Factors affecting the 5 year survival rate of men following acute coronary heart disease

Association of Smoking Cessation and Survival Among Young Adults With Myocardial Infarction in the Partners YOUNG-MI Registry

IMPORTANCE

Despite significant progress in primary prevention, the rate of myocardial infarction (MI) continues to increase in young adults.

OBJECTIVES

To identify the prevalence of tobacco use and to examine the association of both smoking and smoking cessation with survival in a cohort of adults who experienced an initial MI at a young age.

DESIGN, SETTING, AND PARTICIPANTS

The Partners YOUNG-MI registry is a retrospective cohort study from 2 large academic centers in Boston, Massachusetts, that includes patients who experienced an initial MI at 50 years or younger. Smoking status at the time of presentation and at 1 year after MI was determined from electronic medical records. Participants were 2072 individuals who experienced an MI at 50 years or younger between January 2000 and April 2016. The dates of analysis were October to December 2019.

MAIN OUTCOMES AND MEASURES

Deaths were ascertained from the Social Security Administration Death Master File, the Massachusetts Department of Vital Statistics, and the National Death Index. Cause of death was adjudicated independently by 2 cardiologists. Propensity score-adjusted Cox proportional hazards modeling was used to evaluate the association between smoking cessation and both all-cause and cardiovascular mortality.

RESULTS

Among the 2072 individuals (median age, 45 years [interquartile range, 42-48 years]; 1669 [80.6%] men), 1088 (52.5%) were smokers at the time of their index hospitalization. Of these, 910 patients were further classified into either the cessation group (343 [37.7%]) or the persistent smoking group (567 [62.3%]) at 1 year after MI. Over a median follow-up of 11.2 years (interquartile range, 7.3-14.2 years), individuals who quit smoking had a statistically significantly lower rate of all-cause mortality (hazard ratio [HR], 0.35; 95% CI, 0.19-0.63; P < .001) and cardiovascular mortality (HR, 0.29; 95% CI, 0.11-0.79; P = .02). These values remained statistically significant after propensity score adjustment (HR, 0.30 [95% CI, 0.16-0.56; P < .001] for all-cause mortality and 0.19 [95% CI, 0.06-0.56; P = .003] for cardiovascular mortality).

CONCLUSIONS AND RELEVANCE

In this cohort study, approximately half of individuals who experienced an MI at 50 years or younger were active smokers. Among them, smoking cessation within 1 year after MI was associated with more than 50% lower all-cause and cardiovascular mortality.

Cost-benefit aspects of post-myocardial infarction intervention

After myocardial infarction the mortality during the first post hospital year declines from approximately 10 per cent to 5 per cent during the second year. The rates of non-fatal recurrencies are similar. Mortality is related to age but not to the same extent to sex. Non-fatal recurrencies are, however, not related to age. Prediction of mortality is feasible by several prognostic models. Factors related to size of myocardial damage stand out as the important secondary risk factors for the years immediately after infarction. Most of these factors are not generally related to risk of non-fatal recurrencies. The proportion of cardiovascular deaths is 90 per cent during the first years and declines thereafter. Simplistically it may be said that the prognosis during the first years is related to the extent of the myocardial damage and thereafter primary risk factors become more important. Thus, it seems logical in the short-term perspective to influence myocardial factors and related arrhythmias and in the long-term perspective to influence primary risk factors which more likely operate on the vascular factors. Three preventive methods have demonstrated a positive benefit: 1) chronic beta-blockade, 2) cessation of smoking, 3) by-pass surgery in certain categories. After careful calculations it may be argued that at least half of the total mortality may be inhibited by beta-blockade and cessation of smoking. The impact of coronary surgery, lipid lowering and reduction of high blood pressures is more difficult to assess.

Three life-years gained from smoking cessation after coronary artery bypass surgery: a 30-year follow-up study

BACKGROUND

Previous studies have shown that smoking cessation after a cardiac event reduces the risk of subsequent mortality in patients, but the effect of smoking cessation in terms of prolonged life-years is not yet known.

METHODS

We analyzed the 30-year clinical outcome of the first 1,041 consecutive patients (age at operation 51 years, 92% male) who successfully underwent isolated venous coronary artery bypass surgery between 1971 and 1980. All 551 smokers (53%) were included in this study. Of these, 43% stopped smoking throughout the first year whereas 57% persisted smoking.

RESULTS

The median follow-up was 29 years (range 26-36 years). The cumulative 10-, 20-, and 30-year survival rates were 88%, 49%, and 19%, respectively, in the group of patients who quit smoking, and only 77%, 36%, and 11%, respectively, in the persistent smokers (P < .0001). After adjusting for all baseline characteristics, smoking cessation remained an independent predictor of lower mortality (hazard ratio 0.60, 95% CI 0.48-0.72). We were able to assess the exact life expectancy by calculating the area under the Kaplan-Meier curves. Life expectancy in the quitters was 20.0 years and 17.0 years in the persistent smokers (P < .0001).

CONCLUSIONS

Using 30-year follow-up data, we estimated that self-reported smoking cessation after coronary artery bypass surgery was associated with a life expectancy gain of 3 years. Smoking cessation turned out to have a greater effect on reducing the risk of mortality than the effect of any other intervention or treatment.

