CHRONIC EXPOSURE TO SECOND CHRONIC EXPOSURE TO SECOND HAND SMOKE AND 30-DAY HAND SMOKE AND 30-DAY

PROGNOSIS OF PATIENTS WITH PROGNOSIS OF PATIENTS WITH ACUTE CORONARY SYNDROMESACUTE CORONARY SYNDROMES

Demosthenes B. PanagiotakosDemosthenes B. Panagiotakos, , DrMedSci, FESC, MACEDrMedSci, FESC, MACE

Lecturer of EpidemiologyLecturer of EpidemiologyHarokopio University, Athens, GreeceHarokopio University, Athens, Greece

BackgroundBackground Second hand smoke (SHS) has been Second hand smoke (SHS) has been

investigated in several studies before investigated in several studies before and it is now evident that and it is now evident that tthe risk of he risk of illness from SHS is: illness from SHS is: • 2% to 10% that of the risk from active 2% to 10% that of the risk from active

smoking. smoking.

Aim of this workAim of this work In the context of the GREECS study In the context of the GREECS study

we tested we tested whether chronic exposure whether chronic exposure to SHS influences the 30-day to SHS influences the 30-day prognosis of ACS patients.prognosis of ACS patients.

The GREECS StudyThe GREECS Study The GREECS study is an The GREECS study is an

observational study that observational study that was was designed to evaluate designed to evaluate • clinical, lifestyle and behavioral factors clinical, lifestyle and behavioral factors

associated with the severity and prognosis associated with the severity and prognosis of hospitalized patients with Acute Coronary of hospitalized patients with Acute Coronary Syndromes (ACS).Syndromes (ACS).

• Coordinating centerCoordinating center: First Cardiology : First Cardiology Clinic, School of Medicine, University of Clinic, School of Medicine, University of Athens, Athens, GreeceGreece

Pitsavos C, Panagiotakos DB, Antonoulas A, et al., BMC Public Health 2005

Sample of the StudySample of the Study Patients:Patients: 2172 consecutive patients 2172 consecutive patients

(1649 men, 65(1649 men, 6513 years and 523 13 years and 523 women, 72women, 7211 years) with ACS (MI 11 years) with ACS (MI or UA) that entered in the cardiology or UA) that entered in the cardiology clinics or the EU of 6 major hospitals, clinics or the EU of 6 major hospitals, in Greece, were enrolled in the study.in Greece, were enrolled in the study.

Enrolment periodEnrolment period:: Between Between October, 2003 and September, 2004 October, 2003 and September, 2004

MeasurementsMeasurements Biochemical markers (CK-MB, Troponin I, Biochemical markers (CK-MB, Troponin I,

etc)etc) Clinical historyClinical history Socio-demographicSocio-demographic PsychologicalPsychological BehaviouralBehavioural

• Exposure to SHS was measuredExposure to SHS was measured through a through a questionnaire administrated during a specific questionnaire administrated during a specific interview, after the second day of interview, after the second day of hospitalisation.hospitalisation.

SHSmokers were non- current smokers pts who were SHSmokers were non- current smokers pts who were exposed to environmental cigarette smoke (home or exposed to environmental cigarette smoke (home or workplace) for at least 30 min for >5 days per week.workplace) for at least 30 min for >5 days per week.

Design of the StudyDesign of the Study

Enrolment of ACS pts October 2003 to September 2004

Assessment of baseline characteristics:•Socio-demographic•Clinical•Biological•Lifestyle and behavioural

Prognosis of ACS pts

30-day 6-m 12-m

Death, or re-hospitalization due to

CVD

Background: Background: prognosis of MI ptsprognosis of MI ptsRi

sk o

f rec

urre

nt e

vent

s

30-day 6-months 1-year

30-day Follow-up30-day Follow-up • During the first 30-day following During the first 30-day following

hospitalisation information about vital hospitalisation information about vital status or re-hospitalisation due to CVD status or re-hospitalisation due to CVD retrieved from 1683 out of 2172 retrieved from 1683 out of 2172 patients. patients.

The event rate wasThe event rate was • 119 in males (9.2%) and 119 in males (9.2%) and • 38 in females (9.0%), 38 in females (9.0%),

while 41 of them were fatal while 41 of them were fatal (25 in males, (25 in males, p for gender differences = 0.003).p for gender differences = 0.003).

Characteristics of ACS pts according to 30-day outcome

Event free (n = 2015)

Death or re-hospitalization

(n = 157)

P

Socio-demographic and lifestyle characteristics

Age, years 66 13 66 12 0.93

Male sex, n(%) 1511 (75) 119 (76) 0.75

Years of school 7 4 8 4 0.87

Sedentary, n(%) 1209 (60) 119 (76) 0.12

Diet score (0-55) 28 5 26 4 0.03

Ever smokers, n(%) 1350 (67) 107 (68) 0.74

Current smokers, n(%) 625 (31) 57 (36) 0.09

Exposure to SHS, n(%) 967 (48) 97 (62) <0.001

Exposure to SHS at work, n(%) 846 (42) 83 (53) <0.001

Exposure to SHS at home, n(%) 443 (22) 39 (25) 0.18

Discharge diagnosis

Unstable angina, n(%) 544 (27) 61 (39) <0.001

Non-ST elevations MI, n(%) 786 (39) 46 (29) 0.001

ST elevations MI, n(%) 685 (34) 50 (32) 0.42

SHS and ECG findings at SHS and ECG findings at presentationpresentation

Mean duration of exposure to SHS Mean duration of exposure to SHS was 29.6 was 29.6 16 years (median 30 16 years (median 30 years)years)• pts with pts with ST-elevationsST-elevations reported reported longer longer

exposure to SHS compared to those exposure to SHS compared to those who had non-ST-elevations or other who had non-ST-elevations or other ECG abnormalitiesECG abnormalities (32 (3216 vs. 2916 vs. 2916 16 vs. 28vs. 2817 years, p=0.009). 17 years, p=0.009).

