THE SMOKERS PARADOX

THE SMOKERS PARADOX

I receive, by email, the contents of leading cardiology journals as a way to keep up with the changes in cardiology.  I can download an abstract, or, in some cases, the entire article, free of charge.  Recently an article looked at the prognosis of smokers (S) and non-smokers (NS) who were successfully resuscitated from sudden cardiac death.  The results showed it was the S who had a better survival than NS and the S were more apt to leave the hospital with brain function that was better than the NS.  This was called a S paradox because multiple studies, including my own, show that S die of heart disease approximately 10 years sooner than NS, but have less extensive and less severe atherosclerosis.    The real question, not answered by the authors, is how can these results be explained in view of the accelerated plaque development in S.  

This is my explanation, based on what I have seen under the microscope.  I am assuming that the majority of these patients received CPR (cardio pulmonary resuscitation) which involves compressing the heart between the sternum and the spine.  Please remember that the heart is a midline structure and only protrudes into the left chest.  This explains why coronary chest pain is in the middle, not the left chest and why compressing the sternum compresses the heart.  Sixteen years ago I published a paper (J Invas Cardiol 1997:9;578-585) showing that CPR was associated with direct injury to the heart in the form of cracks in the coronary arteries.  In compressing the heart between the sternum and the spine you naturally compress the coronary arteries as well.  The coronary arteries become steadily more calcified as we grow older, making them more brittle.  Thus the coronary arteries in the younger age S are less calcified and more pliable and more easily compressed without injury compared to the older NS patient with more extensive calcification.   If the artery is injured and cracked and is unable to dilate or contract this will affect coronary blood flow and overall cardiac function.  Figure 1 shows a calcified (blue color on right side of photo) coronary artery with fracture and wall rupture in a 61 year old man.  Figure 2 is a fracture of a large calcified plaque with leakage of red injection mass into the artery wall.

I conclude that S do better than the NS after resuscitation from cardiac arrest, because the heart and the coronary arteries in the S are not as severely injured as the NS and they recover heart function and cardiac output more rapidly, resulting in less brain damage.  Smoking has no redeeming features and no one should start smoking on the basis of this recent report.