Effects of smoking on survival and morbidity in patients randomized to medical or surgical therapy in the Coronary Artery Surgery Study (CASS): 10-year follow-up. CASS Investigators

Department of Medicine, University of Alabama, Birmingham.

OBJECTIVES. The goal of this study was to ascertain how continued cigarette smoking or smoking cessation related to long-term survival and morbidity in patients with established coronary artery disease managed with medical therapy or coronary bypass surgery. BACKGROUND. Although the association of cigarette smoking with coronary artery disease is well established, the morbidity and mortality associated with smoking behavior in patients with such disease receiving medical or surgical therapy are less well established. METHODS. The 780 patients randomized to medical therapy or coronary bypass surgery in the Coronary Artery Surgery Study (CASS) were subgrouped according to smoking behavior during a mean 11.2-year follow-up interval. Comparisons between smokers and nonsmokers were accomplished by univariate and Cox time-dependent multivariate analyses. RESULTS. Survival at 10 years after entry into the study was 82% among 468 patients who reported no smoking during follow-up (nonsmokers) compared with 77% among the 312 smokers (p = 0.025). Survival was 80% among those who smoked at entry but stopped (quitters) versus 69% among those who continued smoking (p = 0.025). For patients who smoked at baseline and were randomized to bypass surgery, survival at 10 years was 84% among quitters and 68% among nonquitters (p = 0.018); the difference in survival between quitters (75%) and nonquitters (71%) was less among those randomized to medical therapy (p = NS). Among those who smoked at baseline, continued smoking increased the relative risk of death by 1.73. After 10 years, smokers, in comparison with nonsmokers, were less likely to be angina free and more likely to be unemployed and had more activity limitation and more hospital admissions (primarily for chest pain, heart attack, cardiac catheterization, peripheral vascular surgery and stroke). CONCLUSIONS. Thus, among patients with documented coronary artery disease, continued cigarette smoking may result in decreased survival--especially among those undergoing bypass surgery. Moreover, smokers have more angina, more unemployment, a greater limitation of physical activity and more hospital admissions.

This article has been cited by other articles:

				M. E. Charlson, J. C. Peterson, C. Boutin-Foster, W. M. Briggs, G. G. Ogedegbe, C. E. McCulloch, J. Hollenberg, C. Wong, and J. P. Allegrante Changing health behaviors to improve health outcomes after angioplasty: a randomized trial of net present value versus future value risk communication Health Educ. Res., October 1, 2008; 23(5): 826 - 839. [Abstract] [Full Text] [PDF]

				N. Al-Sarraf, L. Thalib, A. Hughes, M. Tolan, V. Young, and E. McGovern Effect of smoking on short-term outcome of patients undergoing coronary artery bypass surgery. Ann. Thorac. Surg., August 1, 2008; 86(2): 517 - 523. [Abstract] [Full Text] [PDF]

				T. M. Maddox, K. J. Reid, J. A. Spertus, M. Mittleman, H. M. Krumholz, S. Parashar, P. M. Ho, and J. S. Rumsfeld Angina at 1 Year After Myocardial Infarction: Prevalence and Associated Findings Arch Intern Med, June 23, 2008; 168(12): 1310 - 1316. [Abstract] [Full Text] [PDF]

				J. S. Rumsfeld, P. M. Ho, D. J. Magid, M. McCarthy Jr, A. L. W. Shroyer, S. MaWhinney, F. L. Grover, and K. E. Hammermeister Predictors of health-related quality of life after coronary artery bypass surgery Ann. Thorac. Surg., May 1, 2004; 77(5): 1508 - 1513. [Abstract] [Full Text] [PDF]

				M. Sachdev, J. L. Sun, A. A. Tsiatis, C. L. Nelson, D. B. Mark, and J. G. Jollis The prognostic importance of comorbidity for mortality in patients with stable coronary artery disease J. Am. Coll. Cardiol., February 18, 2004; 43(4): 576 - 582. [Abstract] [Full Text] [PDF]

				J. F. Sabik III, B. W. Lytle, E. H. Blackstone, M. Khan, P. L. Houghtaling, and D. M. Cosgrove Does competitive flow reduce internal thoracic artery graft patency? Ann. Thorac. Surg., November 1, 2003; 76(5): 1490 - 1497. [Abstract] [Full Text] [PDF]

				M. E. Charlson and O. W. Isom Care after Coronary-Artery Bypass Surgery N. Engl. J. Med., April 10, 2003; 348(15): 1456 - 1463. [Full Text] [PDF]

