Predictors of Weight Reduction and Smoking Cessation in Overweight and Obese Patients with Acute Myocardial infarctions

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Vol.28No.1p20-30,June2011

Predictors of Weight Reduction and Smoking Cessation in Overweight and Obese Patients

with Acute Myocardial infarctions

JungKyuKang,JangHo onLee ,SuYo ungHa,MyungHwanBae ,DongHe onYang, HunSi kPar k,Yo ngkeunCho ,ShungChul lChae ,JaeEunJun

De par t me nto fI nt e r nalMe di c i ne ,Kyungpo okNat i onalUni ve r s i t yHos pi t al , Dae gu,Re publ i cofKor e a

1)

－Abstract－

Background：Li t t l e i s known aboutpr e di c t or s ofl i f e s t yl e modi f i c at i on i n ove r we i ghtor obe s epat i e nt swi t hac ut emyoc a r di ali nf ar c t i ons .

Methods：Bet we e n Oc t obe r2 00 5a ndMa y 20 07 ,3 11ove r we i ghtorobe s epat i e nt swi t h an AMIvi s i t e dKyungpookNa t i ona lUni ve r s i t yHos pi t a l .Amongt he m,2 16pa t i e nt s( 6 3±1 1ye ar s ol d,1 44mal e s )wi t h≥1ye aroff ol l ow-upwe r ei nc l ude d.

Results：Bodywei ghtofal lpa t i e nt ss howe das i gni f i c antde c r e as eand20 % s howe da>3%

we i ghtr e duc t i onat1ye aroff ol l ow-up.Ni ne t y-s i x( 44 %)pa t i e nt swe r es moki nga tbas e l i ne , and52 % oft he m hadqui tby1ye aroff ol l ow-up.Onl ys i x s moke r swe r es uc c e s s f ulwi t h bot ha>3 % we i ghtr e duc t i onands moki ngc e s s at i on.I nmul t i va r i a t ea nal ys i s ,age( OR 1 . 08 4, 95 % CI1. 02 8-1 . 1 44 ,p=0. 0 03 )ands moki ng c e s s at i on( OR 0 . 16 7,9 5% CI0. 0 48 -0 . 57 5,p=0 . 0 05 ) we r e i nde pe nde ntpr e di c t or s ofwe i ghtr e duc t i on.Abdomi na lc i r c umf e r e nc e wa s a ne ga t i ve pr e di c t orofs moki ngc e s s at i on( OR 0 . 9 03 ,9 5% CI0. 82 0-0 . 9 94 ,p=0 . 03 7) .

Conclusions：Me anbodywe i ghtofal lpat i e nt ss howe das i gni f i c a ntde c r e a s eatf ol l ow-up.

Smoki ng c e s s a t i on andagewe r ei nde pe nde ntpr e di c t or sofwe i ghtr e duc t i on,andabdomi na l c i r c umf e r e nc ewa sane gat i vepr e di c t orofs moki ngc e s s a t i on.

KeyWor ds:Myoc ar di ali nf ar c t i on,We i ghtl os s ,Smoki ngc e s s a t i on

CorrespondingAuthor：YongkeunCho,200Dongduk-ro,Jung-gu,DepartmentofInternalMedicine,KyungpookNational UniversityHospital,Daegu,RepublicofKoreaTel:(053)420-5528,Fax:(053)426-2046,E-mail:[email protected]

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Introduction

Obe s i t y a nd s moki ng ha ve be c ome a maj or t hr e at i n Kor e a.The pr e va l e nc e of obe s i t yi nKor e ai sr api dl yi nc r e a s i ngi nt he ge ne r alpopul at i on.

¹

Al t hough t he s moki ng r a t e i s de c r e a s i ng i n t he ge ne r alKor e a n popul at i on,oft hos eol de rt han2 0ye ar s ,and i sc ur r e nt l y2 7%,whi c hi shi ghc ompar e dt o de ve l ope d We s t e r n c ount r i e s .

²

Ove rt hel a s t f e w de c a de s ,nume r ous e pi de mi ol ogi c ala nd c l i ni c a l s t udi e s i ndi c a t e t hat obe s i t y and s moki ng a r e as s oc i at e d wi t h c ar di ova s c ul ar di s e as e( CVD) ,butl i f e s t yl emodi f i c a t i onc a n de c r e as et hepr e val e nc eofCVD.

³^-7

Bot hs moki ng a ndobe s i t ya r er i s kf ac t or s i npat i e nt swi t hac ut emyoc a r di ali nf ar c t i ons ( AMI s ) .

^6,⁷

Smoki ng i s har mf ul t o pat i e nt s wi t h AMI s ,a nd t he r ei st r e me ndousbe ne f i t of s moki ng c e s s a t i on a f t e r an AMI on r e c ur r e ntc a r di ovas c ul are ve nt s .

^8-1⁰

Al t hough t he r e have be e n c onf l i c t i ng dat a r e gar di ng t her e l at i ons hi pbe t we e nobe s i t yandCVD, 11 r e c e ntdat a i ndi c at e t hatobe s i t y i sal s o a n i nde pe nde nt CVD r i s k f ac t or , a nd t hat we i ght r e duc t i on i n ove r we i ght and obe s e i ndi vi dua l s has be ne f i c i a l e f f e c t s .

