ARYA Atherosclerosis Journal

Impact of Smoking Status on Major Adverse Cardiovascular Events in STEMI Patients: A Retrospective Cohort Study in Western Iran

Document Type : Original Article

Authors

Parisa Janjani 1
Nahid Salehi 1
Sayeh Motevaseli 1, 2
Atiyeh Asadmobini 1

1 Cardiovascular Research Center, Health Policy and Promotion Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran

2 Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran

10.48305/arya.2026.45612.3094
Abstract
BACKGROUND: ST-elevation myocardial infarction (STEMI) remains a major cause of mortality worldwide. Whether smoking status and cumulative exposure influence prognosis in the contemporary era of timely reperfusion and intensive secondary prevention remains uncertain, particularly in populations with very high smoking rates. This study aimed to evaluate the association between smoking status and major adverse cardiovascular events (MACE) among patients with STEMI in western Iran.
METHODS: A retrospective cohort study was conducted involving 645 consecutive patients with STEMI at a tertiary center in Western Iran. Patients were stratified by smoking status: never-smokers (n = 356), moderate smokers (<15 pack-years, n = 124), and heavy smokers (≥15 pack-years, n = 165). Outcomes included 1-year all-cause mortality and MACE over 365 days. Cox regression models adjusted for confounders were used to estimate hazard ratio with 95% confidence intervals (HR, 95% CI).
RESULTS: In crude analyses, heavy smokers had lower 1-year mortality (HR = 0.44, 95% CI: 0.22–0.87) and MACE (HR = 0.60, 95% CI: 0.40–0.91) compared to never-smokers. After full adjustment, these associations became non-significant (mortality HR = 0.92, 95% CI: 0.28–3.02; MACE HR = 1.51, 95% CI: 0.81–2.81). Never-smokers were older, more likely female, and had higher comorbidity rates, explaining crude differences. Socioeconomic factors, particularly education, influenced outcomes.
CONCLUSION: The smoker’s paradox is driven by confounders, not a protective effect of smoking. Smoking cessation and addressing socioeconomic disparities are critical for improving STEMI outcomes in high-risk populations.

