Smoking and coronary artery bypass surgery

Prioritising the cardiac surgery waiting list: the angina patient's perspective

OBJECTIVE

To determine patients' views on how clinical and demographic factors should affect priorities for cardiac revascularisation.

DESIGN

A descriptive survey of patients' views conducted immediately after angiography and treatment counselling.

SUBJECTS

136 patients who were awaiting coronary angioplasty in either of the two regional cardiology centres in Northern Ireland.

RESULTS

About half the subjects (52%) felt that certain social factors such as having dependent relatives should be taken into account when deciding priority for surgery. A sizeable minority felt that younger subjects and non-smokers (40% and 44%, respectively) should be accorded higher priority, with older subjects and smokers being more likely to hold such views.

CONCLUSIONS

While there is little evidence that demographic and lifestyle factors affect the relative efficacy of surgery, the challenge remains to devise a prioritisation guideline that can properly reflect societal values and the evidence base.

Cigarette smoking in British men and selection for coronary artery bypass surgery

OBJECTIVE

To examine the relation between smoking status, clinical need, and likelihood of coronary artery bypass grafting in middle aged men.

DESIGN

A prospective study of cardiovascular disease in British men aged 40 to 59 years, screened in 1978-80 and followed until December 1991.

SUBJECTS AND SETTING

7735 men drawn from one general practice in each of 24 British towns.

MAIN OUTCOME MEASURE

Coronary artery bypass graft surgery.

RESULTS

Of the 3185 current smokers, 38 (1.03/1000/year) underwent coronary artery bypass surgery compared with 47 of 2715 (1.45/1000/year) ex-smokers, and 19 of 1817 (0.85/1000/year) never-smokers. Ex-smokers had a lower incidence of major ischaemic heart disease during follow up than current smokers. After adjustment for incidence of ischaemic heart disease during follow up, the hazard ratio of coronary artery bypass surgery for ex-smokers compared with smokers was 1.52 (95% confidence interval 0.99 to 2.34). Ex-smokers were more likely at screening to recall a doctor diagnosis of ischaemic heart disease than smokers (7.1% v 5.3%), but among those who recalled a doctor diagnosis, smokers were less likely to undergo coronary artery bypass surgery than ex-smokers (9.4% v 3.5%, P = 0.026). By 1992, men defined as smokers at screening were no less likely than ex-smokers to have been referred to a cardiologist (18.5% v 18.8%), nor to report having undergone coronary angiography less frequently than ex-smokers (12.7% v 11.4%).

CONCLUSION

Even allowing for the strong relation between coronary artery bypass surgery and clinical need, continuing smokers were less likely to undergo coronary artery bypass surgery than ex-smokers. A complex interplay exists between the men's experience of heart disease, the decision to stop smoking, and the willingness of doctors to consider coronary artery bypass surgery.