³^,^5,^6,¹²

The c ur r e ntgui de l i ne s oft he Ame r i c a n Col l e ge of Car di ol ogy/ Ame r i c an He ar t As s oc i at i on r e c omme ndt he r ape ut i cl i f e s t yl emodi f i c a t i ons i nc l udi ng we i ght r e duc t i on a nd s moki ng c e s s at i onf ora l love r we i ghtorobe s epat i e nt s wi t hAMI s .

¹³

Ho we ve r ,f e w da t aar eavai l a bl e r e gar di ng t he pa t t e r ns and pr e di c t or s of

we i ght r e duc t i on and s moki ng c e s s at i on de s pi t e t he known be ne f i t s on t he c ar di ovas c ul ar out c ome s .

¹⁴

The pur pos e of t hi s s t udy was t o i nve s t i gat e f ac t or s a s s oc i at e d wi t h s uc c e s s f ulwe i ghtr e duc t i on a nd s moki ng c e s s at i on i n ove r we i ght or obe s epa t i e nt swi t hAMI s .

Methods

St udysubj ect s

A t ot a lof6 1 3pat i e nt swi t hanAMIvi s i t e d Kyungpook Nat i onal Uni ve r s i t y Hos pi t al be t we e nOc t obe r20 05a ndMay2 00 7.Among t hos e pat i e nt s , 2 16 obe s e or ove r we i ght pat i e nt s we r e f ol l owe d f or ≥1 ye ar af t e r t he i rAMIand we r ei nc l ude d i n t hi ss t udy.

One hundr e d-t we l ve ( 52 %) pa t i e nt s we r e obe s e and 9 6 ( 4 4. 4%) we r e s moke r s at bas e l i ne .Al lt he s ubj e c t s we r e gi ve n t he r e c omme ndat i on t o r e duc e t he i rwe i ghtand qui t s moki ng whe n t he y we r e di s c ha r ge d f r om t hehos pi t alaf t e rt heAMI .

An AMIwas de f i ne d a s t he r i s e and/ or

f al li n t hec ar di acbi omar ke r swi t h atl e as t

one va l ue a bove t he 9 9 pe r c e nt i l e of t he

uppe rr e f e r e nc el i mi tt o ge t he rwi t hs ympt oms

ofi s c he mi a ,s i gni f i c a ntECG c ha nge si ndi c a t i ve

ofi s c he mi a ,orbot h. 15Thede mogr a phi cand

c l i ni c alda t a i nc l udi ng t he age ,s e x,he i ght ,

we i ght ,body ma s s i nde x,s moki ng s t at us ,

Ki l l i p c l a s s ,l e f tve nt r i c ul are j e c t i on f r ac t i on

( LVEF) ,c a r di a c bi omar ke r s ,a nd CVD r i s k

f ac t or s we r e obt a i ne d f r om t he hos pi t al

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r e c or ds .Thes t udypr ot oc olwa sa ppr ove dby t he I ns t i t ut i onal Et hi c s Commi t t e e of Kyungpook Nat i onalUni ve r s i t y Hos pi t ala nd i nf or me d c ons e ntwas obt ai ne d f ort he us e ofpe r s onali nf or mat i onf ort heanal ys i s .

Wei ghtandsmoki ngst at usassessment The we i ght a nd s moki ng s t a t us we r e as s e s s e d bot h att het i meoft heAMIa nd one ye a r af t e r t he AMI .To as s e s s any c ha nge i n t he we i ghta nd s moki ng s t at us , t he pat i e nt s we r e as ke d t o r e por t t he i r c ur r e ntwe i ghta nds moki ng s t at usdur i ng a f ol l ow-up phone i nt e r vi e w,one ye ar af t e r t heAMI .Pat i e nt s we r ea s s i gne d t o oneof t wo we i ghtc a t e gor i e s :ove r we i ght( BMI=

23 ∼2 4. 9kg/ m

²

)orobe s e( BMI≥2 5kg/ m

²

) , ba s e d on t he Wor l d He al t h Or ga ni z at i on c r i t e r i af orAs i anpopul at i ons .

¹⁶

We i ght c ha nge s we r e de f i ne d as a pe r c e nt ageofc ha ngei n we i ght :t hewe i ght atf ol l ow-up mi nus t he we i ghtatbas e l i ne di vi de d by t he we i ght at bas e l i ne . We de f i ne d a s uc c e s s f ulwe i ghtr e duc t i on a s a gr e at e rt ha n 3 % de c r e as ef r om t hebas e l i ne we i ght .To c l as s i f y t he s moki ng s t a t us ,a pa t i e ntwas de f i ne d asa “ qui t t e r ”i fheor s he was s moki ng att he t i me oft he AMI andt he nqui ts moki ngf oratl e as t3mont hs by t he1ye arf ol l ow-up.Thepat i e nt swho s moke dbot hatt het i meoft heAMIa nda t 1 ye ar of f ol l ow-up we r e c l as s i f i e d as a

“ non-qui t t e r ” , and t hos e who we r e not s moki ng e i t he ratt het i meoft he i rAMIor

a t 1 ye ar of f ol l ow-up we r e c ons i de r e d nons moke r s .

