Lloyd Steele

Pronounced increase in risk of acute ST-segment elevation myocardial infarction in younger smokers

Objectives Previous studies have shown that smokers presented with ST-segment elevation myocardial infarction (STEMI) a decade earlier than non-smokers. However, no account has been made for population smoking trends, an important deficit addressed by this study. Methods The combination of admission data on patients with acute STEMI undergoing percutaneous coronary intervention and demographic data supplied by the Office for National Statistics for the South Yorkshire population between 2009–2012 were analysed to generate incidence rates and rate ratios (RR) to quantify the relative risk of STEMI from smoking, overall and by age group. Results There were 1795 STEMI patients included of which 72.9% were male. 68 patients were excluded as they had no smoking status recorded, leaving 48.5% of the remaining population as current smokers, 27.2% ex-smokers and 24.3% never smokers. Smokers were over-represented with overall smoking prevalence in South Yorkshire calculated at 22.4%. The incidence of STEMI in smokers aged under 50, 50–65 and over 65 years was 59.7, 316.9 and 331.0 per 100 000 patient years at risk compared to 7.0, 60.9 and 106.8 for the combined group of ex- and never smokers. This gave smokers under the age of 50 years an 8.47 (95% CI 6.80 to 10.54) increase in rate compared to non-smokers of the same age, with the 50–65 and over 65 age groups having RRs of 5.20 (95% CI 4.76 to 5.69) and 3.10 (95% CI 2.67 to 3.60), respectively. Conclusions Smoking was associated with an eightfold increased risk of acute STEMI in younger smokers, when compared to ex- and never smokers. Further efforts to reduce smoking in the youngest are needed.

A retrospective cohort study of the association between smoking and mortality after acute ST-segment elevation myocardial infarction

Background Several studies have shown a ‘smokers paradox’, where following an acute myocardial infarction, smokers have a paradoxically lower mortality than non-smokers. To date, no large study has investigated this paradox in unselected patients with acute ST-segment elevation myocardial infarction (STEMI) managed by primary percutaneous coronary intervention (PCI) alone. Objectives We aimed to examine the association of smoking status and 1-year mortality in patients who had STEMI managed by primary PCI. Methods This retrospective study included all patients admitted with acute STEMI undergoing primary PCI in a single UK centre from January 2009 to April 2012. The survival status for all patients post-STEMI was obtained. Differences in survival by smoking status were assessed using a Kaplan-Meier curve, and after adjustment for age, gender and additional cardiovascular risk factors using a Cox regression analysis. Results The 1-year mortality for patients with STEMI was 149/1796 (8.3%). There were 846/1796 (47.1%) current smokers, 476/1796 (26.5%) ex-smokers and 417/1796 (23.2%) never smokers. Current smokers were approximately 10 years younger than ex-smokers and never smokers (p=0.001). A multivariate Cox proportional hazards model found no evidence of an association between mortality and smoking status after adjustment; p=0.23. Compared with never smokers, the HR (95% CI) for 1-year mortality for current smokers was 1.47 (0.90 to 2.39) and 1.08 (0.66 to 1.77) for ex-smokers. Conclusions In this retrospective cohort study, we found no evidence of an association between mortality and smoking status in patients with acute STEMI treated with PCI, and thus no evidence of a ‘smokers paradox’.

A retrospective cross-sectional study on the association between tobacco smoking and incidence of ST-segment elevation myocardial infarction and cardiovascular risk factors