Keywords

Myocardial Infarction
Smoking
Mortality
Cardiovascular Diseases
1. Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018;39(2):119-77. https://doi.org/10.1093/eurheartj/ehx393
2. Levine GN, Bates ER, Bittl JA, Brindis RG, Fihn SD, Fleisher LA, et al. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease. Circulation. 2016;134(10):e123-55. https://doi.org/10.1016/j.jacc.2016.03.513
3. Jee Y, Jung KJ, Lee S, Back JH, Jee SH, Cho SI. Smoking and atherosclerotic cardiovascular disease risk in young men: the Korean Life Course Health Study. BMJ Open. 2019;9(6):e024453. https://doi.org/10.1136/bmjopen-2018-024453
4. Ishida M, Sakai C, Kobayashi Y, Ishida T. Cigarette Smoking and Atherosclerotic Cardiovascular Disease. J Atheroscler Thromb. 2024;31(3):189-200. https://doi.org/10.5551/jat.RV22015
5. Grines CL, Topol EJ, O’Neill WW, George BS, Kereiakes D, Phillips HR, et al. Effect of cigarette smoking on outcome after thrombolytic therapy for myocardial infarction. Circulation. 1995;91(2):298-303. https://doi.org/10.1161/01.CIR.91.2.298
6. Barbash GI, Reiner J, White HD, Wilcox RG, Armstrong PW, Sadowski Z, et al. Evaluation of paradoxic beneficial effects of smoking in patients receiving thrombolytic therapy for acute myocardial infarction: mechanism of the “smoker’s paradox” from the GUSTO-I trial, with angiographic insights. J Am Coll Cardiol. 1995;26(5):1222-9. https://doi.org/10.1016/0735-1097(95)00299-5
7. Redfors B, Furer A, Selker HP, Thiele H, Patel MR, Chen S, et al. Effect of Smoking on Outcomes of Primary PCI in Patients With STEMI. J Am Coll Cardiol. 2020;75(15):1743-54. https://doi.org/10.1016/j.jacc.2020.02.045
8. Zhang S, Lin Z, Yu B, Liu J, Jin J, Li G, et al. Smoking paradox in coronary function and structure of acute ST-segment elevation myocardial infarction patients treated with primary percutaneous coronary intervention. BMC Cardiovasc Disord. 2024;24(1):427. https://doi.org/10.1186/s12872-024-04093-6
9. Moghadam TZ, Zandian H, Fazlzadeh M, Kalan MB, Pourfarzi F. Socioeconomic and environmental factors associated with waterpipe tobacco smoking among Iranian adults: a PERSIAN cohort-based cross-sectional study. BMC Public Health. 2023;23:1295. https://doi.org/10.1186/s12889-023-16176-8
10. Bernheim SM, Spertus JA, Reid KJ, Bradley EH, Desai RA, Peterson ED, et al. Socioeconomic disparities in outcomes after acute myocardial infarction. Am Heart J. 2007;153(2):313-9. https://doi.org/10.1016/j.ahj.2006.10.037
11. Sia CH, Ko J, Zheng H, Ho AF, Foo D, Foo LL, et al. Association between smoking status and outcomes in myocardial infarction patients undergoing percutaneous coronary intervention. Sci Rep. 2021;11(1):6466. https://doi.org/10.1038/s41598-021-86003-w
12. Van Sloten T, Valentin E, Climie RE, Deraz O, Weiderpass E, Jouven X, et al. Association of Midlife Cardiovascular Health and Subsequent Change in Cardiovascular Health With Incident Cancer. JACC CardioOncol. 2023;5(1):39-52. https://doi.org/10.1016/j.jaccao.2022.11.015
13. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, et al. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ. 2007;335(7624):806-8. https://doi.org/10.1136/bmj.39335.541782.AD
14. Weisz G, Cox DA, Garcia E, Tcheng JE, Griffin JJ, Guagliumi G, et al. Impact of smoking status on outcomes of primary coronary intervention for acute myocardial infarction--the smoker’s paradox revisited. Am Heart J. 2005;150(2):358-64. https://doi.org/10.1016/j.ahj.2004.01.032
15. Angeja BG, Kermgard S, Chen MS, McKay M, Murphy SA, Antman EM, et al. The smoker’s paradox: insights from the angiographic substudies of the TIMI trials. J Thromb Thrombolysis. 2002;13(3):133-9. https://doi.org/10.1023/A:1020470721977
16. Jakobsen L, Niemann T, Thorsgaard N, Nielsen TT, Thuesen L, Lassen JF, et al. Sex- and age-related differences in clinical outcome after primary percutaneous coronary intervention. EuroIntervention. 2012;8(8):904-17. https://doi.org/10.4244/EIJV8I8A139
17. Gitte RN. Effect of Cigarette Smoking on Plasma Fibrinogen and Platelet Count. Asian J Med Sci. 2012;2(3):181-4. https://doi.org/10.3126/ajms.v2i3.4261
18. Kumboyono K, Chomsy IN, Tjahjono CT, Kumala YR, Wihastuti TA. Biochemical Alterations Related to Vascular Injury in Smokers: Evidence from Nitric Oxide, Malondialdehyde, Nicotinic Acetylcholine Receptors, and Cotinine. Vasc Health Risk Manag. 2026;22:589069. https://doi.org/10.2147/VHRM.S589069
19. Huo X, Khera R, Zhang L, Herrin J, Bai X, Wang Q, et al. Education level and outcomes after acute myocardial infarction in China. Heart. 2019;105(12):946-52. https://doi.org/10.1136/heartjnl-2018-313752
20. Liu Y, Chen X, Huang W. Environmental exposures and acute coronary syndromes: Emerging evidence for a new smoker’s paradox. Eur J Prev Cardiol. 2024;31(5):589-98.
21. von Lewinski F, Quehenberger F, Sacherer M, Taucher V, Strohhofer C, Ablasser K, et al. Air Pollution and Myocardial Infarction-A New Smoker’s Paradox? J Clin Med. 2024;13(23):7324. https://doi.org/10.3390/jcm13237324
22. World Health Organization. WHO Global Report on Trends in Prevalence of Tobacco Use 2000-2030. Geneva: World Health Organization; 2024.
23. Huang IC, Klosky JL, Young CM, Murphy SE, Krull KK, Srivastava D, et al. Misclassification of self-reported smoking in adult survivors of childhood cancer. Pediatr Blood Cancer. 2018;65(9):e27240. https://doi.org/10.1002/pbc.27240
24. Deng S, Li H, Zuo W, Liu Z, Wu Y. Smoking prevalence among adults in China Mainland and their age of smoking initiation during adolescence: a national cross-sectional study. BMJ Open. 2024;14(9):e082717. https://doi.org/10.1136/bmjopen-2023-082717
ARYA Atherosclerosis Journal
Volume 22, Issue 3
May and June 2026
Pages 27-35

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