St at i st i calanal ysi s

Theda t aar ee xpr e s s e da st heme a n±SD or pe r c e nt a ge s . Al l c ompar i s ons of t he bas e l i ne var i abl e s we r e as s e s s e d wi t h t he c hi -s quar et e s tf orc at e gor i c alva r i a bl e sand St ude nt ’ s t -t e s t f or c ont i nuous va r i a bl e s . The pat i e nt s we r e c at e gor i z e d i nt o t wo gr oupson t heba s i soft hec hangei n t he i r we i ghtors moki ng s t at us ;pat i e nt s wi t h or wi t houta we i ghtr e duc t i on of>3 %,or a qui t t e rorno n-qui t t e r .A mul t i var i a t el o gi s t i c - r e gr e s s i on mode lwasus e dt ode t e r mi net he i nde pe nde ntpr e di c t or s ofa 1 ye a r we i ght r e duc t i on of >3 % or s uc c e s s f ul s moki ng c e s s a t i on.For al lana l ys e s ,a t wo-s i de d p

<0 . 0 5 was c ons i de r e d a s s t a t i s t i c a l l y s i gni f i c a nt . The s t at i s t i c al a nal ys e s we r e pe r f or me d us i ng SPSS ve r s i on 15 . 0 f or Wi ndows( SPSSI nc . ,Chi c a go,I l l i noi s ,USA) .

Results

Basel i nechar act er i st i cs

The me an a ge of t he s t udy popul at i on

was 63 ± 1 1 ( 3 2∼93 )ye ar s ( Tabl e 1 ) .At

bas e l i ne ,1 12( 52 %)pat i e nt swe r eobe s eand

1 04 ( 4 8%) we r e ove r we i ght . Hype r t e ns i on

( 4 8%)was t he mos tc ommon c o-mor bi di t y

i n t hos e pat i e nt s . One ye ar a f t e r AMI ,

appr oxi mat el y 20% oft he pat i ent s had

a>3% wei ghtr educt i on.Ni ne t y-s i x( 44%)

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De mogr aphi c s Tot a l ( n=21 6) Bas e l i ne

Age( ye ar ) 63 . 2 ±1 1. 4

Ma l e( n,%) 14 4( 66 . 7 )

He i ght( c m) 16 3. 4±9. 1

We i ght( kg) 68 . 8 ±9 . 7

Abdomi nalc i r c umf e r e nc e( c m) 93 . 4 ±6 . 2 Hi pc i r c umf e r e nc e( c m) 97 . 1 ±5 . 6 Bodymas si nde x( kg/ m

²

) 25 . 7 ±2 . 1 Bodymas si nde x≥25( n,%)

Bodymas si nde x=23 -24 . 9( n,%)

11 2( 51 . 9 ) 10 4( 48 . 1 ) Me di c alhi s t or y

Cur r e nts moke r( n,%) 96( 44 . 4 ) Pac k-ye a r s( me an) 32 . 9 ±1 9. 8 Hype r t e ns i on( n,%) 10 5( 48 . 6 ) Di abe t e sme l l i t us( n,%) 63( 29 . 2 ) Hype r l i pi de mi a( n,%) 43( 20 . 0 ) Fami l yhi s t or yofc e r e br ovas c ul ardi s e as e( n,%) 25( 11 . 6 ) Di s e as es e ve r i t y

Ki l l i pc l as s( %)

Ⅰ

Ⅱ

Ⅲ-Ⅳ

19 1( 88 . 4 ) 7( 3. 2) 1 8( 8. 3)

LVEF( %) 54 . 1 ±8 . 9

STEMI( n,%) 93( 43 . 1 )

CK-MB ( ng/ ml ) 67 . 4 ±1 51 . 6

c TnI( ng/ ml ) 94 . 7 ±6 11 . 8

Me di c at i onsa tdi s c har ge

Ant i -pl at e l e tdr ugs( n,%) 21 4( 99 . 1 ) Be t a-bl oc ke r s( n,%) 19 8( 91 . 7 ) ACEi nhi bi t or s( n,%) 18 7( 86 . 6 ) Di ur e t i c s( n,%) 49( 22 . 7 ) Li pi d-l owe r i ngdr ugs( n,%) 16 9( 78 . 2 ) Oneye a rf ol l ow-up

We i ght( kg) 67 . 8 ±9 . 3

Bodymas si nde x( kg/ m

²

) 25 . 5 ±2 . 3 Bodymas si nde x≥25kg/ m

²

( n,%)

Bodymas si nde x=23 -24 . 9kg/ m

²

( n,%)

10 6( 49 ) 10 0( 46 ) We i ghtc hange( %) -1 . 1 ±6 . 5 Qui ts moki ng( n,%) 50( 52 . 1 )

Valuesaremean±SEM,LVEF:leftventricularejectionfraction,STEMI:ST-segmentelevationmyocardial infarction,CK-MB:creatine kinase-MB isoenzyme,cTnI:cardiac troponin I,ACE:angiotensin converting enzyme.