Background Cigarette smoking is a well-established risk factor for the development of coronary heart disease. However, the relationship between smoking and acute ST-segment elevation myocardial infarction (STEMI) is less well described. Objective To determine the relative risk of acute STEMI in smokers and ex-smokers, compared with individuals who had never smoked. Methods This observational study studied all patients with STEMI undergoing percutaneous coronary intervention (PCI) in South Yorkshire, UK from 1 January 2009 to 6 April 2012. Additional contemporary demographical data for the South Yorkshire population, supplied by the Office for National Statistics, allowed derivation of the incidence rate of STEMI in South Yorkshire—both overall and stratified by smoking status. Incidence rate ratios and population attributable risk (PAR) were calculated to quantify STEMI risk. Results There were 1715 STEMIs in 1680 patients during the study period. Smoking status was obtained in 96.2% patients. The prevalence of smoking was 47.3% in patients with STEMI and 22.0% in the general population. In patients with STEMI, smokers were ∼10 years younger, mean (SD) 57.2 (11.1) years, than never-smokers, 66.4 (12.1) years, and ex-smokers, 67.9 (11.9) years. The age-standardised incident rate ratio of STEMI was 5.2 (4.5–6.1) for current smokers and 1.1 (1.0–1.3) for ex-smokers, with the reference group being never-smokers for both. Almost 50% of STEMIs were attributable to smoking (PAR=48.3%). Conclusion Cigarette smoking is associated with a fivefold increased risk of STEMI. Smoking cessation reduced this risk to a level similar to never-smokers.

SOCIOECONOMIC STATUS AND ITS INFLUENCE ON SURVIVAL AFTER ACUTE ST-SEGMENT MYOCARDIAL INFARCTION TREATED WITH PRIMARY PERCUTANEOUS CORONARY INTERVENTION

17 Figure 1 Abstracts Heart 2018;104(Suppl 6):A1–A118 A17 atherosclerotic disease and outcome following respiratory and urinary tract infections. Methods We used a retrospective, longitudinal naturalistic follow-up design using the Algorithm for Comorbidities, Associations, Length of stay and Mortality (ACALM) study of 1,220,024 patients admitted to UK hospitals between 2000– 2013. All patients aged 40 with urinary/chest infection on index admission (but no previous ischaemic heart disease (IHD) or ischaemic stroke) were followed-up for development of IHD or stroke and compared with an age/gender matched control group (n=34,02, 59% female, mean age 73±14). Logistic regression adjusted for cardiovascular risk factors and top causes of death was performed comparing rates of developing IHD, ischaemic stroke and mortality. Results Patients with a prior infection had higher unadjusted incidences of IHD (9.9% vs 5.9%) and stroke (4.2% vs 1.5%). Figure 1 shows adjusted risk factors associated with development of IHD and stroke.%). Logistic regression demonstrated that prior infection was associated with 36% higher risk of developing IHD (OR 1.36 95% CI 1.28–1.44), and, 3 fold higher risk of mortality in those who developed IHD (OR 2.98 95% CI 2.52–3.51). Similarly, prior infection was associated with 2.5 fold increased risk of stroke (OR 2.50, 95% CI 2.26–2.78) and 80% higher risk of subsequent mortality (OR 1.80, 95% CI 1.27–2.52). Conclusion In a large UK registry we demonstrate increased risk of atherosclerotic disease and greater subsequent mortality in patients with prior infection. In light of the CANTOS trial targeted therapy in reducing inflammation requires further exploration. 19 RECURRENT MYOCARDIAL INFARCTION IS AN INDEPENDENT PREDICTOR OF COGNITIVE DECLINE IN OLDER PATIENTS WITH NON-ST ELEVATION ACUTE CORONARY SYNDROME: A PROSPECTIVE COHORT STUDY Sophie Zhaotao Gu*, Jonathan Batty, Murugapathy Veerasamy, Hannah Sinclair, Richard Edwards, Rajiv Das, Azfar Zaman, Mohaned Egred, Javed Ahmed, Ian Purcell, Alan Bagnall, Ioakim Spyridopoulos, Dermot Neely, Weiliang Qiu, Vijay Kunadian. Newcastle University; Freeman Hospital; Royal Victoria Infirmary; Brigham and Women’s Hospital and Harvard Medical School; Newcastle University and Freeman Hospital 10.1136/heartjnl-2018-BCS.19 Abstract 18 Figure 1 Risk factors for development of ischaemic stroke and ischaemic heart disease showing the influence of infection Abstract 19 Figure 1 Overall change in mean MoCA score at 1-year from baseline. Abstracts19 Figure 1 Overall change in mean MoCA score at 1-year from baseline. Abstracts A18 Heart 2018;104(Suppl 6):A1–A118