Coronary artery disease screening, treatment, and follow-up

Heart disease causes more than 30% of US deaths. Evidence-based screening allows a primary care physician to identify patients at risk before symptom onset. Estimating disease probability before screening affects which tests are appropriate. Low-risk adults should not be screened. ECG, exercise treadmill testing, cardiac stress imaging, electron beam computed tomography, and angiography are possible screening tests. Special populations may have additional screening indications. Management of patients who have coronary artery disease includes antiplatelet therapy; aggressive lipid lowering; management of hypertension with beta blockers and angiotensin-converting enzyme inhibitors; risk factor management, including smoking cessation, diet, and exercise; symptom management; and sometimes revascularization. Primary care physicians are well-suited to the monitoring and care of patients who have known coronary artery disease.

Association of bodyweight with total mortality and with cardiovascular events in coronary artery disease: a systematic review of cohort studies

BACKGROUND

Studies of the association between obesity, and total mortality and cardiovascular events in patients with coronary artery disease (CAD) have shown contradictory results. We undertook a systematic review to determine the extent and nature of this association.

METHODS

We selected cohort studies that provided risk estimates for total mortality, with or without cardiovascular events, on the basis of bodyweight or obesity measures in patients with CAD, and with at least 6 months' follow-up. CAD was defined as history of percutaneous coronary intervention, coronary artery bypass graft, or myocardial infarction. We obtained risk estimates for five predetermined bodyweight groups: low, normal weight (reference), overweight, obese, and severely obese.

FINDINGS

We found 40 studies with 250,152 patients that had a mean follow-up of 3.8 years. Patients with a low body-mass index (BMI) (ie, <20) had an increased relative risk (RR) for total mortality (RR=1.37 [95% CI 1.32-1.43), and cardiovascular mortality (1.45 [1.16-1.81]), overweight (BMI 25-29.9) had the lowest risk for total mortality (0.87 [0.81-0.94]) and cardiovascular mortality (0.88 [0.75-1.02]) compared with those for people with a normal BMI. Obese patients (BMI 30-35) had no increased risk for total mortality (0.93 [0.85-1.03]) or cardiovascular mortality (0.97 [0.82-1.15]). Patients with severe obesity (> or =35) did not have increased total mortality (1.10 [0.87-1.41]) but they had the highest risk for cardiovascular mortality (1.88 [1.05-3.34]).

INTERPRETATION

The better outcomes for cardiovascular and total mortality seen in the overweight and mildly obese groups could not be explained by adjustment for confounding factors. These findings could be explained by the lack of discriminatory power of BMI to differentiate between body fat and lean mass.

Impact of Smoking Status on Long-Term Mortality in Patients With Acute Myocardial Infarction

BACKGROUND

Cessation of smoking after a cardiovascular event has been shown in Western countries to have a beneficial effect on clinical events during long-term follow-up. However, knowledge of the effect of smoking status after acute myocardial infarction (AMI) on the long-term mortality based on a large-scale sample is still limited in Japan.

METHODS AND RESULTS

In the present study 2,579 AMI patients were enrolled in the Osaka Acute Coronary Insufficiency Study (OACIS) between April 1998 and March 2003. Smoking status was assessed at baseline and 3 months after hospital discharge by mailed questionnaire. Patients were divided into nonsmokers (n=823), former smokers (those who had stopped smoking before AMI onset, n=332), quitters (those who stopped smoking after AMI onset, n=1,056), and persistent smokers (those who smoked before and after AMI, n=368). Quitters had lower long-term mortality rates than persistent smokers (3.0% vs 5.2%; log rank, p=0.032). Multivariate Cox regression analysis revealed that smoking cessation was independently associated with a reduction in risk of long-term mortality (hazard ratio, 0.39; 95% confidence interval, 0.20-0.77).

CONCLUSIONS

Patients who continue to smoke after AMI are at greater risk for death than patients who quit smoking. Cessation of smoking benefits the long-term prognosis in patients with AMI.

Hospital- and clinic-based smoking cessation interventions for smokers with cardiovascular disease

Cigarette smoking is the leading preventable cause of death in the United States and a major risk factor for cardiovascular disease (CVD). Large observational epidemiologic studies conducted in diverse populations have demonstrated a strong association between smoking and CVD morbidity and mortality. Observational epidemiologic studies have also demonstrated a substantial benefit of smoking cessation on cardiovascular morbidity and mortality. Smoking cessation after myocardial infarction reduces subsequent cardiovascular mortality by nearly 50%. Therefore, the use of effective strategies to reduce the prevalence of tobacco use is a high priority for both the primary and secondary prevention of CVD. Effective smoking cessation interventions have been identified in randomized controlled trials in the general population of smokers. These methods, which include behavioral counseling and pharmacotherapy, are incorporated into clinical practice guidelines for physicians in the United States and Great Britain. A smaller but still substantial body of evidence demonstrates the efficacy of these interventions in hospital- and clinic-based settings for smokers with CVD. This evidence is sufficient to support the routine implementation of these smoking cessation methods in inpatient and outpatient settings for smokers with CVD.

[Smoking cessation and risk of myocardial reinfarction in coronary patients: a nested case-control study]

INTRODUCTION AND OBJECTIVES

Smoking cessation reduces mortality in coronary patients. The aim of this study was to estimate association measures between the risk of occurrence of fatal or non-fatal reinfarction in patients who either continue to smoke or stop after a first infarction and are treated with secondary prevention measures.

PATIENTS AND METHOD

The study was a case-control (1:1) design nested in a cohort of 985 coronary patients under the age of 76 years who were not treated with invasive procedures and survived more than 6 months after the first acute myocardial infarction. Cases were all patients who suffered reinfarction (n = 137) between 1997 and 2000. A control patient was matched with each case by gender, age, hospital, interviewer, and the secondary prevention timeframe.