Tabl e1 .Char ac t e r i s t i c satbas e l i neand1ye aroff ol l ow-up

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De mogr aphi c s

We i ghtc hange( n=2 16 ) Smoki ngs t at us( n=9 6) Re duc e d

( n=44 )

No tr e duc e d

( n=1 7 2 ) pval ue Qui t t e r ( n=5 0)

No n-qui t t e r

( n=4 6 ) pva l ue Bas e l i ne

Age( ye ar ) 64 . 4 ±11 . 6 62 . 9 ±1 1. 3 0 . 4 25 61 . 0 ±1 1. 3 5 7. 8±1 1. 7 0. 17 9 Ma l e( n,%) 28( 63 . 6 ) 11 6( 67 . 4 ) 0 . 6 33 4 3( 86 . 0 ) 4 3( 9 3. 5) 0. 23 1 He i ght( c m) 16 5. 3±9 . 4 16 3. 0±9. 0 0 . 1 25 16 7. 1±8. 8 1 67 . 4 ±6. 7 0. 82 7 We i ght( kg) 72 . 6 ±13 . 2 6 7. 8±8 . 3 0 . 0 25 7 0. 3±9 . 7 7 2. 7±1 0. 9 0. 25 4 Abdomi nalc i r c umf e r e nc e( c m) 94 . 9 ±6 . 8 9 3. 0±6 . 1 0 . 1 03 9 1. 7±5 . 3 9 4. 3±5. 8 0. 04 2 Hi pc i r c umf e r e nc e( c m) 98 . 5 ±5 . 6 9 6. 8±5 . 5 0 . 1 01 9 5. 6±5 . 2 9 7. 6±5. 5 0. 10 3 BMI( kg/ m

²

) 26 . 4 ±2 . 5 2 5. 5±2 . 0 0 . 0 13 2 5. 1±1 . 8 2 5. 8±2. 2 0. 07 9 BMI≥2 5kg/ m

²

( n,%) 29( 65 . 9 ) 8 3( 48 . 3 ) 0 . 0 37 2 1( 42 . 0 ) 2 4( 5 2. 2) 0. 31 8 Me di c alhi s t or y

Cur r e nts moke r( n,%) 22( 50 . 0 ) 7 4( 43 . 0 ) 0 . 3 43 NA NA NA Pac k-ye a r s( me an) 31 . 2 ±13 . 9 33 . 3 ±2 1. 2 0 . 6 67 34 . 0 ±2 2. 6 3 1. 7±1 6. 5 0. 58 2 Hype r t e ns i on( n,%) 27( 61 . 4 ) 7 8( 45 . 3 ) 0 . 0 58 2 4( 48 . 0 ) 1 9( 4 1. 3) 0. 51 0 Di abe t e sme l l i t us( n,%) 16( 36 . 4 ) 4 7( 27 . 3 ) 0 . 0 55 1 0( 20 . 4 ) 1 2( 2 6. 1) 0. 51 2 Hype r l i pi de mi a( n,%) 7( 1 6. 3) 3 6( 20 . 9 ) 0 . 7 12 5( 1 3. 5) 1 0( 2 4. 4) 0. 22 4 Fa mi l yhi s t o r yo fCVD n,( %) 4( 9. 1) 2 1( 12 . 3 ) 0 . 1 71 4( 8. 2) 1 0( 2 3. 3) 0. 07 8 Di s e as es e ve r i t y

Ki l l i pc l as s( %) I

I I I I I -I V

37( 84 . 1 ) 3( 6. 8) 4( 9. 1)

15 4( 89 . 5 ) 4( 2. 3) 1 4( 8. 1)

0 . 3 11 4 5( 90 . 0 ) 3( 6. 0) 2( 4. 0)

4 5( 9 7. 8) 0( 0 . 0 ) 1( 2 . 2 )

0. 20 5

LVEF( %) 53 . 9 ±9 . 1 5 4. 1±8 . 9 0 . 8 74 5 3. 8±8 . 4 5 4. 7±1 0. 3 0. 66 3 STEMI( n,%) 17( 38 . 6 ) 7 6( 44 . 2 ) 0 . 5 07 2 9( 58 . 0 ) 2 0( 4 3. 5) 0. 15 5 CK-MB ( ng/ ml ) 53 . 9 ±10 1. 2 70 . 9 ±1 62 . 1 0 . 5 08 57 . 4 ±1 04 . 5 89 . 0 ±2 39 . 6 0. 39 9 c TnI( ng/ ml ) 44 . 4 ±90 . 9 1 07 . 7 ±6 84 . 3 0 . 5 42 66 . 5 ±8 1. 9 2 49 . 9 ±1 , 32 5. 8 0. 33 1 Me di c at i onsa tdi s c har ge