17 Socioeconomic status and its influence on survival after acute ST-segment myocardial infarction treated with primary percutaneous coronary intervention

Background In the era of thrombolytic treatment, lower socioeconomic status (SES) was strongly associated with poorer survival after acute myocardial infarction. However, data for ST-elevation myocardial infarction (STEMI) in the current era of primary percutaneous coronary intervention (PPCI) is much more limited. Within existing studies, case identification has often been reliant on coding, a significant proportions of patients have been treated with thrombolysis, or there wasn’t an emphasis on door-to-balloon times of less than 90 min. This was often because in these studies data collection started in the early 2000s. Methods Data was collected for all patients with acute STEMI undergoing PPCI at The South Yorkshire Cardiothoracic Centre, UK between 2009 and 2014. Cox regression analysis was used to assess differences in survival at 30 days, 1 year, and 3 years, by SES quartile (using an area-level measure) after adjustment for confounding factors. Results There were 3059 STEMI patients. There were no statistically significant differences in survival between SES quartiles at 30 days (p=0.46), 1 year (p=0.69), and 3 years (p=0.75) (figure 1). Risk factors that were significantly differently distributed among SES quartiles were smoking prevalence (p=0.001), age (p=0.001), previous MI (p=0.025), diabetes (p=0.007) and gender (p=0.041). Q1 (the most deprived quartile) had a higher prevalence of smoking (61.9% vs 33.3%), previous MI (39.6% vs 16.0%), and diabetes (39.7% vs 16.2%) compared to Q4 (the least deprived quartile). Q1 also had a greater female preponderance (29.7% vs 24.0%) and a lower mean (SD) age (59.7±12.8 years vs 64.6±12.0 years). In smokers, those within lower SES groups presented with first STEMI at a significantly younger age than those within higher SES groups (Q1: 55.5 years, Q2: 56.4 years, Q3: 58.3 years, Q4: 57.5 years, p=0.01). In contrast, there was no significant difference in mean age at time of first STEMI by SES in never smokers (Q1: 66.5 years, Q2: 65.6 years, Q3: 65.0 years, Q4: 65.8 years, p=0.72). Conclusions There were no statistically significant differences in either short- or long-term survival post-STEMI between SES quartiles. However, first STEMI occurred at a significantly earlier age in lower SES groups compared to higher SES groups in current smokers but not never smokers, indicating that smoking plays a significant role in the younger age of presentation with STEMI in lower SES groups. Abstract 17 Figure 1

61 Investigating the smokers paradox by gender: differences in survival following acute st-?segment elevation myocardial infarction

Background The smokers paradox, where smokers have better survival after acute myocardial infarction, was predominantly observed in the thrombolytic era. Evidence for the smokers paradox in the current era of primary percutaneous coronary intervention (PCI) therapy is limited and inconsistent. Furthermore, there is no data regarding gender differences relating to this phenomenon. Methods Data were collected for all patients with acute STEMI undergoing primary PCI at South Yorkshire Cardiothoracic Centre, UK between 2009 and 2014. Cox regression analysis was used to assess differences in survival (at 30 days, 1 year, and 3 years) by smoking status and gender after adjustment for confounding factors. Results There were 2726 STEMI patients (26.4% female) during the study period. Male patients were younger than females (61.0±12.1 vs 65.5±13.1 years, p=0.02). Smoking prevalence was similar in both genders (males 48.3%, females 48.0%), but a greater proportion of females had never smoked (27.8% vs 21.0%, p=0.01). Male current smokers had a significantly worse 3 year mortality than never smokers (HR 1.51, 95% CI 1.04–2.21, p=0.03). In female patients smoking status had no significant effect on survival (p=0.58), which could potentially be due to the modest number (n=723) of female patients in this study. Overall survival was similar in both males and females (p=0.72). Conclusions There was no evidence of a smokers paradox in STEMI patients followed up to 3 years in either males or females.Abstract 61 Figure 1

