A smoker's paradox in patients hospitalized for heart failure: Findings from OPTIMIZE-HF

Gregg C. Fonarow, William T. Abraham, Nancy M. Albert, Wendy Gattis Stough, Mihai Gheorghiade, Barry H. Greenberg, Christopher M. O'Connor, Eduardo Nunez, Clyde W. Yancy, James B. Young

Research output: Contribution to journalArticlepeer-review

50 Scopus citations


Aims: Cigarette smoking is a well-established risk factor for cardiovascular disease yet several studies have shown lower mortality after acute coronary syndromes in smokers compared with non-smokers, the so called 'smoker's paradox'. This study aimed to ascertain the relationship between smoking and clinical outcomes in patients hospitalized with heart failure (HF). Methods and results: OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) collected data on 48 612 patients from 259 hospitals. Characteristics, treatments, and outcomes were compared for current/recent smokers vs. those without current/recent smoking, and multivariable regression analyses with adjustment for hospital clustering were performed. There were 7743 (15.9%) smokers, 39 126 (80.5%) non-smokers, and 1743 (3.6%) missing. Smokers were younger, had similar renal function, but lower ejection fraction. The risk of in-hospital mortality was less in smokers (2.3 vs. 3.9%, P < 0.001). After extensive covariate adjustment, smokers still had lower in-hospital mortality risk OR (odds ratio) 0.70, 95% CI (confidence interval) 0.56-0.88, P = 0.002. Post-discharge, smokers (n = 998) had similar mortality risk (6.7 vs. 8.4%, P = 0.29) compared with those without current/recent smoking. Conclusion: Smokers hospitalized with HF had lower risk adjusted in-hospital mortality and similar early post-discharge mortality compared with non-smokers. The residual association of smoking and better prognosis, the 'smoker's paradox', was not fully explained by measured covariates. Published on behalf of the European Society of Cardiology. All rights reserved.

Original languageEnglish (US)
Pages (from-to)1983-1991
Number of pages9
JournalEuropean heart journal
Issue number16
StatePublished - Aug 2008


  • Heart failure
  • Hospitalization
  • Mortality
  • Registry
  • Smoking

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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