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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">This editorial refers to the article &#8220;The smoker&#39;s paradox in acute coronary syndromes &#8211; is it real&#63;&#8221; by Madalena Coutinho Cruz and co-workers&#44; published in this issue of the <span class="elsevierStyleItalic">Journal</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In order to assess the possible protection provided by smoking during the in-hospital period and in the first year after acute coronary syndrome &#40;ACS&#41;&#44; the so-called &#8216;smoker&#39;s paradox&#8217;&#44; the authors collected data from all consecutive patients &#40;n&#61;3298&#41; hospitalized due to ACS in their center between 2005 and 2014&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">After excluding former smokers &#40;n&#61;368&#41; and patients treated by fibrinolysis &#40;n&#61;203&#41;&#44; and taking into consideration potential confounding factors related to smokers&#8217; prothrombotic status&#44; the authors performed a retrospective analysis of the remaining 2727 patients&#44; comparing two groups&#58; current smokers &#40;n&#61;1138&#44; 41&#46;7&#37; of the population&#41; and non-smokers &#40;n&#61;1589&#44; 58&#46;3&#37;&#41;&#46; Two endpoints were defined&#58; in-hospital mortality and a composite endpoint including all-cause mortality&#44; rehospitalization for cardiovascular causes&#44; angiography&#44; percutaneous coronary intervention and coronary artery bypass graft surgery at one year after ACS&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">They found that current smokers&#44; on average 15 years younger at presentation&#44; showed a higher rate of STEMI than non-smokers &#40;69&#46;8&#37; vs&#46; 56&#46;3&#37;&#44; p&#60;0&#46;001&#41;&#44; in whom NSTEMI predominated&#46; Current smokers also had a more benign clinical&#44; hemodynamic and angiographic profile at hospital admission and a better in-hospital course&#46; They also appeared to have a more favorable prognosis at one year&#44; although they were more likely to be revascularized&#44; mainly by PCI &#40;84&#46;1&#37; vs&#46; 67&#46;0&#37; in non-smokers&#44; p&#60;0&#46;001&#41;&#44; during hospital stay and in follow-up&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The raw data assessed by univariate statistics suggested that the smoker&#39;s paradox would be found in this population&#44; but after multivariate analysis with full adjustment for age&#44; gender&#44; heart rate&#44; systolic blood pressure&#44; Killip class&#44; creatinine at admission and ACS type&#44; all the differences disappeared&#44; supporting the authors&#8217; conclusions that the smoker&#39;s paradox was not observed in the study population and that the initial apparent differences in outcome could be explained simply by smokers&#8217; lower baseline risk&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The study&#39;s data and conclusions&#44; coming from a tertiary center with a large ACS population&#44; managed by current state-of-the-art drug regimes and interventions&#44; are significant&#46; To the best of our knowledge&#44; this is the first paper published in Portugal to study the smoker&#39;s paradox with a sufficiently large population and with sufficient statistical power to support its conclusions&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The topic addressed by the authors is important&#44; since several articles have been published in high-ranking medical journals &#40;although contradicted by many others<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">2&#44;3</span></a>&#41; that suggest the existence of a paradoxical protection afforded by smoking in patients with coronary artery disease &#40;CAD&#41;&#44; heart failure and stroke&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">4&#8211;6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">This is cited by many patients as an argument for not quitting smoking&#44; losing weight or strictly controlling their other risk factors&#44; since they believe that they would benefit from the lower residual cardiovascular risk due to the protection conferred by tobacco smoking&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Arguments are also made in favor of electronic cigarettes&#46; There is the perception that e-cigarettes are neutral for cardiovascular health&#44; but this is not supported by epidemiological studies&#44; since none have yet been performed to elucidate the impact of new forms of tobacco smoking on cardiovascular health&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">7&#8211;9</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">This misperception is clearly contradicted by other trials&#46; The Organization to Assess Strategies in Acute Ischemic Syndromes &#40;OASIS&#41; 5 trial&#44; which included 18<span class="elsevierStyleHsp" style=""></span>809 ACS patients&#44; showed that smoking cessation reduced the risk of a new ACS by 43&#37; at six months&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The study has some limitations&#44; most of them acknowledged by the authors&#58; its retrospective nature&#44; and the lack of data regarding smoking burden and on compliance with drug regimes