RESULTS

Patients who smoke after the first acute myocardial infarction had an Odds ratio (OR) of 2.83 (95% CI, 1.47-5.47) for a new acute myocardial infarction. Adjustment for lifestyle, drug treatment, and risk factors (family history of coronary disease, high blood pressure, hypercholesterolemia, and diabetes mellitus) did not change the OR (2.80 [95% CI, 1.35-5.80]). Patients who quit smoking had an adjusted OR of 0.90 (95% CI, 0.47-1.71) compared with non-smokers before the first acute myocardial infarction. Continued smoking had an adjusted OR of 2.90 (95% CI, 1.35-6.20) compared to quitting after the first acute myocardial infarction.

CONCLUSION

The risk of acute myocardial infarctions is three times higher in patients who continue to smoke after an acute coronary event compared with patients who quit. The risk of reinfarction in patients who stop smoking is similar to the risk of non-smokers before the first infarction.

Smoking cessation reduces mortality after coronary artery bypass surgery: a 20-year follow-up study

OBJECTIVES

The goal of this study was to determine the influence of smoking cessation on mortality after coronary artery bypass graft surgery (CABG), which has still not been established clearly.

BACKGROUND

Cigarette smoking is one of the known major risk factors of coronary artery disease.

METHODS

One thousand and forty-one patients underwent CABG between 1971 and 1980. The preoperative and postoperative smoking habits of 985 patients (95%) could be retrieved and were analyzed in a multivariate Cox analysis.

RESULTS

The median follow-up was 20 years (range 13 to 26 years). Smoking status before surgery did not entail an increased risk of mortality: patients who had smoked before surgery and those who had not smoked in the year before surgery had a similar probability of survival. However, smoking cessation after surgery was an important independent predictor of a lower risk of death and coronary reintervention during the 20-year follow-up when compared with patients who continued smoking. In analyses adjusted for baseline characteristics, the persistent smokers had a greater relative risk (RR) of death from all causes (RR 1.68 [95% confidence interval 1.33 to 2.13]) and cardiac death (RR 1.75 [1.30 to 2.37]) as compared with patients who stopped smoking for at least one year after surgery. The estimated benefit of survival for the quitters increased from 3% at five years to 14% at 15 years. The quitters were less likely to undergo repeat CABG or a percutaneous coronary angioplasty procedure (RR 1.41 [1.02 to 1.94]).

CONCLUSIONS

Patients who continued to smoke after CABG had a greater risk of death than patients who stopped smoking. They also underwent repeat revascularization procedures more frequently. Cessation of smoking is therefore strongly recommended after CABG. Clinicians are encouraged to start or to continue smoking-cessation programs in order to help smokers to quit smoking, especially after CABG.

[Ambulatory cardiac phase II rehabilitation--"the Cologne model"--including 3-year-outcome after termination of rehabilitation]

From January 1992 until December 1994 the Cologne model of ambulant cardiac rehabilitation (ACR) in the greater area of Cologne, Germany, was performed and is still in progress. In Germany until 1992 the cardiac rehabilitation was exclusively performed stationary. The objective of the "Cologne model" was to evaluate, whether the transfer of the stationary cardiac rehabilitation programs into the ambulatory setting is achievable without deficits in efficiency, safety and overall quality. The results obtained are intended to serve for standardization and quality control of future ambulatory cardiac rehabilitation programs in Germany. From 1992 to 1994 108 patients (94 men, 14 women; 52.3 +/- 8.0 years old) with coronary artery disease (CAD) which were compatible with the criteria of the "Cologne model" (Table 1) participated in the 4-week ACR. The indications for inclusion into the ACR were in 74 cases a myocardial infarction (MI), in 34 cases CAD without MI, but with PTCA/stent-procedure (Table 3). Seven patients discontinued the ACR prematurely, 2 patients because of cardiovascular reasons. Reasons for the preference of the ambulatory over a stationary cardiac rehabilitation program were in 40.6% of the patients refusal of "hospital ambience", in 43.6% familiar or in 12.9% professional reasons. During the 4-week ACR patients participated in a mean of 72.9 +/- 6.7 hours of therapy (Table 4). As a result of the ACR exercise tolerance increased highly significantly (**) from 116.4 +/- 28.8 to 129.9 +/- 34.6 watt). This improvement was maintained at the 1- and 3-year control (128.7 +/- 35.8**) examinations (Tables 5 and 7). One year after ACR 77% of the patients stated to be physically active in ambulatory heart groups (AHG) (27.6%) or on their own (49.4%). Three years after ACR the rate of regularly physically active patients still was 59.2%. Furthermore, as a result of ACR the dietary behavior was changed significantly. There was a reduction in the consumption of lipids by 20.8%, saturated fatty acids by 30.7% and of cholesterol by 30.5%. The plasma concentrations of cholesterol decreased from 231 +/- 49.8 to 213.2 +/- 35.9 mg%**. Six (and 12) months after ACR they increased again to 225.6 +/- 39.4 mg%. Three years after ACR the mean cholesterol level was 219.1 +/- 39.3 mg%. In the high risk group (cholesterol at the initial visit > 220 mg%) cholesterol levels were reduced from 266 +/- 44 to 232 +/- 31.9 mg%**. Six and 12 months after ACR they were 239.7 +/- 35.8 mg% and 245.8 +/- 32.6 mg%, respectively, (Tables 6 and 7) and still significantly lower than before ACR, though only 19% of the patients were treated with lipid lowering agents. Three years after ACR cholesterol were 234.6 +/- 37.7 mg%** in the high-risk group. 34.2% of the patients received lipid lowering agents. Mean body weight remained unaltered over the 3-year period. Smoking behavior was not altered significantly during the 4-week ACR. However, before the cardiovascular event 67.3% of the patients had smoked cigarettes. At the beginning and at the end of ACR 20.8% of the patients still smoked. During the ACR the number of smoked cigarettes was reduced significantly from 32.4 +/- 15.2 to 6.9 +/- 5.2 cigarettes per day. One year after ACR 23% of the patients were smokers, 3 years after ACR the percentage of smokers increased to 30.3%. Before ACR 73.3% of the patients were still working. During the first 6 months after ACR 68.2% returned to work and the percentage increased to 73% in the following 6 months. The results demonstrate that it is achievable to transfer the contents of the established stationary cardiac rehabilitation programs into the ambulatory setting without loss of efficiency, safety and overall quality. It is further confirmed, that it is necessary to continuously evaluate the results of the cardiac rehabilitation program on a long-term basis. (ABSTRACT TRUNCATED)