				S. C. Smith Jr, J. T. Dove, A. K. Jacobs, J. Ward Kennedy, D. Kereiakes, M. J. Kern, R. E. Kuntz, J. J. Popma, H. V. Schaff, D. O. Williams, et al. ACC/AHA guidelines for percutaneous coronary intervention (revision of the 1993 PTCA guidelines): A report of the American College of Cardiology/ American Heart Association Task Force on practice guidelines (Committee to revise the 1993 guidelines for percutaneous transluminal coronary angioplasty) endorsed by the Society for Cardiac Angiography and Interventions J. Am. Coll. Cardiol., June 15, 2001; 37(8): 2239 - 2239. [Full Text] [PDF]

				D. A. Taira, T. B. Seto, K. K. L. Ho, H. M. Krumholz, D. E. Cutlip, R. Berezin, R. E. Kuntz, and D. J. Cohen Impact of Smoking on Health-Related Quality of Life After Percutaneous Coronary Revascularization Circulation, September 19, 2000; 102(12): 1369 - 1374. [Abstract] [Full Text] [PDF]

				R. T. van Domburg, K. Meeter, D. F. M. van Berkel, R. F. Veldkamp, L. A. van Herwerden, and A. J. J. C. Bogers Smoking cessation reduces mortality after coronary artery bypass surgery: a 20-year follow-up study J. Am. Coll. Cardiol., September 1, 2000; 36(3): 878 - 883. [Abstract] [Full Text] [PDF]

				W. D. Clouse, H. Yamaguchi, M. R. Phillips, R. D. Hurt, L. A. Fitzpatrick, T. P. Moyer, C. Rowland, H. V. Schaff, and V. M. Miller Effects of transdermal nicotine treatment on structure and function of coronary artery bypass grafts J Appl Physiol, September 1, 2000; 89(3): 1213 - 1223. [Abstract] [Full Text] [PDF]

				R J. Irving, S H. Oram, J. Boyd, P. Rutledge, F. McRae, and P. Bloomfield Ten year audit of secondary prevention in coronary bypass patients BMJ, July 1, 2000; 321(7252): 22 - 23. [Full Text]

				W D. Clouse, K. S Rud, R. D Hurt, and V. M Miller Short-term treatment with transdermal nicotine affects the function of canine saphenous veins Vascular Medicine, May 1, 2000; 5(2): 75 - 82. [Abstract] [PDF]

				T.F.M. Van Berkel, H. Boersma, J.W. Roos-Hesselink, R.A.M. Erdman, and M.L. Simoons Impact of smoking cessation and smoking interventions in patients with coronary heart disease Eur. Heart J., December 2, 1999; 20(24): 1773 - 1782. [PDF]

				K. A. Eagle, R. A. Guyton, R. Davidoff, G. A. Ewy, J. Fonger, T. J. Gardner, J. P. Gott, H. C. Herrmann, R. A. Marlow, W. C. Nugent, et al. ACC/AHA guidelines for coronary artery bypass graft surgery: A report of the American College of Cardiology/ American Heart Association task force on Practice Guidelines (Committee to revise the 1991 Guidelines for Coronary Artery Bypass Graft Surgery) J. Am. Coll. Cardiol., October 1, 1999; 34(4): 1262 - 1347. [Full Text] [PDF]

				J. G. Motwani and E. J. Topol Aortocoronary Saphenous Vein Graft Disease : Pathogenesis, Predisposition, and Prevention Circulation, March 10, 1998; 97(9): 916 - 931. [Abstract] [Full Text] [PDF]

				W. B. Kannel Curbing the Tobacco Menace Circulation, August 19, 1997; 96(4): 1070 - 1070. [Full Text]

				J. M. Lightwood and S. A. Glantz Short-term Economic and Health Benefits of Smoking Cessation : Myocardial Infarction and Stroke Circulation, August 19, 1997; 96(4): 1089 - 1096. [Abstract] [Full Text]

				D. Hasdai, K. N. Garratt, D. E. Grill, A. Lerman, and D. R. Holmes Effect of Smoking Status on the Long-Term Outcome after Successful Percutaneous Coronary Revascularization N. Engl. J. Med., March 13, 1997; 336(11): 755 - 761. [Abstract] [Full Text] [PDF]

				N. Payne and C. Saul Variations in use of cardiology services in a health authority: comparison of coronary artery revascularisation rates with prevalence of angina and coronary mortality BMJ, January 25, 1997; 314(7076): 257 - 257. [Abstract] [Full Text]

				A. A. Voors, B. L. van Brussel, H.W. Thijs Plokker, S. M.P.G. Ernst, N. M. Ernst, E. M. Koomen, J. G.P. Tijssen, and F. E.E. Vermeulen Smoking and Cardiac Events After Venous Coronary Bypass Surgery : A 15-Year Follow-up Study Circulation, January 1, 1996; 93(1): 42 - 47. [Abstract] [Full Text]

				A. Kazmers Outcome After Surgery: An Evolving Concept Perspectives in Vascular Surgery and Endovascular Therapy, January 1, 1995; 8(1): 109 - 128. [PDF]