and cardiovascular mortality after discharge&#46; None of these should be considered a major challenge to the study&#39;s conclusions&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">It would also have been interesting to assess the patients&#8217; global cardiovascular risk previous to ACS&#44; by the EuroSCORE or another tool validated for the Portuguese population&#44; to ascertain whether the overall risk of smokers&#44; who also had higher rates of dyslipidemia and family history of CAD&#44; would have been predicted to be similar to the non-smokers group&#44; who were 15 years older and had higher rates of hypertension and diabetes&#46;</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&#44; considering that greater numbers of pack&#47;years are associated with increased risk&#46; With this information it would be possible to quantify the risk of smoking in a different way&#44; demonstrating&#44; according to Bradford Hill&#39;s causal criteria&#44; a risk that increases proportionally to the smoking burden&#46;<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&#44; its findings and conclusions would probably be even stronger&#46; The study population would decrease by excluding patients with previously known CAD &#40;35&#46;8&#37;&#41;&#44; stroke&#47;transient ischemic attack &#40;5&#46;9&#37;&#41; and peripheral arterial disease &#40;3&#46;1&#37;&#41;&#44; but this would probably would strengthen the study&#39;s conclusions&#46;</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&#46;</p></span></span>"
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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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    "cabecera" => "<span class="elsevierStyleTextfn">Editorial comment</span>"
    "titulo" => "The smoker&#39;s paradox&#58; Not an argument against quitting smoking after acute coronary syndrome"
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        "autoresLista" => "Miguel Mendes"
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            "nombre" => "Miguel"
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            "entidad" => "Hospital de Santa Cruz-CHLO&#44; Carnaxide&#44; Portugal"
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    "titulosAlternativos" => array:1 [
      "pt" => array:1 [
        "titulo" => "Paradoxo do tabagismo na s&#237;ndrome coron&#225;ria aguda - n&#227;o se trata de um argumento contra deixar de fumar ap&#243;s a s&#237;ndrome coronariana aguda&#33;"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">This editorial refers to the article &#8220;The smoker&#39;s paradox in acute coronary syndromes &#8211; is it real&#63;&#8221; by Madalena Coutinho Cruz and co-workers&#44; published in this issue of the <span class="elsevierStyleItalic">Journal</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In order to assess the possible protection provided by smoking during the in-hospital period and in the first year after acute coronary syndrome &#40;ACS&#41;&#44; the so-called &#8216;smoker&#39;s paradox&#8217;&#44; the authors collected data from all consecutive patients &#40;n&#61;3298&#41; hospitalized due to ACS in their center between 2005 and 2014&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">After excluding former smokers &#40;n&#61;368&#41; and patients treated by fibrinolysis &#40;n&#61;203&#41;&#44; and taking into consideration potential confounding factors related to smokers&#8217; prothrombotic status&#44; the authors performed a retrospective analysis of the remaining 2727 patients&#44; comparing two groups&#58; current smokers &#40;n&#61;1138&#44; 41&#46;7&#37; of the population&#41; and non-smokers &#40;n&#61;1589&#44; 58&#46;3&#37;&#41;&#46; Two endpoints were defined&#58; in-hospital mortality and a composite endpoint including all-cause mortality&#44; rehospitalization for cardiovascular causes&#44; angiography&#44; percutaneous coronary intervention and coronary artery bypass graft surgery at one year after ACS&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">They found that current smokers&#44; on average 15 years younger at presentation&#44; showed a higher rate of STEMI than non-smokers &#40;69&#46;8&#37; vs&#46; 56&#46;3&#37;&#44; p&#60;0&#46;001&#41;&#44; in whom NSTEMI predominated&#46; Current smokers also had a more benign clinical&#44; hemodynamic and angiographic profile at hospital admission and a better in-hospital course&#46; They also appeared to have a more favorable prognosis at one year&#44; although they were more likely to be revascularized&#44; mainly by PCI &#40;84&#46;1&#37; vs&#46; 67&#46;0&#37; in non-smokers&#44; p&#60;0&#46;001&#41;&#44; during hospital stay and in follow-up&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The raw data assessed by univariate statistics suggested that the smoker&#39;s paradox would be found in this population&#44; but after multivariate analysis with full adjustment for age&#44; gender&#44; heart rate&#44; systolic blood pressure&#44; Killip class&#44; creatinine at admission and ACS type&#44; all the differences disappeared&#44; supporting the authors&#8217; conclusions that the smoker&#39;s paradox was not observed in the study population and that the initial apparent differences