Modification of smoking habits five months after myocardial infarction: relationship with personality characteristics

The relationship between personality characteristics and spontaneous modification of smoking habits was assessed in 164 patients after their first myocardial infarction (MI). Smoking habits before the MI were investigated in retrospect and 5 months later. Smoking appeared to have decreased significantly. Persistent smokers could be differentiated from nonsmokers and exsmokers by a significantly high level of state-anxiety and depression. Young persistent smokers had a high level of depression; elderly persistent smokers were highly anxious and had a low level of somatization. The relationship between smoking behaviour modification and personality characteristics is discussed in association with intervention programmes.

Smoking and cardiac events after venous coronary bypass surgery. A 15-year follow-up study

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.

Coronary risk factor status after percutaneous transluminal coronary angioplasty

OBJECTIVE

To determine whether patients modify their risk factors after undergoing percutaneous transluminal coronary angioplasty (PTCA).

DESIGN

One-group, pretest-posttest. Pretest data were collected on the day before PTCA, and posttest data were collected at a mean follow-up of 11 months after PTCA. Data were collected from medical records and by patient self-report.

SETTING

University-affiliated, metropolitan public and private hospitals.

PATIENTS

Two hundred nine patients undergoing PTCA.

OUTCOME MEASURES

Patients' smoking and exercise habits were assessed by self-report. Serum cholesterol level and body mass index were determined from entries in medical charts.

RESULTS

All measured risk factors, with the exception of smoking, underwent favorable change (p < 0.001) after PTCA. The number of current smokers, however, increased significantly (p < 0.001), as did the number of cigarettes these patients smoked per day (p < 0.05).

CONCLUSION

Evaluation of the effect of intervention strategies on reducing patients' smoking behavior after PTCA is required.

The prevention of cardiovascular disease. Emphasis on secondary prevention

Atherosclerosis is a progressive disease affecting all major arteries. Clinical evidence of atherosclerosis increases the risk of subsequent morbid and mortal events fivefold to sevenfold over the next 5 to 10 years. The same risk factors contribute to the initial development of CVD events as to their recurrence. Both coronary and noncoronary events, such as stroke or PAD, reflect the severity of the underlying atherosclerotic process and strongly predict future excess CVD morbidity and mortality. Short-term and long-term survival depends on modifying the risk factors that contribute to CVD events. Although absolute proof of benefit for secondary prevention does not exist for all risk factors, the data from primary prevention trials and the secondary prevention trials that have been done argue strongly for aggressive intervention. Benefit has been demonstrated for smoking cessation, cholesterol reduction, and blood pressure control. Selected patients may benefit from additional medical, procedural, or surgical interventions to prolong life, such as beta-blocking agents, aspirin, or carotid endarterectomy. Many secondary prevention measures are a cost-effective way to reduce the substantial morbidity and mortality due to CVD. Contrary to primary prevention, even modest treatment effects from secondary prevention efforts can benefit large numbers of patients. Finally, secondary prevention may be more successful because patients with clinical evidence of CVD may be more highly motivated than their healthy counterparts to make and maintain lifestyle changes.

Long-term predictors of subsequent cardiovascular events with coronary artery disease and 'desirable' levels of plasma total cholesterol

BACKGROUND

Patients with coronary artery disease (CAD) are at considerable risk for subsequent cardiovascular events. Although hyperlipidemia accentuates the risk, predictors of subsequent events with CAD and desirable total cholesterol (TC) (less than 5.2 mmol/l) have not been assessed.

METHODS AND RESULTS

A survival analysis was performed in a subset of 740 consecutive patients who underwent diagnostic coronary arteriography between 1977 and 1978. Eight-three men and 24 women with angiographically documented CAD and desirable TC were followed for subsequent cardiovascular events, including myocardial infarction and cardiovascular death. Over a 13-year period, 75% of CAD subjects with reduced high density lipoprotein cholesterol (HDL-C) (less than 0.9 mmol/l) developed a subsequent cardiovascular event compared with 45% of those with HDL-C greater than or equal to 0.9 mmol/l (p = 0.002). A Kaplan-Meier analysis revealed significantly greater survival from cardiovascular end points in patients with baseline levels of HDL-C greater than or equal to 0.9 mmol/l (p = 0.005). After 11 variables were tested, an age-adjusted Cox proportional-hazards model identified two pairs of independent predictors of subsequent cardiovascular events: they were a left ventricular ejection fraction (LVEF) less than 35% (relative risk [RR], 6.5; 95% confidence interval [CI], 2.8, 15.3; p less than 0.001) and reduced HDL-C (RR, 2.0; 95% CI, 1.2, 3.3; p = 0.01) in the first model and LVEF less than 35% (RR, 6.5; 95% CI, 2.7, 15.6; p less than 0.001) and TC:HDL ratio greater than or equal to 5.5 (RR, 1.9; 95% CI, 1.1, 3.1; p = 0.02) in the second model.