Ant i -pl at e l e tdr ugs( n,%) 44( 1 00 . 0 ) 17 0( 98 . 9 ) 0 . 4 72 50( 1 00 . 0 ) 4 6( 10 0. 0) NA Be t a-bl oc ke r s( n,%) 39( 88 . 6 ) 15 9( 92 . 4 ) 0 . 4 15 4 6( 92 . 0 ) 4 3( 9 3. 5) 0. 78 1 ACEi nhi bi t or s( n,%) 39( 88 . 6 ) 14 8( 86 . 0 ) 0 . 6 53 4 6( 92 . 0 ) 4 2( 9 1. 3) 0. 90 2 Di ur e t i c s( n,%) 10( 22 . 7 ) 3 9( 22 . 7 ) 0 . 9 94 8( 1 6. 0) 8( 17 . 4 ) 0. 85 5 Li pi d-l owe r i ngdr ugs( n,%) 30( 68 . 2 ) 13 9( 80 . 8 ) 0 . 0 70 3 8( 76 . 0 ) 3 3( 7 1. 7) 0. 63 5 Oneye a rf ol l ow-up

BMI( kg/ m

²

) 24 . 7 ±2 . 8 2 5. 6±2 . 1 0 . 0 19 2 5. 0±2 . 0 2 5. 5±2. 3 0. 30 1 BMI≥2 5kg/ m

²

( n,%) 17( 39 . 5 ) 8 9( 53 . 6 ) 0. 10 2 2( 44 . 9 ) 2 4( 5 4. 5) 0. 35 3 We i ghtc hange( %) -9 . 0 ±9. 4 1 . 0 ±3 . 3 <0 . 0 01 0 . 2 ±6 . 7 -2. 8±7 . 2 0. 03 4 Qui ts moki ng( n, %) 6( 2 7. 3) 4 4( 59 . 5 ) 0 . 0 08 NA NA NA Val ue sar eme an±SEM,BMI :bodymas si nde x,CVD:c ar di ovas c ul ardi s e as e ,LVEF:l e f tve nt r i c ul ar e j e c t i on f r ac t i on,STEMI :ST-s e gme nte l e vat i onmyoc ar di ali nf ar c t i on,CK-MB:c r e at i neki nas e -MB i s oe nz yme ,c TnI :c ar di act r oponi nI ,ACE:angi ot e ns i nc onve r t i nge nz yme .

Tabl e 2 .Char ac t e r i s t i c s a tba s e l i ne and t he i rdi s t r i but i on by t he c ha nge i n t he we i ghta nd

s moki ngs t at usa t1ye arf ol l ow-up

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Fi g.1.Anunadj us t e dwei ghtchangeac c or di ngt ot hese ve r i t yoft hebas e l i neobe s i t yands moki ngs t at us at1yearaf t e ranac ut emyocar di ali nf ar ct i oni nover we i ghtpat i e nt s( A)andobe s epat i e nt s( B) .

*p<0.05comparedwithbaselineweight.

pa t i e nt s we r e s moki ng a tba s e l i ne ,a nd 5 0 ( 52 %)ofs moke r sha dqui tf ormor et ha n 3 mont hs one ye ar af t e r AMI . None of nons moke r s a t t he t i me of t he i r AMI s moke doneye araf t e rAMI .

Wei ghtchangeand smoki ng cessat i on at 1yearaf t ert hemyocar di ali nf ar ct i on

Af t e r1 ye a r ,4 5. 1 % oft he s ubj e c t s l os t we i ght ,3 1. 6 % oft hes ubj e c t shadnowe i ght c ha nge ,a nd 23 . 3 % oft he s ubj e c t s gai ne d we i ght .The me an body we i ght and BMI c ha nge df r om 6 8. 8±9. 7kgt o67 . 8±9. 3kg ( p=0. 01 4)a nd25 . 7±2. 1kg/ m

²

t o2 5. 5± 2 . 3 kg/ m

²

( p=0 . 0 2)a tbas e l i nea nd 1ye araf t e r AMI ,r e s pe c t i ve l y.Oneye ara f t e rAMI ,10 6 ( 49 %)pa t i e nt swe r eobe s e ,1 00( 4 6%)we r e ove r we i ght , a nd anot he r 1 0 ( 5 %) we r e nor malwe i ght( Ta bl e2 ) .Thewe i ghtc hange va r i e dbyt hes e ve r i t yo ft hebas e l i neo be s i t y and s moki ng s t at us one ye a r af t e r AMI .

