Smoking and myocardial infarction case-fatality: hospital and population approach

Elosúa, Roberto; Vega, Gema; Rohlfs, Izabella; Aldasoro, Elena; Navarro, Carmen; Cabadés, Adolfo; Demissie, Serkalem; Segura, Antonio; Fiol, Miquel; Moreno-Iribas, Concepción; Echánove, Ildefonso; Arteagoitia, José M.; Sala, Joan; Marrugat, Jaume

doi:10.1097/hjr.0b013e32804955b3

Cited by 25 publications

(19 citation statements)

References 28 publications

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“…The 'smoker's paradox' observed in our study has been well described in previous studies of myocardial infarctions [28][29][30] , but was not observed in a large stroke outcome study conducted in China [31] . The Copenhagen Stroke Study found a protective effect of smoking on 5-year survival in univariate analyses, but a 20% excess after multivariate adjustment [32] .…”

Section: Discussionsupporting

confidence: 87%

Recent Racial/Ethnic Disparities in Stroke Hospitalizations and Outcomes for Young Adults in Florida, 2001–2006

Pathak¹,

Sloan

2009

Neuroepidemiology

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Background: Black-white disparities in stroke mortality are well documented, but few recent studies have examined racial/ethnic disparities in stroke hospitalizations among young adults. We analyzed recent (2001–2006) trends in stroke hospitalizations and hospital case-fatality for black, Hispanic, and white adults aged 25–49 years in Florida. Methods: Hospitalization rates were calculated using population estimates from the census, and hospital discharges with a primary diagnosis of stroke (ICD-9-CM 430, 431, 434, 436) (n = 16,317). Multivariate logistic regression modeling was used to examine racial/ethnic disparities in stroke mortality prior to discharge, after adjustment for patient sociodemographics, stroke subtype, risk factors, and comorbidities. Results: Age-adjusted stroke hospitalization rates for blacks were over 3 times higher than rates for whites, while rates for Hispanics were slightly higher than rates for whites. Hemorrhagic strokes were proportionally greater among Hispanics compared with blacks and whites (p < 0.0001). Blacks were most likely to have diagnosed hypertension (62.3%), morbid obesity (10.9%) or drug abuse (13.6%). Whites were most likely to have diagnosed hyperlipidemia (21.0%), alcohol abuse (9.5%), and to be smokers (30.6%). The in-hospital fatality rate for all strokes was highest among blacks (10.0%) compared with whites (9.0%) and Hispanics (8.2%). After adjustment for age, gender, insurance status, and all diagnosed risk factors and comorbidities, the black excess was no longer observed [odds ratio (OR) 1.01, 95% confidence interval (CI) 0.88–1.15, p = 0.93]. However, the Hispanic advantage in case-fatality was strengthened (OR 0.66, 95% CI 0.55–0.79, p < 0.0001). Separate case-fatality analyses for ischemic versus hemorrhagic strokes yielded similar results. Conclusions: Our study found a strong and persistent black-white disparity in stroke hospitalization rates for young adults. In contrast, rates were similar for Hispanics and whites. Multivariate adjustment explained the 15% excess case-fatality for blacks; the short-term mortality advantage among Hispanics was strengthened after adjustment.

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Section: Discussionsupporting

confidence: 87%

Recent Racial/Ethnic Disparities in Stroke Hospitalizations and Outcomes for Young Adults in Florida, 2001–2006

Pathak¹,

Sloan

2009

Neuroepidemiology

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“…Four observational studies did not adjust for any treatment provided during hospitalisation [14,16,25,26]. Three registries [15,17,19], in addition to the CADILLAC trial [27], included invasive treatment in the multivariate analyses. The NRMI 2 registry adjusted for "any reperfusion therapy" without specifying the proportion of patients undergoing invasive procedures [18].…”

Section: Resultsmentioning

confidence: 99%

“…One of these studies was an observational single-centre study enrolling unselected AMI patients between 1982 and 1984 [25]. The five other studies dated from the late 1980s and early 1990s and included patients according to the former WHO classification and before the routine use of invasive revascularisation [12,13,15,18,26]. …”

Section: Commentsmentioning

confidence: 99%

“…The declining frequency of papers reporting the "smoker's paradox" during the last decade supports our argument that the paradox was the result of skewed reports during the 1980s to 1990s. Another systematic error might be that smokers with an acute cardiac event could have a greater case fatality before admission to hospital than non-smokers [15,30,31]. Those admitted alive to the hospital would, therefore, already represent the survivors.…”

Section: Commentsmentioning

confidence: 99%

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The "smoker's paradox" in patients with acute coronary syndrome: a systematic review