63 Increased risk of acute st-segment myocardial?infarction in female smokers – a?contemporary demographic study

Background Studies have shown that smoking increases the risk of acute ST-segment elevation myocardial infarction (STEMI). However, the impact of gender on this risk is unknown. Methods This retrospective ecological cohort study examined all patients presenting with acute STEMI undergoing primary percutaneous coronary intervention at the South Yorkshire Cardiothoracic Centre (UK) between 2009–14. Index cases were compared to population data from the UK Office for National Statistics for smoking status, gender and age. Incidence rates of STEMI for current and non-smokers were calculated by gender and their associated 95% confidence intervals (CI) determined from the Poisson distribution. Age-standardised incidence rate ratios (IRR) comparing STEMI rates between smokers and non-smokers were calculated between genders in three age groups (18–49, 50–64,>65). Results There were 2,996 STEMI patients. 27.1% were female, who were significantly older than male patients (mean age: 66.3 vs 60.9, p=0.03). Risk factor prevalence was similar between genders, although hypertension was more common in females (44.9% vs 36.7%, p<0.001). In current smokers, the peak STEMI rate in females was in the 70–79 age range (233/100,000 pt/yrs) and the 50–59 (458/100,000 pt/yrs) in males. Across all ages, smokers had a significantly higher acute STEMI risk with an IRR of 5.11 (CI: 4.83–5.40). Compared to their non-smoking gender counterparts, females had a significantly higher IRR than males (6.62 (CI: 5.91–7.38) vs 4.46 (CI: 4.18–4.76)), and this difference was significant in all three age groups. The highest IRR was in female smokers in the 18–49 group at 12.67 (CI: 9.69–16.28), vs 8.47 (CI: 7.50–9.53) in males. The most striking difference between genders was in the 50–64 group (IRR 11.03 (CI: 9.33–12.96) vs 4.63 (CI: 4.21–5.08)). Conclusion Smoking status had a significantly differential effect between genders, with female smokers at increased risk of acute STEMI over male smokers by a factor of 1.48. Young female smokers (18-49) had the highest IRR and were over 12 times more likely to suffer an acute STEMI than their non-smoking peers. The largest IRR gender difference, by a factor of 2.38, was in the 50–64 age group.

SMOKING STATUS AND MORTALITY FOLLOWING ACUTE ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION: TIME TO DISMISS THE SMOKER’S PARADOX

The “smoker’s paradox”, where smokers have improved survival post-myocardial infarction, has been observed in numerous studies. To date, no large study has investigated the existence of the smoker’s paradox in the era of invasive therapy in unselected patients with acute ST-segment elevation

NO EVIDENCE TO SUPPORT THE EXISTENCE OF A SMOKER’S PARADOX IN ACUTE ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION MANAGED BY PRIMARY PERCUTANEOUS CORONARY INTERVENTION

Several studies have shown that in acute coronary syndrome, smokers have a lower mortality than non-smokers. This has been referred to as the “smoker’s paradox”. However, to date, no large, single-centre registry study involving patients with acute ST-segment elevation myocardial infarction (

IMPACT OF CIGARETTE SMOKING ON THE QUANTATIVE RISK OF DEVELOPING ACUTE ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION AND THE SUBSTANTIAL BENEFIT OF SMOKING

Cigarette smoking is a well-established risk factor for the development of coronary heart disease. However, the relationship between smoking and acute ST-segment elevation myocardial infarction (STEMI) is less well described. In the UK, the Department of Health reports that over a third of smokers