Ove r we i ghtqui t t e r s s howe d a 1. 8 % we i ght gai n,ove r we i ghtnon-qui t t e r ss howe da1 . 8 % we i ghtr e duc t i on,t heobe s equi t t e r ss howe d a 2 . 0% we i ght r e duc t i on,and obe s e non- qui t t e r s s howe d a 3 . 8 % we i ght r e duc t i on ( p=0 . 0 29 )( Fi g.1) .Thewe i ght ,BMI ,obe s i t y, a nd s moki ng c e s s at i on one ye araf t e rAMI we r e s i gni f i c a nt l y as s oc i at e d wi t h a we i ght r e duc t i on of >3%. The we i ght c hange s be t we e ndi ur e t i c -us e randnon-us e rwe r enot s i gni f i c a nt l y di f f e r e nt . The r e we r e no s i gni f i c a nt di f f e r e nc e s i n age , s e x, BMI , bas e l i neobe s i t y,me di c a lhi s t or yofCVD r i s k f ac t or s ,Ki l l i p c l as s ,LVEF,s e r um l e ve l s of t he c ar di ac bi omar ke r s , or di s c har ge me di c at i ons be t we e n t he qui t t e r s and non-qui t t e r s .Howe ve r ,t he qui t t e r s ha d a s i gni f i c a nt l y l owe r a bdomi nalc i r c umf e r e nc e t hant henon-qui t t e r satbas e l i ne( 91 . 7± 5. 3 c m vs .94 . 3 ± 5 . 8 c m;p=0 . 0 42 ) .Thepac k/

ye a r so fs mo ki nga tba s e l i neha dnos i gni f i c a nt

A B

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Fi g.2.Per c e nt ageoft hewe i ghtr e duc t i onands moki ngc e s sat i onacc or di ngt ot henumbe rofc ar di ovasc ul ar r i s kf ac t or s .( A)We i ghtr e duct i on.Cl os e dbar :awe i ghtr educ t i onof>3 %,ope nbar :awe i ghtc hangeof≤

3 % orwe i ghtgai n of>3%.( B)Smoki ng c e ss at i on.Cl os e d bar :qui t t er ,ope n bar :non-qui t t e r ,CVD:

c ar di ovas cul ardi s e ase .

OR 9 5% CI pval ue

We i ghtr e duc t i on

Age 1 . 06 7 1 . 01 7-1 . 12 1 0. 0 09 Mal e 1 . 62 4 0 . 26 0-1 0. 1 46 0. 6 04 BMI 1 . 20 6 0 . 94 6-1 . 53 7 0. 1 31 Smoki ngc e s s at i on 0 . 21 6 0 . 06 8-0 . 68 8 0. 0 09 Smoki ngc e s s at i on

Age 0 . 41 8 0 . 06 8-2 . 56 2 0. 3 46 Mal e 1 . 02 6 0 . 98 0-1 . 07 5 1. 0 26 Abdomi nalc i r c umf e r e nc e 0 . 90 3 0 . 82 0-0 . 99 4 0. 0 37

OR:oddsratio,CI:confidenceinterval,BMI:bodymassindex.

Tabl e 3 .Mul t i var i at e l ogi s t i c r e gr e s s i on anal ys i s f or pr e di c t i ng t he we i ght r e duc t i on a nd s moki ngc e s s at i onat1ye araf t e ra nac ut emyoc ar di ali nf ar c t i on

as s oc i at i on wi t h t he we i ght c hange or s moki ng s t a t us one ye ara f t e rAMI( Ta bl e 2) .Thenumbe rofmaj orCVD r i s k f a c t or s i nc l udi ng ahi s t or y ofhype r t e ns i on,di abe t e s me l l i t us , hype r l i pi de mi a, c ur r e nt s moki ng, and f a mi l y hi s t or y of CVD was not as s oc i at e d wi t h a we i ght r e duc t i on and/ or s moki ng c e s s at i on ( Fi g.2 ) .Al t houghi twas nots t at i s t i c al l y s i gni f i c ant ,t hepa t i e nt swho

had a hi ghe rnumbe rofCVD r i s k f ac t or s we r e l e s s l i ke l y t o l os e we i ght and qui t s moki ng.

Mul t i var i at eanal ysi spr edi ct i ng awei ght r educt i onandsmoki ngcessat i on

I nt hemul t i var i at eanal ys i s ,t heage( odds r at i o[ OR]1 . 06 7,9 5% c onf i de nc ei nt e r val[ CI ] 1 . 01 7t o 1 . 1 21 ,p=0 . 00 9)wa sa n i nde pe nde nt

A B

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pr e di c t or of a we i ght r e duc t i on one ye ar af t e rAMI( Tabl e3 ) .Smoki ngc e s s at i on( OR 0. 2 1695 % CI0. 06 8t o0 . 6 88 ,p=0 . 0 05 )wasa ne ga t i vepr e di c t orofawe i ghtr e duc t i onaf t e r an adj us t me nt f or c onf oundi ng va r i abl e s . Al t hought heBMIwa ss i gni f i c a nt l yas s o c i a t e d wi t h a we i ghtr e duc t i on of>3 % one ye ar af t e rAMIi n t heuni va r i a t eana l ys i s ,i t( OR 0. 8 05 ,95 % CI0 . 4 94 t o 1 . 3 12 ,p=0 . 3 84 )was not an i nde pe nde nt pr e di c t or of a we i ght r e duc t i ononeye araf t e rAMIwhe nadj us t i ng f ort hec onf oundi ngva r i a bl e s .Theabdomi na l c i r c umf e r e nc e ( OR 0 . 9 03 ,9 5% CI0 . 8 20 t o 0. 9 94 ,p=0. 03 7)was a ne gat i ve pr e di c t orof s moki ngc e s s at i ononeye a raf t e rAMI ,af t e r adj us t i ng f ora ge and s e x ( Ta bl e 3 ) .Onl y s i x ( 27 . 3 %)s moke r s ac hi e ve d bot h a >3%

we i ght r e duc t i on and s moki ng c e s s a t i on.