SHS and indices of myocardial SHS and indices of myocardial necrosis at hospital admissionnecrosis at hospital admission

A positive correlation was observed A positive correlation was observed between years of exposure to SHS between years of exposure to SHS and and • Troponin I (r=0.23, p=0.001) Troponin I (r=0.23, p=0.001) • CK-MB levels (r=0.13, p=0.001). CK-MB levels (r=0.13, p=0.001).

Years of exposure to SHS and Years of exposure to SHS and Troponin I (at entry)Troponin I (at entry)

Regression line is adjusted for age, sex, physical activity status, presence of CVD risk factors and smoking habits.

30-day event rate (death or re-hospitalization) and 30-day event rate (death or re-hospitalization) and smoking habits of ACS ptssmoking habits of ACS pts

30-day event rate and smoking

0%

2%

4%

6%

8%

10%

12%

14%

Eversmokers

Smokers(current)

SHS Overall

P<0.1

P<0.001

P<0.01

6-month event rate (death or re-hospitalization) 6-month event rate (death or re-hospitalization) and smoking habits of ACS ptsand smoking habits of ACS pts

6-month event rate and smoking

0%

5%

10%

15%

20%

25%

Eversmokers

Smokers(current)

SHS Overall

P<0.05P<0.07

P<0.009

SHS and risk of 30-day re-current SHS and risk of 30-day re-current eventsevents

ACS pts reporting exposure to SHS ACS pts reporting exposure to SHS had had • 61% higher adjusted-risk of having 61% higher adjusted-risk of having

a recurrent CVD event during the a recurrent CVD event during the first 30-dayfirst 30-day following hospitalization as following hospitalization as compared to pts who were not exposed compared to pts who were not exposed to SHS. to SHS.

Results from multiple logistic regression analysis that Results from multiple logistic regression analysis that evaluated the association of SHS exposure on the 30-evaluated the association of SHS exposure on the 30-

day prognosis of ACS patients.day prognosis of ACS patients.

Odds ratio 95% confidence interval

Exposure vs. no-exposure to SHS 1.61 1.14 – 2.28

Age (per year) 1.04 1.00 – 1.08

Male vs. female sex 1.27 0.59 – 2.68

Discharge diagnosis (MI vs. UA) 1.85 1.25 – 2.74

Current smoking (yes / no) 1.25 0.76 – 2.08

Hypertension (yes / no) 0.97 0.43 – 2.95

Hypercholesterolemia (yes / no) 1.47 0.71 – 3.00

Diabetes mellitus (yes / no) 2.54 1.22 – 5.25

Family history of CHD (yes / no) 1.37 0.64 – 2.35

Previous CHD (yes / no) 0.47 0.22 – 0.97

Obesity (yes / no) 1.01 0.43 – 2.98

Physical activity (yes / no) 0.48 0.20 – 1.12

Education (per 1-year of school) 1.02 0.92 – 1.14

Diet score (per 5 units) 0.80 0.60 – 0.97

SHS and risk of 30-day re-current SHS and risk of 30-day re-current eventsevents

A A dose-response linear dose-response linear relationshiprelationship was observed between was observed between the risk of re-current events and the the risk of re-current events and the years of exposure (years of exposure (rhorho=0.17, =0.17, p<0.001).p<0.001).

LimitationsLimitations Self-reports of SHS exposure Self-reports of SHS exposure

unable to evaluate misreportingunable to evaluate misreporting Lack of biochemical evaluation of Lack of biochemical evaluation of

exposure exposure unable to evaluate unable to evaluate misreportingmisreporting

Information about continuing Information about continuing smoking or exposure to SHS was smoking or exposure to SHS was retrieved after dischargeretrieved after discharge bias due bias due to the CVD eventto the CVD event

ConclusionConclusion Although people’s right not to be exposed to SHS Although people’s right not to be exposed to SHS

at the workplace has become increasingly at the workplace has become increasingly recognised over the past years, it seems that in recognised over the past years, it seems that in Greece this right has been clearly infringed. Greece this right has been clearly infringed. • Since the late 1980s several Ministerial Decisions Since the late 1980s several Ministerial Decisions

(A2/1989, A2g/1980, 4508/ 1990 and Y3/4322/1993) (A2/1989, A2g/1980, 4508/ 1990 and Y3/4322/1993) have prohibited smoking in hospitals, private clinics, in have prohibited smoking in hospitals, private clinics, in places belonging to State agencies, in private or public places belonging to State agencies, in private or public companies and organisations, as well as during the companies and organisations, as well as during the flights of all domestic airlines.flights of all domestic airlines.

•However, about 5 out of 10 pts However, about 5 out of 10 pts reported exposure to SHS!reported exposure to SHS!

ConclusionConclusion SHS was associated with 61% higher SHS was associated with 61% higher

odds of recurrent events in pts who odds of recurrent events in pts who had had an ACShad had an ACS

45% of the recurrent events in our 45% of the recurrent events in our sample were attributable to the sample were attributable to the exposure to SHS. exposure to SHS. • The later may be due to the greater The later may be due to the greater

duration and intention of exposure.duration and intention of exposure.

What this work adds…What this work adds… Our findings may clearly state a Our findings may clearly state a

hypothesis for the effect of exposure hypothesis for the effect of exposure to SHS on a recurrent CVD event to SHS on a recurrent CVD event among people with ACS.among people with ACS.