Impact of Smoking on Health-related Quality of Life After Percutaneous Coronary
Revascularization

Taira DA, Seto TB, Ho KK, et al
Circulation. 2000;102:1369-1374

More than 500,000 percutaneous interventions (PCIs) are performed each year in the United States. PCI is
performed primarily to improve the health-related quality of life (HRQOL) in patients with coronary artery
disease. Prior studies have shown that smoking increases the risks of late myocardial infarction (MI) and death in
patients undergoing percutaneous transluminal coronary angioplasty (PTCA). In the United States, 25% of all
patients undergoing PTCA are smokers. Taira and coworkers set out to examine the relation of smoking to
HRQOL in patients after PCI. They used data from 2 multicenter trials, the Balloon vs Optimal Atherectomy
Trial (BOAT) and the ACS Multi-Link Stent System Trial (ASCENT), which included more than 1400 patients.
HRQOL was assessed at baseline and at 6 and 12 months after PCI using the SF-36, the 36-item Medical
Outcomes Study Short-Form health status questionnaire. Patients were classified into 3 groups: nonsmokers,
quitters, or persistent smokers, based on information provided at study entry and at 1-year follow up.

Results

There were no differences in the initial PCI results or in the incidence of major events at 1 year of follow-up
according to smoking status. Overall, the HRQOL scores were higher in all 3 patient groups at 6- and 12-month
follow-up compared with baseline, indicating that PCI provided benefit to most patients. However, results
differed by the extent of improvement: The improvement of quitters was comparable to that of nonsmokers in all
HRQOL scales, except for social functioning, where quitters tended to exceed nonsmokers. Persistent smokers
demonstrated significantly less improvement in all dimensions of HRQOL by 25% to 75%.

Editor's Comment

PCI is usually done to improve the quality of life in patients with symptomatic coronary artery disease. This
well-done study convincingly shows that patients who continue to smoke after this procedure only receive half of
the benefits of those who quit or who are nonsmokers. The authors used data from other multicenter trials of
PCI, which allowed for significant cost savings.

The obvious question is: Why do people continue to smoke after undergoing a major cardiovascular intervention?
The answer clearly lies with the addictive nature of tobacco and human nature. Some cardiologists recommend
withholding this therapy from patients who refuse to quit smoking, but such an approach seems draconian -- and
against medical ethics. More useful are the results of a study such as this one -- which can be discussed rationally
with patients and may have some impact on their subsequent behavior. The costs of PCI and other interventions
in these patients are relatively high compared with the costs of an antismoking education program. At present,
cardiologists can only redouble their efforts to counsel their patients and to help them find effective antismoking
programs