Ali Syed F, Smith Eric E, Reeves Mathew J, Zhao Xin, Xian Ying, Hernandez Adrian F, Bhatt Deepak L, Fonarow Gregg C, Schwamm Lee H
From the Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston (S.F.A., L.H.S.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); Department of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.J.R.); Duke Clinical Research Institute, Durham, NC (X.Z., Y.X., A.F.H.); Division of Cardiology, Brigham and Women's Hospital Heart and Vascular Institute, Boston, MA (D.L.B.); Harvard Medical School, Boston, MA (D.L.B.); and Division of Cardiology, Ronald Reagan-UCLA Medical Center (G.C.F.).
Circ Cardiovasc Qual Outcomes. 2015 Oct;8(6 Suppl 3):S73-80. doi: 10.1161/CIRCOUTCOMES.114.001244.
Smoking is a potent risk factor for coronary artery disease (CAD) and acute ischemic stroke (AIS), but there are numerous reports of lower in-hospital mortality among smokers versus nonsmokers hospitalized for these events.
We analyzed all consecutive patients hospitalized with a first index CAD (n=158 054) or AIS (n=899 295) event in Get With The Guidelines from 2002 to 2012; 20.4% of AIS and 30.4% of patients with CAD were past-year smokers. Multivariable models and age-stratified analyses were used to estimate the adjusted odds ratio of in-hospital mortality in smokers versus nonsmokers. Smokers were younger, more often male, with fewer vascular risk factors, and were more likely to be admitted to hospitals that were large, academic, or in the South. In-hospital mortality was significantly lower among smokers in both CAD (2.7% versus 5.2%; P<0.0001) and AIS (3.5% versus 5.8%; P<0.0001). The difference between unadjusted and adjusted odds ratios for smoking (0.57 versus 0.86 in CAD; 0.56 versus 0.86 in AIS) indicates the presence of substantial confounding by age and other covariates, but a significant association of past-year smoking remained.
Among patients hospitalized with CAD and AIS, smoking is a risk factor for early age of onset, even among those with few vascular risk factors. The persistent association with lower in-hospital mortality after adjusted and stratified analyses probably represents residual unmeasured confounding, although a biological effect of smoking cannot be excluded. Further clinical and prospective population-based studies are needed to explore variables that contribute to outcomes in these patients.
吸烟是冠状动脉疾病（CAD）和急性缺血性中风（AIS）的一个重要危险因素，但有大量报告显示，因这些疾病住院的吸烟者的院内死亡率低于非吸烟者。
我们分析了2002年至2012年参与“遵循指南”项目的所有因首次发生CAD（n = 158054）或AIS（n = 899295）事件而住院的连续患者；20.4%的AIS患者和30.4%的CAD患者在过去一年吸烟。采用多变量模型和年龄分层分析来估计吸烟者与非吸烟者院内死亡的调整比值比。吸烟者更年轻，男性比例更高，血管危险因素更少，且更有可能入住大型、学术性或位于南部的医院。CAD患者中吸烟者的院内死亡率显著低于非吸烟者（2.7%对5.2%；P<0.0001），AIS患者中也是如此（3.5%对5.8%；P<0.0001）。吸烟的未调整和调整后比值比之间的差异（CAD中为0.57对0.86；AIS中为0.56对0.86）表明存在年龄和其他协变量的显著混杂，但过去一年吸烟仍存在显著关联。
在因CAD和AIS住院的患者中，吸烟是发病年龄较早的一个危险因素，即使在血管危险因素较少的患者中也是如此。经调整和分层分析后，与较低院内死亡率的持续关联可能代表残留的未测量混杂因素，尽管不能排除吸烟的生物学效应。需要进一步开展临床和基于人群的前瞻性研究，以探索影响这些患者预后的变量。