Conve r s e l y, 16 % of t he qui t t e r s ha d a we i ghtga i n>3%.

Discussion

We de mons t r a t e t ha t s moki ng c e s s at i on and age ar e i nde pe nde nt pr e di c t or s of a we i ght de c r e as e i n ove r we i ght or obe s e pa t i e nt s one ye ar af t e r AMI . Al t hough r a ndomi z e dc ont r ol l e dt r i al sa r enota va i l a bl e on t he pr e di c t or s of we i ght c hange s i n pa t i e nt swi t hAMI s ,amul t i c e nt e ro bs e r va t i ona l s t udy s ugge s t s t hat de pr e s s i on, l a c k of he a l t h i ns ur anc e ,s moki ng c e s s a t i on,mor bi d obe s i t y,a nd i nc r e as e d age ar e s i gni f i c ant l y as s oc i at e d wi t h a we i ght c ha nge .

¹⁴

The

obs e r vat i on t hat obe s e pat i e nt s a r e mor e l i ke l y t o l os e we i ght t han ove r we i ght pat i e nt s may notbe s ol e l y due t o hi ghe r r e s t i ng me t a bol i c r a t e s a mong he avi e r pat i e nt s ,buta l s o may r e f l e c tgr e at e rs oc i al pr e s s ur e t o l os e we i ght .

¹^4,¹⁷

Al t hough a gr e a t e r we i ght r e duc t i on was obs e r ve d i n t he obe s e pat i e nt s butnott he ove r we i ght pat i e nt s i n t he uni var i at e a nal ys i s , t he bas e l i ne BMI was not an i nde pe nde nt pr e di c t orofawe i ghtr e duc t i on.I nt e r e s t i ngl y, a l t hough t he r e was a n e f f e c t of age on we i ght r e duc t i on, i t mi ght be due t o a ge -r e l at e dl os sofmus c l ema s s .

I n t hi s s t udy,5 2% of t he s moke r s at

bas e l i ne had qui t s moki ng one ye ar a f t e r

AMI . Si mi l ar f i ndi ngs we r e obs e r ve d i n

ot he rs t udi e sde mons t r a t i ng t ha tt her at eof

s moki ng c e s s at i on wa s 4 2∼71 % wi t hi n 6

mont hsaf t e ranAMI .

¹⁰^,¹⁸^,¹⁹

Al t hough70 % of

t hes moki ng pat i e nt swi t h a n AMIs t oppe d

s moki ng 3mont hsa f t e rt heAMI ,one -t hi r d

hadr e s ume ds moki ng af t e r4ye a r s .

¹⁹

The s e

f i ndi ngs s ugge s t t hat an i nt e r ve nt i on t hat

may i nduc e a br i e fs moki ng c e s s at i on ma y

not be e f f e c t i ve f or l ong-t e r m s moki ng

c e s s a t i on.The r e f or e ,i tma y bei mpor t antt o

i de nt i f y t he de mogr a phi c ,ps yc hos oc i al ,and

c l i ni c al f ac t or s t ha t ar e pr e di c t or s of t he

l ong-t e r m s moki ng c e s s at i on i n t hos e

pat i e nt s . We f ound t ha t pat i e nt s wi t h a

r e l a t i ve l yhi ghabdomi nalc i r c umf e r e nc ewe r e

mor el i ke l yt oc o nt i nues moki ng,e ve nt hough

t he y we r e al r e a dy ove r we i ght or obe s e .

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Al t houghobe s i t yi ss t r ongl ya s s oc i a t e dwi t h t her i s kofac ut ec or onar y e ve nt sr e gar dl e s s of t he s moki ng s t at us ,obe s e nons moke r s haveal owe rr i s k ofac ut ec or onar y e ve nt s t ha n obe s es moke r s .

³

Smoki ng pat i e nt swi t h obe s i t y and a n AMIma y have t he wor s t pr ognos i s f orma j oradve r s e c a r di ac e ve nt s i nc l udi ngr e c ur r e ntMI ,r e vas c ul ar i z at i on,a nd de at h.A r e l i abl e a nd e f f e c t i ve i nt e r ve nt i on f ors moki ng c e s s at i on i s r e qui r e d f ort he s e pa t i e nt s .

De s pi t et hes ubs t a nt i a lbe ne f i t sofs moki ng c e s s at i on,t hepr oc e s sofac hi e vi ng t hatgoa l i snots i mpl e .Suc c e s s f uls moki ng c e s s at i on may beas s oc i at e dwi t has i gni f i c antwe i ght gai n.

²⁰

We i ghtgai n af t e rs moki ng c e s s at i on ne e dsa t t e nt i on,asi tmi ghtat t e nuat es ome of t he be ne f i c i a l e f f e c t s of t he s moki ng c e s s at i on.Obe s e nons moke r s havea hi ghe r r i s kofa c ut ec or o nar ye ve nt st handohe a l t hy nor mal we i ght or ove r we i ght s moke r s .

