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Cigarette smoking in British men and selection for coronary artery bypass surgery
R W Morris1, A K McCallum, M Walker
1Department of Primary Care and Population Sciences, Royal Free Hospital School of Medicine, London.
Insights
Continuing smokers were less likely to undergo coronary artery bypass surgery than ex-smokers, even when accounting for clinical need. This suggests a complex interplay between heart disease experience, smoking cessation, and surgical consideration.
Area of Science:
- Cardiovascular Medicine
- Public Health
- Epidemiology
Background:
- Smoking is a major risk factor for cardiovascular disease.
- Coronary artery bypass grafting (CABG) is a common surgical intervention for severe coronary artery disease.
- Understanding factors influencing CABG referral and uptake is crucial for patient outcomes.
Purpose of the Study:
- To investigate the relationship between smoking status and the likelihood of receiving coronary artery bypass grafting (CABG) in middle-aged men.
- To explore how clinical need, defined by ischemic heart disease, influences CABG rates across different smoking groups.
Main Methods:
- Prospective cohort study involving 7735 British men aged 40-59.
- Follow-up from 1978-1980 until December 1991 to track cardiovascular events and surgical procedures.
- Analysis of smoking status (current, ex-, never-smokers) and its association with CABG, adjusting for clinical indicators of ischemic heart disease.
Main Results:
- Current smokers had a lower incidence of CABG (1.03/1000/year) compared to ex-smokers (1.45/1000/year) and never-smokers (0.85/1000/year).
- Ex-smokers showed a higher likelihood of undergoing CABG (hazard ratio 1.52) after adjusting for ischemic heart disease incidence.
- Smokers with a recalled doctor diagnosis of ischemic heart disease were less likely to undergo CABG than ex-smokers with a similar diagnosis (9.4% vs 3.5%).
Conclusions:
- Continuing smokers were less likely to undergo coronary artery bypass surgery than ex-smokers, irrespective of clinical need.
- A complex interplay exists between patient-reported heart disease experience, smoking cessation decisions, and physician consideration for CABG.
- Further research is needed to understand the mechanisms behind these disparities in surgical referral and uptake.
Objective:
To examine the relation between smoking status, clinical need, and likelihood of coronary artery bypass grafting in middle aged men.
Design:
A prospective study of cardiovascular disease in British men aged 40 to 59 years, screened in 1978-80 and followed until December 1991.
Subjects And Setting:
7735 men drawn from one general practice in each of 24 British towns.
Main Outcome Measure:
Coronary artery bypass graft surgery.
Results:
Of the 3185 current smokers, 38 (1.03/1000/year) underwent coronary artery bypass surgery compared with 47 of 2715 (1.45/1000/year) ex-smokers, and 19 of 1817 (0.85/1000/year) never-smokers. Ex-smokers had a lower incidence of major ischaemic heart disease during follow up than current smokers. After adjustment for incidence of ischaemic heart disease during follow up, the hazard ratio of coronary artery bypass surgery for ex-smokers compared with smokers was 1.52 (95% confidence interval 0.99 to 2.34). Ex-smokers were more likely at screening to recall a doctor diagnosis of ischaemic heart disease than smokers (7.1% v 5.3%), but among those who recalled a doctor diagnosis, smokers were less likely to undergo coronary artery bypass surgery than ex-smokers (9.4% v 3.5%, P = 0.026). By 1992, men defined as smokers at screening were no less likely than ex-smokers to have been referred to a cardiologist (18.5% v 18.8%), nor to report having undergone coronary angiography less frequently than ex-smokers (12.7% v 11.4%).
Conclusion:
Even allowing for the strong relation between coronary artery bypass surgery and clinical need, continuing smokers were less likely to undergo coronary artery bypass surgery than ex-smokers. A complex interplay exists between the men's experience of heart disease, the decision to stop smoking, and the willingness of doctors to consider coronary artery bypass surgery.