What the Smoker's Paradox Means for ACS Patients

JULY 26, 2016
Jeannette Y. Wick, RPh, MBA, FASCP
A lifetime of smoking shortens life expectancy by a decade or more.

Smoking damages the blood vessel lining, vasoconstricts coronary arteries and capillaries, induces clotting, and damages cellular DNA. Yet, smokers are more likely to survive a myocardial infarction (MI) than nonsmokers. This is known as the smoker’s paradox.

Smokers experience MIs at earlier ages and have fewer comorbidities, less advanced coronary artery disease, and less anterior MI than nonsmokers. ST segment elevated MI (STEMI) survival in smokers has remained steady despite medical advances.

An authority in smoking and MI recently investigated the trend in smoker survival after acute coronary syndromes (ACS) overall, using data from the GRACE study. The results, which were published ahead-of-print in the International Journal of Cardiology, reveal 30-day mortality has decreased for smokers with ACS, except after STEMI.

The GRACE study recorded the outcomes of more than 70,000 hospitalized ACS patients across 14 countries from 1999 to 2007. The researchers stratified patients into 3 arms: current smokers, former smokers (stopped at least 1 month prior to hospitalization), and never-smokers.

Former and never-smokers experienced significantly improved survival (4% and 3% per year, respectively) over the study period, although both groups remained at higher risk for death than current smokers. Current smokers had a limited, insignificant decrease in mortality (2% per year) after ACS events overall.

The survival of smokers experiencing STEMIs remained unchanged across the study period. The study was limited by age of the data (9 years old at time of publishing), but the survival trend has likely continued. Providers treated smokers in this cohort more aggressively, and smokers had similar follow-up visit adherence (unlike in past studies).

Smokers who quit are less likely to have another MI. Even reducing the number of cigarettes smoked daily is beneficial.

The smoker’s paradox—higher post-MI survival in smokers—should not be an excuse to continue smoking. The gap in survival between smokers and nonsmokers is narrowing each year. Providers should encourage patients to reduce or abstain from smoking after an MI to prevent a recurrence.