Smoking and Its Impact on Cardiovascular Disease 10 Years After Coronary Angioplasty

Smoking is a well-established risk factor for atherosclerotic cardiovascular diseases. However, some historical reports have suggested a lower risk of adverse cardiovascular events in smokers compared to non-smokers. This observation, known as the “smokers’ paradox,” was first described in 1968 and has since been reported in various clinical settings, including patients undergoing myocardial revascularization for coronary artery disease (CAD).

More recent data have questioned the existence of this paradox in patients undergoing coronary revascularization procedures, reporting that smoking is independently associated with adverse outcomes in the medium- and long-term follow-up, both in individuals undergoing percutaneous and surgical myocardial revascularization. However, data specifically evaluating 10-year cardiovascular outcomes based on smoking status at baseline are still lacking.

The aim of this study was to investigate the impact of baseline smoking on 10-year outcomes in patients undergoing percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation.

The primary endpoint (PEP) was all-cause mortality. The secondary endpoint (SEP) included cardiovascular death, acute myocardial infarction (AMI), definite stent thrombosis, target lesion revascularization (TLR), target vessel revascularization (TVR), and non-target vessel revascularization (nTVR) at 10 years.

Researchers analyzed a total of 9527 patients, of whom 2365 were included in the smoker group and 7162 in the non-smoker group. Only 7.7% of the total underwent the complete 9.5-year follow-up (smokers, n = 201; non-smokers, n = 534). Patients in the smoker group were generally younger, predominantly men, and had a lower frequency of other cardiovascular risk factors.

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After multivariable adjustment, smoking was associated with a higher risk of all-cause death (hazard ratio [HR]: 1.45; 95% confidence interval [CI]: 1.33–1.59), cardiovascular death (HR: 1.59; 95% CI: 1.41–1.80), and definite stent thrombosis (HR: 2.09; 95% CI: 1.34–3.26) at 10 years after PCI. The risk of myocardial infarction was comparable in the first 30 days after PCI but increased significantly between 1 and 10 years in the smoker group (HR: 1.60; 95% CI: 1.36–1.90). Smoking was associated with a lower risk of TLR and TVR but showed a comparable risk to non-smokers regarding nTVR.

Conclusion 

During the 10-year follow-up after PCI with DES, smoking was associated with a higher risk of death, myocardial infarction, and stent thrombosis. These findings support that smoking has a detrimental effect on long-term cardiovascular outcomes in patients undergoing coronary angioplasty. It is essential to implement targeted strategies for risk factor modification in smoking patients undergoing PCI, as they have a higher risk of recurrent events compared to non-smokers.

Original Title: Smoking Status at Baseline and 10-Year Outcomes After Drug-Eluting Stent Implantation Insights From the DECADE Cooperation.

Reference: Antonia Presch, MD et al JACC CardiovascInterv.2025.