 11 | 41 |
| 2023 May | 44 | 23 | 67 |
| 2023 April | 20 | 9 | 29 |
| 2023 March | 46 | 17 | 63 |
| 2023 February | 34 | 16 | 50 |
| 2023 January | 24 | 21 | 45 |
| 2022 December | 48 | 24 | 72 |
| 2022 November | 55 | 20 | 75 |
| 2022 October | 46 | 27 | 73 |
| 2022 September | 31 | 25 | 56 |
| 2022 August | 29 | 20 | 49 |
| 2022 July | 35 | 42 | 77 |
| 2022 June | 31 | 20 | 51 |
| 2022 May | 26 | 30 | 56 |
| 2022 April | 34 | 24 | 58 |
| 2022 March | 36 | 34 | 70 |
| 2022 February | 25 | 28 | 53 |
| 2022 January | 19 | 19 | 38 |
| 2021 December | 36 | 28 | 64 |
| 2021 November | 41 | 40 | 81 |
| 2021 October | 46 | 33 | 79 |
| 2021 September | 31 | 24 | 55 |
| 2021 August | 28 | 29 | 57 |
| 2021 July | 27 | 22 | 49 |
| 2021 June | 26 | 21 | 47 |
| 2021 May | 31 | 40 | 71 |
| 2021 April | 41 | 80 | 121 |
| 2021 March | 53 | 16 | 69 |
| 2021 February | 30 | 18 | 48 |
| 2021 January | 31 | 11 | 42 |
| 2020 December | 23 | 15 | 38 |
| 2020 November | 26 | 20 | 46 |
| 2020 October | 20 | 12 | 32 |
| 2020 September | 22 | 19 | 41 |
| 2020 August | 13 | 13 | 26 |
| 2020 July | 13 | 7 | 20 |
| 2020 June | 15 | 7 | 22 |
| 2020 May | 18 | 10 | 28 |
| 2020 April | 17 | 9 | 26 |
| 2020 March | 14 | 9 | 23 |
| 2020 February | 47 | 57 | 104 |
| 2020 January | 18 | 10 | 28 |
| 2019 December | 16 | 7 | 23 |
| 2019 November | 20 | 13 | 33 |
| 2019 October | 12 | 10 | 22 |
| 2019 September | 18 | 12 | 30 |
| 2019 August | 20 | 8 | 28 |
| 2019 July | 16 | 11 | 27 |
| 2019 June | 33 | 17 | 50 |
| 2019 May | 25 | 10 | 35 |
| 2019 April | 20 | 17 | 37 |
| 2019 March | 18 | 15 | 33 |
| 2019 February | 20 | 5 | 25 |
| 2019 January | 34 | 18 | 52 |
| 2018 December | 37 | 20 | 57 |
| 2018 November | 62 | 34 | 96 |
| 2018 October | 4 | 2 | 6 |
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