³

Re c e nts t udi e s r e por t e d t ha t s moke r s who qui twi t hi n onemont h a f t e ran AMIha d a me anofa2. 7 % we i ghtgai na sc ompar e dt o t hos ewhoc ont i nue dt os moke ,and2 8. 2% of t hequi t t e r shad awe i ghtgai n ove r5%.

¹⁴^,²¹

Si mi l a r l y,wer e por tt hatonl y af e w oft he s moki ng pat i e nt s a c hi e ve d bot h a we i ght r e duc t i on and s moki ng c e s s at i on i n t hi s s t udy.

I n t he pr e s e nt s t udy, t he r e we r e no s i gni f i c antdi f f e r e nc e si n t hewe i ghtc hange and s moki ng c e s s at i on ac c or di ng t o t he numbe rofCVD r i s k f ac t or s .One pot e nt i a l

e xpl anat i on of t hi s f i ndi ng i s t he poor knowl e dgeofone ’ sown r i s k f ac t or si n t he pos t -MIpat i e nt s .Ove r80 % oft hepa t i e nt s a r e unabl e t o s t a t e any of t he i r own modi f i abl e r i s k f a c t or s .

²²

Ful lknowl e dge of t he r i s k f a c t or s c or r e l a t e s wi t h a gr e at e r a dhe r e nc e t o l i f e s t yl e c ha nge s .

²³

Al t hough c ar di a c e duc at i on pr ogr ams appe ar t o i nc r e as et heknowl e dgei n pa t i e nt swi t h an AMI ,whe t he rornott hi sknowl e dgea c t ua l l y i nf l ue nc e s a c ha nge i n t he i r be havi or i s unknown. A s ubs t ant i al ga p ma y e xi s t be t we e n ‘ knowi ng’a nd ‘ doi ng’ac c or di ng t o t hede mo gr a phi ca nds o c i oe c ono mi cba c kgr o und oft he pa t i e nt s .St r uc t ur e d,s ys t e ma t i c ,and i ndi vi dual i z e d c ar di ac t e ac hi ng pr ogr ams t o e l i c i tbe havi or alc hange sar eur ge nt l yne e de d.

Our s t udy ha d s ome l i mi t a t i ons t hat s houl dbec ons i de r e d.Fi r s t ,t her e t r os pe c t i ve na t ur eoft hi sanal ys i sa ndt hes mal ls ampl e s i z e ar e maj or l i mi t at i ons of t hi s s t udy.

Se c ond,onl y pa t i e nt swhos ur vi ve d a tl e as t 1 ye ar we r e i nc l ude d.Pat i e nt s who di e d be f or et he1ye a rf ol l ow-upmi ghtha vebe e n t hebe s tc a ndi dat e sf orl i f e s t yl emodi f i c at i on.

Thi r d,bodywe i ghtwa sme a s ur e do bj e c t i ve l y by t he phys i c i ans at bas e l i ne , but was me a s ur e ds ubj e c t i ve l y vi as e l fr e por tby t he pa t i e ntdur i ngt hef ol l o w-upphonedi s c us s i on.

The us e ofpat i e nt -r e por t e d we i ghtdat a i s

l i ke l y t o yi e l d an unde r e s t i ma t i on of t he i r

a c t ua l we i ght . Four t h, t he r ol e s of t he

be ha vi or ala nd s oc i oe c onomi cf a c t or sknown

t o i nf l ue nc e a we i ghtc ha nge and s moki ng

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c e s s at i on s uc h as t he phys i c al ac t i vi t y, di e t ar y ha bi t , he al t h i ns ur anc e , e duc at i on s t a t us ,a ndoc c upa t i onwe r enoti nve s t i gat e d.

Fi f t h,wede f i ne d a we i ghtc hangeof>3%

as a s i gni f i c antwe i ghtc ha nge be c aus e we hadl e s sobe s epat i e nt st ha npr e vi ouss t udi e s whi c hde f i ne dawe i ghtr e duc t i onof>5 % as s i gni f i c ant .

²¹

Summary

Smoki ng c e s s at i on a nd hi ghe r age we r e i nde pe nde ntpr e di c t or s ofa we i ghtc hange , and t he abdomi na l c i r c umf e r e nc e was a ne ga t i ve pr e di c t or ofs moki ng c e s s at i on i n ove r we i ghtandobe s epat i e nt swi t hanAMI , one ye ar af t e r t he i nc i de nt .Onl y a f e w s moke r swe r es uc c e s s f uli nbot ha c hi e vi nga we i ght r e duc t i on and s moki ng c e s s a t i on.

Ne w i nt e r ve nt i ons t o s uppor t a we i ght r e duc t i on a nd s moki ng c e s s at i on i n t hos e pa t i e nt sar eur ge nt l yne e de d.

Acknowl edgement s

We t hank Mr . J ohn Mar t i n a nd Dr . SungHe eKi m f ort he i ras s i s t anc e wi t h t he pr e pa r at i onoft hi sma nus c r i pt .

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