Abstract 5598: Angiographic Evidence of Early Coronary Artery Disease and Inceased Risk of Mortality in Smokers with Non-ST-Segment Elevation Acute Coronary Syndromes: An Analysis of the ACUITY Trial

Abstract

To determine the relationship between smoking and outcomes in a contemporary population of patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). Smoking has been associated with the “paradox” of reduced mortality following acute MI. This is thought to be due to favorable baseline characteristics and less diffuse CAD of smokers. In the ACUITY trial, 13,819 patients (29.1% smokers) with moderate- to high-risk NSTE-ACS underwent angiography and, if indicated, revascularization. Smokers were significantly younger and had fewer co-morbidities than nonsmokers. Incidence of death and MI were comparable at 30-days, although smokers had significantly reduced risks of 30-day major bleeding (HR=0.80, 95% CI=0.67– 0.96, p=0.016) and 1-year mortality (HR=0.797, 95% CI=0.65– 0.97, p=0.027). After multivariate correction for baseline and clinical differences, however, smoking status was no longer predictive of major bleeding (OR=1.06, 95% CI=0.85–1.32, p =0.59) and was associated with higher 1-year mortality (HR=1.38, 95% CI=1.07–1.78, p =0.013). This pattern of reversed risk following multivariable correction held true, as well, for those smokers requiring PCI. Core laboratory angiographic analysis showed that smokers and nonsmokers were comparable in terms of the extent of coronary artery disease, TIMI flow, myocardial blush and the presence of thrombi, but smokers had significantly less coronary artery calcification and fewer collaterals. In contrast to the paradox previously described in STEMI, our analysis finds smoking to be an independent predictor of higher 1-year mortality in patients presenting with NSTE-ACS, and our angiographic study demonstrates CAD disease in smokers that is comparable to nonsmokers but evident approximately one decade earlier.