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Smokeless Tobacco (Snus) and Outcome of Myocardial Infarction: a SWEDEHEART Study
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiovascular epidemiology.
Uppsala University, Disciplinary Domain of Science and Technology, Mathematics and Computer Science, Department of Mathematics. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, UCR-Uppsala Clinical Research Center.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, UCR-Uppsala Clinical Research Center. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiovascular epidemiology.ORCID iD: 0000-0002-6534-2613
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, UCR-Uppsala Clinical Research Center. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Clinical Physiology.ORCID iD: 0000-0003-4413-9736
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(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background

Based on effects of nicotine and snus (a smokeless tobacco) on hemodynamics, pro-arrhythmia and remodelling, in combination with indications of increased risk for fatal myocardial infarction (MI) in snus users; we hypothesised that the outcome of an MI may be worse in snus users.

Methods

Data was extracted from the SWEDEHEART registry for all patients who underwent coronary angiography in Sweden due to MI between December 2009 and December 2014. In snus users (n=4,950) relative to snus non-users (n=55,412), we compared risks of a large MI (defined as hs-cTnT of  > 10,000 ng/L, cTnT > 10 μg/L or cTnI > 10 μg/L) and death in the acute (in-hospital) setting, and death+HF (a combined endpoint of all-cause death or hospitalization for heart failure) and all-cause death at short- (<28 days) and long-term follow-up. Relations of snus use to outcomes were also analysed in pre-specified subgroups of never, previous and current smokers.

Results

A large MI was diagnosed in 10,975 patients. During long-term follow-up (median 1.9 years), 7,758 either died (n=6,044) or were hospitalized due to heart failure (n=1,714). In models adjusting for age, gender, smoking, previous MI and occupational classification (employed, unemployed/sick leave and retired), snus use was not associated with risk of large MI (odds ratio 1.01; 95% confidence interval (CI) 0.93-1.09) or death+HF (long-term Cox proportional hazard ratio (HR) 0.99; 95% CI 0.90-1.10). Nonetheless, among never-smokers snus use was associated with an increased risk for death+HF (long-term HR 1.26, 95% CI 1.03-1.55), driven by a higher mortality risk (long-term HR for death of any cause 1.29, 95% CI 1.02-1.64).

Conclusions

In this study, snus use was unrelated to acute, short-term or long-term adverse outcomes after an MI. Among never-smokers, snus use was associated with an increased risk of post-MI death.

National Category
Medical and Health Sciences Cardiac and Cardiovascular Systems
Research subject
Cardiology; Epidemiology; Medical Science
Identifiers
URN: urn:nbn:se:uu:diva-342247OAI: oai:DiVA.org:uu-342247DiVA, id: diva2:1191326
Available from: 2018-03-18 Created: 2018-03-18 Last updated: 2018-03-22
In thesis
1. Smokeless Tobacco (Snus) and Cardiovascular Disease: Associations with Heart Failure and Prognosis after Myocardial Infarction
Open this publication in new window or tab >>Smokeless Tobacco (Snus) and Cardiovascular Disease: Associations with Heart Failure and Prognosis after Myocardial Infarction
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Previous investigations of snus use (oral moist snuff, a Swedish form of smokeless tobacco) and cardiovascular disease have generally focused on atherosclerotic events such as myocardial infarction and stroke, likely because smoking is such a well-established risk factor for atherosclerotic disease. Smokeless administration of tobacco circumvents most of the atherogenic effects of the combusted products from smoked tobacco, but it is possible that the potent autonomic and hemodynamic effects of snus and nicotine per se are detrimental for cardiovascular tissues.

The aim of this thesis was to investigate if snus is associated with development of heart failure and the prognosis after myocardial infarction. We used data from Swedish cohort studies and the national quality register for myocardial infarctions (SWEDEHEART), with linkages to national registers.

Snus use was associated with a higher risk of heart failure in a dose-response manner. This association was specific to non-ischemic heart failure, implying a direct myocardial effect, rather than an atherogenic effect (papers I and II).

Acute, short-term or long-term outcomes following a myocardial infarction were not consistently worse among snus users relative to snus non-users, although snus use was associated with an increased risk of death after myocardial infarction among never-smokers (paper III).

Discontinuation of snus use after a myocardial infarction was associated with an almost halved mortality risk, similar to the benefit associated with smoking cessation (paper IV).

Although smoking was consistently stronger related to all adverse outcomes, and with reservations due to the observational design, the findings from this thesis indicate that snus should not be regarded as harmless. Snus use was associated with a higher risk of heart failure and post-myocardial infarction mortality, which may have public health implications for the risk assessment of snus, and potentially other modes of smokeless nicotine.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2018. p. 67
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1445
Keyword
Snus, smokeless tobacco, nicotine, cardiovascular disease, heart failure, myocardial infarction, mortality, prognosis, epidemiology
National Category
Clinical Medicine Cardiac and Cardiovascular Systems Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Epidemiology
Identifiers
urn:nbn:se:uu:diva-345869 (URN)978-91-513-0283-6 (ISBN)
Public defence
2018-05-09, Enghoffsalen, Akademiska Sjukhuset, ingång 50 BV, Uppsala, 09:00 (Swedish)
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Supervisors
Available from: 2018-04-18 Created: 2018-03-18 Last updated: 2018-04-18

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Arefalk, GabrielSvennblad, BodilAndersen, KasperJames, Stefan KVarenhorst, ChristophSundström, Johan

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