Aune

Røislien

Mathisen

et al. 2011

BMC Med

133

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BackgroundSmokers have been shown to have lower mortality after acute coronary syndrome than non-smokers. This has been attributed to the younger age, lower co-morbidity, more aggressive treatment and lower risk profile of the smoker. Some studies, however, have used multivariate analyses to show a residual survival benefit for smokers; that is, the "smoker's paradox". The aim of this study was, therefore, to perform a systematic review of the literature and evidence surrounding the existence of the "smoker's paradox".MethodsRelevant studies published by September 2010 were identified through literature searches using EMBASE (from 1980), MEDLINE (from 1963) and the Cochrane Central Register of Controlled Trials, with a combination of text words and subject headings used. English-language original articles were included if they presented data on hospitalised patients with defined acute coronary syndrome, reported at least in-hospital mortality, had a clear definition of smoking status (including ex-smokers), presented crude and adjusted mortality data with effect estimates, and had a study sample of > 100 smokers and > 100 non-smokers. Two investigators independently reviewed all titles and abstracts in order to identify potentially relevant articles, with any discrepancies resolved by repeated review and discussion.ResultsA total of 978 citations were identified, with 18 citations from 17 studies included thereafter. Six studies (one observational study, three registries and two randomised controlled trials on thrombolytic treatment) observed a "smoker's paradox". Between the 1980s and 1990s these studies enrolled patients with acute myocardial infarction (AMI) according to criteria similar to the World Health Organisation criteria from 1979. Among the remaining 11 studies not supporting the existence of the paradox, five studies represented patients undergoing contemporary management.ConclusionThe "smoker's paradox" was observed in some studies of AMI patients in the pre-thrombolytic and thrombolytic era, whereas no studies of a contemporary population with acute coronary syndrome have found evidence for such a paradox.

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“…Several studies have reported lower mortality after acute myocardial infarction in smokers [17][18][19] . Smoking is a well-known risk factor for vascular diseases and mortality; therefore our paradoxical findings might be explained by differences in the distribution of other risk factors for stroke mortality, and by differences in comorbidity between smokers and non-smokers.…”

Section: Discussionmentioning

confidence: 99%

Mortality and Predictors of Death 1 Month and 3 Years after First-Ever Ischemic Stroke: Data from the First National Acute Stroke Israeli Survey (NASIS 2004)

Koton¹,

Tanné²,

Green³

et al. 2009

Neuroepidemiology

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Background: Despite declining age-adjusted stroke mortality rates, the disease remains the third most common cause of death in Israel. Based on a national survey, we examined mortality rates during the first 3 years after a first-ever acute ischemic stroke (IS) and the major predictors of short-term (1 month) and long-term (3 years) mortality. Methods: In the National Acute Stroke Israeli Survey (NASIS 2004), data were collected on all hospitalized stroke patients in Israel during a 2-month period. Mortality rates for first-ever IS were assessed at 1 month and 3 years and predictors of death were evaluated using the Cox proportional hazard model. Results: A total of 1,079 first-ever IS patients were included. Survival data were complete for over 99% of patients. Cumulative mortality rates were 9.9% at 1 month and 31.1% at 3 years. Of the survivors at 1 month, 23.5% did not survive for 3 years. At 1 month, the hazard ratio (HR) for death significantly increased with stroke severity. One-month mortality was also associated with a decreased level of consciousness (HR 2.9, 95% CI 1.7–5.1), total anterior circulation infarction (TACI); HR 4.9, 95% CI 1.6–15.2), temperature on admission (HR 1.5, 95% CI 1.1–2.1 per 1°C), age (HR 1.04, 95% CI 1.02–1.07 per year) and glucose levels on admission (HR 1.003, 95% CI 1.001–1.006 per 1 mg/dl). Age-adjusted proportions of diabetes and chronic heart failure were considerably higher in the deceased compared with survivors at 3 years (48 vs. 38 and 21 vs. 9%, respectively). In the multivariate survival analyses, predictors of death at 1 month also predicted death at 3 years; however, history of dementia (HR 1.5, 95% CI 1.0–2.4), diabetes (HR 1.6, 95% CI 1.0–2.4), peripheral artery disease (HR 1.7, 95% CI 1.1–2.8), chronic heart failure (HR 1.6, 95% CI 1.1–2.4) and malignancy (HR 1.7, 95% CI 1.1–2.7) were additional predictors of long-term mortality for patients surviving the first month after stroke. Conclusions: Approximately one third of patients did not survive 3 years after the first-ever IS. While age and markers of severe stroke were the major predictors of death at 1 month, comorbidities and variables associated with atherosclerotic vascular disease predicted long-term mortality. Improved control of these factors can potentially reduce long-term mortality in stroke victims.

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Smoking and myocardial infarction case-fatality: hospital and population approach

Cited by 25 publications

References 28 publications

Recent Racial/Ethnic Disparities in Stroke Hospitalizations and Outcomes for Young Adults in Florida, 2001–2006

Recent Racial/Ethnic Disparities in Stroke Hospitalizations and Outcomes for Young Adults in Florida, 2001–2006

The "smoker's paradox" in patients with acute coronary syndrome: a systematic review

Mortality and Predictors of Death 1 Month and 3 Years after First-Ever Ischemic Stroke: Data from the First National Acute Stroke Israeli Survey (NASIS 2004)

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