CONCLUSIONS

Low HDL-C (or high TC:HDL-C) is strongly predictive of subsequent cardiovascular events in subjects with CAD, despite desirable TC. As such, identification of this potentially modifiable risk factor should be actively pursued in this high-risk subgroup.

Early predictors of smoking cessation after myocardial infarction

The determinants of long-term smoking cessation were evaluated in 80 patients who smoked cigarettes and survived a myocardial infarction. All patients underwent a program of rehabilitation and secondary prevention including in-hospital counseling and physician-guided reinforcing sessions at 1, 3, and 6 months after discharge. At 18 months of follow-up, 53 patients (66.3%) had quit smoking. Variables associated with smoking cessation were duration of hospital stay greater than or equal to 19 days (79 vs. 48%; p less than 0.005) and peak creatine phosphokinase (CPK) elevation greater than or equal to 500 U/l (76 vs. 54%; p less than 0.05). Males tended to quit in higher proportion than females (68 vs. 44%). Age, prior myocardial infarction, other cardiovascular risk factors, infarction location, Killip class at entry, and duration of stay in coronary care unit did not significantly affect the quitting rates. Logistic regression analysis singled out the duration of hospital stay as a significant predictor of smoking cessation (p less than 0.005). Early and intensive secondary prevention during the hospital stay is crucial in promoting sustained smoking cessation after myocardial infarction.

Beneficial six-year outcome of smoking cessation in older men and women with coronary artery disease. Results from the CASS registry

We investigated the effects of cigarette smoking and cessation of smoking in a cohort of 1893 men and women from the Coronary Artery Surgery Study (CASS) registry who were 55 years of age or older and had angiographically documented coronary artery disease. The six-year mortality rate was greater among continuing smokers (n = 1086) than among those who quit smoking during the year before enrollment in the study and abstained throughout the study (n = 807) (relative risk, 1.7 [95 percent confidence limits, 1.4, 2.0]). Continuing smokers were also at higher risk of either myocardial infarction or death (1.5 [1.2, 1.7]). There was no diminution of the beneficial effect with increasing age. The relative risks of death were 1.7 (1.4, 2.1) and 1.6 (1.1, 2.3) for the groups 55 to 64 years old and 65 or older, respectively, and 1.6 (1.4, 1.9) for comparable subgroups among CASS subjects 35 to 54 years of age. When subjects were arrayed according to risk quartile, the benefits of smoking cessation were greatest in those at moderate risk. We conclude that smoking cessation lessens the risk of death or myocardial infarction in older as well as younger persons with coronary artery disease.

Left ventricular end-systolic volume as the major determinant of survival after recovery from myocardial infarction

Impairment of left ventricular function is the major predictor of mortality after acute myocardial infarction, but it is not known whether this is best described by ejection fraction or by end-systolic or end-diastolic volume. We measured volumes, ejection fractions, and severity of coronary arterial occlusions and stenoses in 605 male patients under 60 years of age at 1 to 2 months after a first (n = 443) or recurrent (n = 162) myocardial infarction and followed these patients for a mean of 78 months for survivors (range 15 to 165 months). There were 101 cardiac deaths, 71 (70%) of which were sudden (instantaneous or found dead). Multivariate analysis with log rank testing and the Cox proportional hazards model showed that end-systolic volume (chi 2 = 82.9) had greater predictive value for survival than end-diastolic volume (chi 2 = 59.0) or ejection fraction (chi 2 = 46.6), whereas stepwise analysis showed that once the relationship between survival and end-systolic volume had been fitted, there was no additional significant predictive information in either end-diastolic volume or ejection fraction. Severity of coronary occlusions and stenoses showed additional prediction of only borderline significance (p = .04 in one analysis), but continued cigarette smoking did remain an independent risk factor after stepwise analysis. For a subset of patients (n = 200) who had taken part in a randomized trial of coronary artery surgery after recovery from infarction, surgical "intention to treat" showed no predictive value.(ABSTRACT TRUNCATED AT 250 WORDS)

Factors related to patient smoking status

To investigate those factors associated with patients' cigarette smoking status, 455 consecutive patients seen in two specialty clinics and one general medicine clinic at a university medical center were studied. Patient's age, sex, health status, and number of previous cessation attempts discriminated current from ex-smokers. A strong interaction was observed between sex and disease status with females showing a greater impact of smoking-related disease on smoking behavior than males.

A low-cost environmental intervention for reducing smoking among cardiac inpatients

Abstinence rates for smokers following a myocardial infarction or coronary artery bypass graft surgery may not be superior to those for nonpatient groups, and thus there is a need for novel approaches to smoking cessation in this population. The present study evaluated the effectiveness of using two sets of educational posters to reduce smoking among veterans in an inpatient cardiology unit's designated smoking area. One set of posters outlined the benefits of cessation (positive message) for cardiac patients while the other highlighted the risks of continued smoking (negative message). The positive posters had no consistent effect on indices of smoking, but the negative posters produced a substantial decline in both number of observed smokers and daily cigarette butts.

