Score-2 in heavy smokers: are we underestimating the risk?

Abstract Background The shared diagnostic decision-making process in patients with atypical chest pain is challenging, especially when functional tests are negative. SCORE2 (1) can help in making decisions. In this score, the risk is assessed based on geographical origin, age, sex, current smoking, systolic blood pressure, cholesterol values. However, it does not take into account the quantity of cigarettes smoked but only the current binary value, yes or no. In our study we wanted to evaluate the impact of smoking on prognosis, considering the number of cigarettes smoked and in particular focusing on heavy smokers. Methods In the last 15 years we evaluated 3,588 outpatients aged >35 years (average 64±9, women 55%) for the presence of stable chest pain. We excluded 290 patients who had ECG changes compatible with recent ischemia, history of myocardial infarction or any other major cardiovascular event, evidence of heart failure, left ventricular dysfunction, or cardiomyopathies. In the other 3,298 cases we applied the traditional classification of typical, atypical angina and non-anginal pain. A functional test was performed in all patients. In 2,774 patients with atypical chest pain and negative functional test we evaluated the extent of cardiovascular risk based on SCORE2 and the number of cigarettes currently smoked. One year follow-up was carried out to evaluate vital status and any fatal and non-fatal cardiovascular events. Results Table 1 shows the events in patients classified according to the degree of cardiovascular risk of SCORE2 and in heavy smokers (≥ 20 cigarettes per day) aged <70 years as a cathegory in itself. In moderate smokers (<20 cigarettes/day) of any age, the risk was considered binary as in the conventional assessment. Tables 2 and 3 show the risk stratification in male and female patients. SCORE2 is unable to intercept the extremely high risk of heavy smokers aged <70 years. This happens both in males, considered at moderate risk in 76% of cases but with a rate of fatal events of 2.4% and as many non-fatal events, both in women with a risk considered moderate in 80% of cases but with a 12% rate of fatal events (as seen in Table 1). Conclusions SCORE2 does not consider the quantity of cigarettes smoked per day, so if we rely on it heavy smokers seem to have a moderate risk. On the contrary, based on our analysis, they all have an extremely high risk, regardless of other risk factors, and in any case higher than non-smoking or moderately smoking patients. Especially heavy smoking women aged <70 years with atypical chest pain and negative functional tests have an extreme risk of fatal cardiac events (12% at one year). Probably these patients (male and female), regardless of the outcome of functional tests, should be sent for an anatomical evaluation for the detection of high-risk stenosis, as well as firmly urged to improve lifestyles and treat risk factors .