title: Smoking is associated with adverse clinical outcomes in patients undergoing revascularization with PCI or CABG: the SYNTAX trial at 5-year follow-up.
abstract: BACKGROUND
  Cigarette smoking is a well-known risk factor for development of coronary artery disease (CAD). However, some studies have suggested a "smoker's paradox," meaning neutral or favorable outcomes in smokers who have developed CAD, especially myocardial infarction (MI).
  
  
  OBJECTIVE
  The study aimed to examine the association of smoking status with clinical outcomes in the randomized controlled SYNTAX (SYNergy Between PCI With TAXUS and Cardiac Surgery) trial at 5-year follow-up.
  
  
  METHODS
  Detailed smoking history was collected at baseline, 6-month, 1-year, 3-year, and 5-year follow-up. The composite endpoints included death/MI/stroke (primary endpoint) plus major adverse cardiac and cerebrovascular events (MACCE) (combination of death/MI/stroke and target lesion revascularization) according to patient smoking status. The comparison of 5-year clinical outcomes between the groups according to smoking status was performed with Cox regression using smoking status at baseline or smoking as a time-dependent covariate.
  
  
  RESULTS
  A sizeable proportion (n = 322, 17.9%) of patients had changing smoking status during 5-year follow-up. One in 5 patients with complex CAD was smoking at baseline. However, 60% stopped after revascularization while others continued to smoke. Smokers had worse clinical outcomes due to a higher incidence of recurrent MI in both revascularization arms. Smoking was an independent predictor of the composite endpoint of death/MI/stroke (hazard ratio [HR]: 1.8; 95% confidence interval [CI]: 1.3 to 2.5; p = 0.001) and MACCE (HR: 1.4; 95% CI: 1.1 to 1.7; p = 0.02).
  
  
  CONCLUSIONS
  Smoking is associated with poor clinical outcomes after revascularization in patients with complex CAD. This places further emphasis on efforts at smoking cessation to improve revascularization benefits. (SYNTAX Study: TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries; NCT00114972).
authors: Thoraxcenter, Erasmus Medical Centre, Rotterdam, the Netherlands; Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China.
authors: Yao-Jun
authors: YJ
authors: Zhang
authors: Sheffield Teaching Hospitals and the University of Sheffield, Sheffield, United Kingdom.
authors: Javaid
authors: J
authors: Iqbal
authors: Department of Public Health, Erasmus Medical Centre, Rotterdam, the Netherlands.
authors: David
authors: D
authors: van Klaveren
authors: Thoraxcenter, Erasmus Medical Centre, Rotterdam, the Netherlands.
authors: Carlos M
authors: CM
authors: Campos
authors: Mayo Clinic, Rochester, Minnesota.
authors: David R
authors: DR
authors: Holmes
authors: Thoraxcenter, Erasmus Medical Centre, Rotterdam, the Netherlands.
authors: Arie Pieter
authors: AP
authors: Kappetein
authors: Institut Jacques Cartier, Massy, France.
authors: Marie-Claude
authors: MC
authors: Morice
authors: Oxford University Hospitals, Oxford, United Kingdom.
authors: Adrian P
authors: AP
authors: Banning
authors: Sheffield Teaching Hospitals and the University of Sheffield, Sheffield, United Kingdom.
authors: Ever D
authors: ED
authors: Grech
authors: Thoraxcenter, Erasmus Medical Centre, Rotterdam, the Netherlands.
authors: Christos V
authors: CV
authors: Bourantas
authors: Thoraxcenter, Erasmus Medical Centre, Rotterdam, the Netherlands.
authors: Yoshinobu
authors: Y
authors: Onuma
authors: Thoraxcenter, Erasmus Medical Centre, Rotterdam, the Netherlands.
authors: Hector M
authors: HM
authors: Garcia-Garcia
authors: The Heart Hospital, Plano, Texas.
authors: Michael J
authors: MJ
authors: Mack
authors: San Raffaele Scientific Institute, Milan, Italy.
authors: Antonio
authors: A
authors: Colombo
authors: Herzzentrum Universität Leipzig, Leipzig, Germany.
authors: Friedrich W
authors: FW
authors: Mohr
authors: Department of Public Health, Erasmus Medical Centre, Rotterdam, the Netherlands.
authors: Ewout W
authors: EW
authors: Steyerberg
authors: Thoraxcenter, Erasmus Medical Centre, Rotterdam, the Netherlands; International Centre for Circulatory Health, Imperial College London, London, United Kingdom. Electronic address: patrick.w.j.c.serruys@gmail.com.
authors: Patrick W
authors: PW
authors: Serruys
mesh_terms: D001026:Coronary Artery Bypass; D003324:Coronary Artery Disease / Q000401:mortality / Q000601:surgery*; D054855:Drug-Eluting Stents; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D009203:Myocardial Infarction / Q000453:epidemiology*; D017239:Paclitaxel; D062645:Percutaneous Coronary Intervention; D016016:Proportional Hazards Models; D012907:Smoking / Q000009:adverse effects*; D020521:Stroke / Q000453:epidemiology*; D016896:Treatment Outcome
chemical_list: D017239:Paclitaxel
keywords: cessation; major adverse cardiac and cerebrovascular event(s); smoker’s paradox