Lifestyle changes in long term survivors of acute myocardial infarction

A retrospective questionnaire and interview study of 10 year survivors of uncomplicated myocardial infarction examined smoking, diet, exercise, weight, medication, and treatment since discharge from hospital in 1973-4 and made comparisons with controls (using the same questionnaire) and with normal populations (as reported by others). Long term survivors of myocardial infarction previously smoked more than controls; made more dietary changes than controls; and presently eat less butter, sugar, cake, and biscuits and drink less milk than controls; previously weighed more than controls; exercised less than controls both previously and presently; use more 'non-cardiac' as well as 'cardiac' drugs than controls; and are more depressed and more anxious than controls.

Highlighting specific patient education needs in an aging cardiac population

Given the utility of a multifactoral approach to cardiac rehabilitation and the importance of tailoring such an approach to the needs of the specific cardiac population being treated, early assessment of targeted risk factors and health-related practices is becoming increasingly indicated. The present article describes how, by using a paper-and-pencil multiple-risk-factor assessment instrument referred to as the Heart Health Assessment Questionnaire, the specific educational needs of an aging veteran population were more clearly identified. Among the health areas found in need of particular attention were patient smoking behavior, medication education, and reported tension and worry over health problems. In addition, given the large unemployment rate within this population, the need for the adoption of activities such as physical exercise and hobbies that could have a positive impact on self-esteem and quality of life was strongly indicated. These and other findings are discussed in relation to the pivotal role of the health education professional for older cardiac populations.

Does stopping smoking delay onset of angina after infarction?

This study was designed to determine the relation between stopping smoking and angina after infarction in survivors of an acute coronary attack. The study population comprised 408 men aged under 60 who survived a first attack of unstable angina or myocardial infarction by 28 days and were smoking cigarettes at the time of their attack. These patients were followed up for an average of nine years. Three hundred and eighty four were alive at the one year follow up examination, when the presence or absence of angina together with habits of smoking were recorded. The prevalence of angina at one year was 19.5% in the 241 who had stopped smoking cigarettes compared with 32.2% in those who had continued (p less than 0.01). Six years later, however, the prevalence of angina after infarction was the same in the two groups. It is concluded that the onset of angina after infarction can be delayed by stopping smoking cigarettes but that this effect is not maintained in the long term.

Smoking status at the time of acute myocardial infarction and subsequent prognosis

A population of 2955 patients admitted to the hospital with acute myocardial infarction (AMI) was followed for 1 year after AMI or until death. Smokers as compared to nonsmokers were over 10 years younger (p less than 0.001) and had a lower prevalence of hypertension (p less than 0.01), congestive heart failure (p less than 0.0001), angina pectoris (p less than 0.01), and diabetes (p less than 0.0001). They had less severe myocardial infarction evidenced, for example, by lower prevalence of pulmonary congestion on chest x-ray (p less than 0.01). Both early (1 month) and late (6 and 12 months) mortality rates were lower in the smoking population (p less than 0.0001 at 1 month, p less than 0.05 at 6 months, and p less than 0.01 at 1 year). Adjusting for age and other variables reduced but did not reverse the survival differential favoring smokers at 1 month, but adjusting for age alone eliminated the differences in mortality rates at 6 and 12 months. We conclude that while smoking is a risk factor for cardiovascular disease and may contribute to the occurrence of AMI at a younger age, smoking at the time of AMI does not appear to be an independent predictor of death during the first year after AMI.

Effect of smoking habits and timolol treatment on mortality and reinfarction in patients surviving acute myocardial infarction

The Norwegian Multicenter Group Study noted the effect of smoking habits before and after myocardial infarction and their relation to mortality and reinfarction rate after treatment with timolol in patients surviving acute myocardial infarction. The mean follow up period was 17.3 (range 12-33) months. No relation was found between initial smoking habits and risk category after infarction or between initial smoking habits and later outcome. At the time of their first infarct smokers were seven years younger than non-smokers. One moth after infarction nearly 60% of the smokers had stopped smoking completely. A significantly lower incidence of early cardiac death and lower total mortality was found in patients treated with timolol in both those who continued smoking and in the combined non-smoking groups and a significantly lower reinfarction rate among non-smokers. Cessation of smoking alone was associated with a reduced reinfarction rate by 45% but a non-significant reduction in mortality by 26%. It is concluded that treatment with timolol and cessation of smoking have an additive effect in reducing mortality and reinfarction rate after myocardial infarction.

Variables related to long-term smoking status following cardiac events

Abstinence rates for smokers following a myocardial infarction (MI) or coronary by-pass surgery (CABG) are far superior to those for persons attending formal cessation programs. However, only two studies have used any biochemical verification of self-report in this population, and it is unclear what variables are associated with successful cessation post-MI or -CABG. The present study used alveolar carbon monoxide levels to verify self-report of post-MI and -CABG veterans and obtained only a 29% abstinence rate. Most abstinent veterans quit immediately after their first cardiac event, and only the belief that smoking contributed to their cardiac problems predicted long-term smoking status.