in outcome could be explained simply by smokers&#8217; lower baseline risk&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The study&#39;s data and conclusions&#44; coming from a tertiary center with a large ACS population&#44; managed by current state-of-the-art drug regimes and interventions&#44; are significant&#46; To the best of our knowledge&#44; this is the first paper published in Portugal to study the smoker&#39;s paradox with a sufficiently large population and with sufficient statistical power to support its conclusions&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The topic addressed by the authors is important&#44; since several articles have been published in high-ranking medical journals &#40;although contradicted by many others<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">2&#44;3</span></a>&#41; that suggest the existence of a paradoxical protection afforded by smoking in patients with coronary artery disease &#40;CAD&#41;&#44; heart failure and stroke&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">4&#8211;6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">This is cited by many patients as an argument for not quitting smoking&#44; losing weight or strictly controlling their other risk factors&#44; since they believe that they would benefit from the lower residual cardiovascular risk due to the protection conferred by tobacco smoking&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Arguments are also made in favor of electronic cigarettes&#46; There is the perception that e-cigarettes are neutral for cardiovascular health&#44; but this is not supported by epidemiological studies&#44; since none have yet been performed to elucidate the impact of new forms of tobacco smoking on cardiovascular health&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">7&#8211;9</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">This misperception is clearly contradicted by other trials&#46; The Organization to Assess Strategies in Acute Ischemic Syndromes &#40;OASIS&#41; 5 trial&#44; which included 18<span class="elsevierStyleHsp" style=""></span>809 ACS patients&#44; showed that smoking cessation reduced the risk of a new ACS by 43&#37; at six months&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The study has some limitations&#44; most of them acknowledged by the authors&#58; its retrospective nature&#44; and the lack of data regarding smoking burden and on compliance with drug regimes and cardiovascular mortality after discharge&#46; None of these should be considered a major challenge to the study&#39;s conclusions&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">It would also have been interesting to assess the patients&#8217; global cardiovascular risk previous to ACS&#44; by the EuroSCORE or another tool validated for the Portuguese population&#44; to ascertain whether the overall risk of smokers&#44; who also had higher rates of dyslipidemia and family history of CAD&#44; would have been predicted to be similar to the non-smokers group&#44; who were 15 years older and had higher rates of hypertension and diabetes&#46;</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&#44; considering that greater numbers of pack&#47;years are associated with increased risk&#46; With this information it would be possible to quantify the risk of smoking in a different way&#44; demonstrating&#44; according to Bradford Hill&#39;s causal criteria&#44; a risk that increases proportionally to the smoking burden&#46;<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&#44; its findings and conclusions would probably be even stronger&#46; The study population would decrease by excluding patients with previously known CAD &#40;35&#46;8&#37;&#41;&#44; stroke&#47;transient ischemic attack &#40;5&#46;9&#37;&#41; and peripheral arterial disease &#40;3&#46;1&#37;&#41;&#44; but this would probably would strengthen the study&#39;s conclusions&#46;</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&#46;</p></span></span>"
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2023 Maio 46 27 73
2023 Abril 29 4 33
2023 Maro 49 26 75
2023 Fevereiro 34 21 55
2023 Janeiro 23 14 37
2022 Dezembro 66 17 83
2022 Novembro 40 18 58
2022 Outubro 53 19 72
2022 Setembro 33 41 74
2022 Agosto 30 30 60
2022 Julho 39 48 87
2022 Junho 36 26 62
2022 Maio 27 33 60
2022 Abril 41 39 80
2022 Maro 37 46 83
2022 Fevereiro 26 25 51
2022 Janeiro 39 29 68
2021 Dezembro 22 31 53
2021 Novembro 29 41 70
2021 Outubro 35 45 80
2021 Setembro 27 29 56
2021 Agosto 44 40 84
2021 Julho 37 27 64
2021 Junho 37 24 61
2021 Maio 44 29 73
2021 Abril 47 56 103
2021 Maro 65 22 87
2021 Fevereiro 46 19 65
2021 Janeiro 49 15 64
2020 Dezembro 28 13 41
2020 Novembro 25 11 36
2020 Outubro 21 15 36
2020 Setembro 25 5 30
2020 Agosto 19 10 29
2020 Julho 29 11 40
2020 Junho 18 7 25
2020 Maio 38 6 44
2020 Abril 26 12 38
2020 Maro 29 9 38
2020 Fevereiro 27 24 51
2020 Janeiro 19 8 27
2019 Dezembro 15 4 19
2019 Novembro 21 18 39
2019 Outubro 19 9 28
2019 Setembro 29 15 44
2019 Agosto 22 7 29
2019 Julho 12 10 22
2019 Junho 29 21 50
2019 Maio 22 4 26
2019 Abril 18 15 33
2019 Maro 13 11 24
2019 Fevereiro 6 14 20
2019 Janeiro 22 8 30
2018 Dezembro 17 15 32
2018 Novembro 69 40 109
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