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Journal of the American College of Cardiology

Clinical Articles, Lead Article

Smokers fare much worse after revascularisation procedures

Patients with coronary artery disease who continue to smoke following angioplasty or bypass surgery have considerably poorer long-term outcomes, including a higher chance of myocardial infarction (MI), compared to non-smokers and patients who quit smoking, according to research published recently in the Journal of the American College of Cardiology.1

Researchers examined the relationship between smoking status and outcomes in 1,793 patients with severe coronary artery disease who underwent either angioplasty or bypass surgery. This was the first study to track smoking status at regular intervals – at baseline, six months and one, three and five years. While it initially appeared patients who reported smoking at the study’s outset had a similar combined rate of death, MI and stroke at five years, this did not turn out to be the case once researchers looked at smoking at different points in time.

Patients included in this study were part of the SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) trial, which with 1,800 participants is the largest contemporary trial comparing angioplasty versus bypass in patients with extensive coronary artery disease, according to authors. Smokers were younger, predominantly male and had extensive coronary artery disease despite having fewer cardiovascular risk factors such as diabetes, high blood pressure and high cholesterol. They were also more likely to have chronic obstructive pulmonary disease, peripheral vascular disease and poor left ventricle ejection fraction.

Smokers in this study were also nearly twice as likely to have an MI within five years of receiving either of these artery-opening procedures. Smoking was also associated with a significantly greater combined risk of dying, having an MI or stroke, or needing a repeat revascularisation. The study was not powered to evaluate the effect of continued smoking on mortality alone but the combined endpoint of death/MI/stroke was 80% higher in smokers than in non-smokers. Smoking remained a significant factor for adverse outcomes after adjusting for other cardiovascular risk factors and confounding variables.

“Our data has unequivocally shown that smoking has adverse outcomes after revascularisation,” said lead researcher Dr Javaid Iqbal (University of Sheffield, UK). “It is strongly advisable for patients with heart disease to quit smoking, especially those undergoing angioplasty or bypass, and clinicians should be asking about smoking status at every visit.”

“Smokers who [find out they] have established coronary artery disease and need a procedure to help fix it may stop smoking permanently or intermittently. Conversely, some patients may start smoking again at any time during follow-up,” said Dr Iqbal. “Using baseline smoking status to predict long-term outcomes is a potentially flawed approach.”

Smoking status was far from static. In all, 18% of patients changed their smoking habits during the follow-up period. Non-smokers remained non-smokers, however, current and ex-smokers has a considerable change in their status during the study. One in 5 patients were still smoking at baseline. A significant number stopped smoking following revascularisation (8.6% at six months and 8.7% at one year). However the number of smokers increased after a year, particularly among the group undergoing bypass surgery (10.8 percent of bypass patients were smokers compared to 8.7% of PCI patients at the five-year follow-up).

Based on the findings, authors urge clinicians to step up efforts to talk to patients with heart disease – especially smokers and former smokers – about the dangers of smoking and benefits of smoking cessation.

“This analysis provides compelling evidence that for patients undergoing revascularisation, smoking continuance carries a markedly increased risk of adverse outcomes, largely driven by subsequent MI,” the authors said. They add that it is critical for treating clinicians to focus assiduously on smoking cessation with all patients, remembering relapses are common, even in high risk patients who have undergone multivessel coronary revascularisation.


1. Zhang YJ, Iqbal J, van Klaveren D, et al. Smoking is associated with adverse clinical outcomes in patients undergoing revascularization with PCI or CABG – the SYNTAX trial at 5-year follow-up. J Am Coll Cardiol 2015;65:1107–15.

Published on: March 27, 2015

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