Factors affecting cigarette smoking status in patients with ischemic heart disease

To determine the factors affecting cigarette smoking status after the development of ischemic heart disease, 200 patients were studied who were hospitalized with a coronary event and enrolled in a cardiac rehabilitation program. There were significantly more current smokers (55%) among the 96 patients hospitalized with an initial presentation of a coronary event as compared to the percent of current-smokers (34%) among the 104 patients hospitalized with a recurrent coronary event (p less than 0.01). In addition to the occurrence of a prior event, increasing age also significantly discriminated ex-cigarette smokers from current smokers. Among the patients with a recurrent event ex-smokers (44%) and current smokers (34%) differed significantly with respect to age, education, occupation, negative attitudes towards smoking and peak number of cigarettes smoked. Two models were developed which were able to correctly classify 61.7 and 69.1% of the patients with regard to smoking status.

The fall in mortality from ischemic heart disease in Australia: has survival after myocardial infarction improved?

Trends in mortality and survival after myocardial infarction (MI) were studied by use of computerised death and hospital discharge records for 25 to 64 year old residents of the Perth Statistical Division between 1971 and 1979. Highly significant falls in ischemic heart disease (IHD) mortality rates were found for men (18%) and women (29%) but 4, 26 and 52 week survival after hospital admission for MI remained constant at around 88%, 84% and 81% respectively. Further, as 75% of all IHD deaths between 1971 and 1979 occurred before the victim was admitted to hospital, the survival of those receiving treatment would have had to be greatly improved to influence total mortality from IHD appreciably. As the age and sex composition of persons hospitalised for MI and the proportion of MI victims hospitalised did not change during the study period it would seem that improved survival after hospital admission for MI did not contribute to the fall in IHD deaths between 1971 and 1979.

Long-term prognosis after recovery from myocardial infarction: a nine year follow-up of the Perth Coronary Register

Patients registered by the 1971 Perth Coronary Register as having suffered a myocardial infarction were followed up for 9 years. The Register was a community-based study that used standard methods and criteria as part of a World Health Organization collaborative investigation. Of the 1078 patients studied, 77% survived the first 24 hr and 62% the first 28 days; 0.3% were lost to follow-up. For the 666 patients alive at 28 days, the crude 1, 5, and 9 year survival rates were 88%, 67%, and 52%, respectively. The relationship between 54 variables and the survival of patients alive 28 days after myocardial infarction was examined by life-table methods and the log rank test, and then by fitting a proportional hazards model to the data. The important prognostic factors were age, sex, past history of myocardial infarction, stroke, diabetes and hypertension, tachycardia at presentation, hypotension at presentation, and the occurrence of arrhythmias as short-term complications. The most appropriate mathematical description of the joint effects of the prognostic factors was a multiplicative model with no interaction.

Long term effect on mortality of stopping smoking after unstable angina and myocardial infarction

Subjects who stop smoking cigarettes after myocardial infarction have an improved rate of survival compared with those who continue, but to date it was not known whether the benefit persisted for more than six years. A total of 498 men aged under 60 years who had survived a first episode of unstable angina or myocardial infarction by two years were followed up by life table methods for a further 13 years. Mortality in those who continued to smoke was significantly higher (82.1%) than in those who stopped smoking (36.9%). These differences increased with time. Mortality in those who were non-smokers initially and who continued not to smoke was intermediate (62.1%). The adverse effect of continued smoking was most pronounced in those with unstable angina. Continuing to smoke increased the rate of sudden death to a greater degree in those with less severe initial attacks, while the effect of smoking on fatal reinfarctions was most apparent in those with a more complicated presentation. These findings suggest that stopping cigarette smoking is the most effective single action in the management of patients with coronary heart disease.

Cessation of smoking after myocardial infarction. Effects on mortality after 10 years

Ten annual cohorts of men suffering from their first myocardial infarction have been followed up to a maximum period of 10.5 years. One thousand and twenty-three male patients of 1306 were smokers. Three months after the infarction 55% had stopped smoking and 45% continued smoking. These two groups were then compared and followed with regard to non-fatal reinfarctions and deaths. Preinfarction characteristics were shown to be similar for the two groups. The prognostic comparability of the two groups was tested using two multiple logistic models. Those who stopped smoking had a slightly higher predicted two year mortality after the infarction. In different age groups it is shown with life table technique that those who stopped smoking had a considerably higher survival rate and lower cumulative frequency of reinfarction. The present study shows a reversion of the expected prognosis after myocardial infarction caused by changing the smoking habit.

Cigar and pipe smoking related to four year survival of coronary patients

Six hundred and thirty-four male patients under 60 years who survived a first attack of unstable angina or myocardial infarction were followed for a period of four years. Details of initial and follow-up smoking habits were examined. Patients who continued to smoke cigarettes or cigars had an excess mortality compared with non-smokers, with those who stopped smoking, and with cigarette smokers who changed to pipe smoking. Pipe smokers who continued smoking the pipe had an observed mortality which was greater than that of the non-smokers, but the numbers were small and the results were not statistically significant. The effect of smoking habit on mortality was not influenced by two other determinants of prognosis: age and severity of initial attack. These results confirm that the long-term prognosis of patients after unstable angina or myocardial infarction may be significantly influenced by smoking habits. They are consistent with the hypothesis that cigar and pipe smoking may have an adverse effect after myocardial infarction but further studies are needed to corroborate the association between cigar and pipe smoking and prognosis of coronary heart disease.

Natural history of coronary heart disease: a study of 586 men surviving an initial acute attack

A total of 586 men who survived an initial attack of unstable angina or myocardial infarction have been followed for up to 15 years. A policy of early mobilization and sustained risk factor advice was employed. A conservative approach to treatment was adopted during the acute and follow-up stages. Drugs were employed only for symptomatic reasons, and only two patients proceeded to coronary artery bypass surgery. Survival at 5, 10, and 15 years was 80%, 61%, and 43%. Older patients and those with more severe initial attacks had a higher mortality, but these factors did not relate to combined fatal and nonfatal recurrence of myocardial infarction. Of 22 studies reviewed, 18 report a higher mortality than does our study. Four studies, none strictly comparable, report a similar 5-year mortality. A conservative approach to management does not appear to be harmful and may be beneficial.

A randomised controlled trial of anti-smoking advice: 10-year results

Ten-year results are reported from a randomised controlled trial of anti-smoking advice in 1445 male smokers, aged 40-59, at high risk of cardiorespiratory disease. After one year reported cigarette consumption in the intervention group (714 men) was one-quarter that of the "normal care" group (731 men); over 10 years the net reported reduction averaged 53%. The intervention group experienced less nasal obstruction, cough, dyspnoea, and loss of ventilatory function. Over 10 years their mortality from coronary heart disease was 18% lower than controls (49 and 62 deaths), and that for lung cancer was 23% lower (18 and 24 deaths). Deaths from non-lung cancers were higher in the intervention group (28 v 12 deaths). This unexpected difference was due about equally to an excess in intervention and a deficiency in normal care men, it showed no site specificity, and it was unrelated to change in smoking habit. These findings suggest that it is more likely to have been due to change than to intervention. The total number of deaths were 123 in the intervention group and 128 in normal care (95% confidence limits of difference -22% to +23%). The policy of encouraging smokers to give up the habit should not be changed.

Rapid resumption of cigarette smoking following myocardial infarction: inverse relation to MI severity

In order to identify factors associated with relapse to cigarette smoking, medical and interview data were collected from 66 chronic smokers hospitalized for acute myocardial infarction (MI). Relapse to smoking during the in-hospital recovery period was prevalent (38% of patients). The major correlate of smoking relapse was MI severity, with relapse probability declining as MI severity increased; patients who relapsed to smoking during the recovery period had experienced less severe MIs, as indicated by their serum creatine phosphokinase (CPK) enzyme levels and their requiring significantly shorter intensive-care treatment. Smoking relapse was not related to patients' smoking histories, their reported craving experiences, their reported health beliefs or demographic characteristics. The fact that relapse is most likely among patients with the best medical prognostic status suggests that the benefits of post-MI smoking cessation may have been underestimated in previous studies.

Shortened cardiac rehabilitation: a three year experience

One-hundred-and-twenty-four (19%) of patients with acute myocardial infarction seen in a three year period from 1975 to 1978 were considered low risk patients suitable for rapid mobilisation, early discharge, and early exercise testing. Their mean long term Norris Prognostic Index was 3.2; the mean date of discharge was 9.6 days, and the mean date of exercise testing was 10.5 days. There were seven deaths and nine non-fatal recurrent myocardial infarctions in a mean follow up time of 14.2 months. These events were best predicted by a history of angina prior to myocardial infarction or radiological cardiomegaly detected in the CCU. Altogether 98 (80%) of the patients returned to work at a median time of six weeks after their infarct. The nett effect of the team activity has been to reduce the need for referral to the National Heart Foundation Assessment Centre from an average of 15 patients per year to an average of two per year.

Stopping smoking and long-term mortality after acute myocardial infarction

A prospective follow-up study was carried out to investigate the relation between smoking and risk of death after an acute myocardial infarction. The study consisted of male patients under the age of 65 years, who had had an acute myocardial infarction between 1972 and 1975 in North Karelia, Finland. Of these patients, 888 survived the first six months after the acute infarction and were followed-up for three years after the infarction with regard to their deaths. The cumulative all-causes mortality rate of the patients who were still smoking six months after the acute myocardial infarction was 1.7 times that of the patients who had stopped smoking within the first six months. There was a dose-response relation between the number of cigarettes smoked daily and the mortality. The impact of smoking was greatest in the subgroups of patients with an otherwise good prognosis. We estimated that 28 per cent of the deaths in the whole group of initial smokers was attributable to continuing smoking after the infarction. On the basis of these findings we suggest that the anti-smoking advice should be an important part of the modern comprehensive care of patients with an acute myocardial infarction.

Five-year survival of 728 patients after myocardial infarction. A community study

This study deals with the five-year survival of 728 myocardial infarction patients who survived the first 28 days after the onset of symptoms. The series was collected by the Helsinki Coronary Register and includes all cases of acute myocardial infarction in the population who were under 66 years of age during the period 1 July 1970 to 30 June 1971. Of the 219 patients who subsequently died, 81.8 per cent died from ischaemic heart disease. The mortality was highest during the first year after the acute phase but did not decrease after the second year. The mortality was higher in patients with a transmural infarction (five-year mortality 34.0%) compared with those with a nontransmural infarction (19.7%). The mortality also was higher for recurrent acute myocardial infractions than for first attacks. The five-year mortality for women was less (20.5%, age-adjusted) than for men (31.6%). This is mainly because of the higher incidence of nontransmural infarcts in women. Acute ischaemic heart disease is more common, more often fatal, and has a poorer long-term prognosis in men than in women in Helsinki. The acute mortality from acute ischaemic heart disease is high in Helsinki when compared with other WHO registers and, in addition, the long-term prognosis seems to be relatively poor in Helsinki.