The so-called “smoking paradox”, conditioning lower mortality in smokers among STEMI patients, has seldom been addressed in the settings of modern primary PCI protocols. The ISACS−STEMI COVID-19 is a large-scale retrospective multicenter registry addressing in-hospital mortality, reperfusion, and 30-day mortality among primary PCI patients in the era of the COVID-19 pandemic. Among the 16,083 STEMI patients, 6819 (42.3%) patients were active smokers, 2099 (13.1%) previous smokers, and 7165 (44.6%) non-smokers. Despite the impaired preprocedural recanalization (p < 0.001), active smokers had a significantly better postprocedural TIMI flow compared with non-smokers (p < 0.001); this was confirmed after adjustment for all baseline and procedural confounders, and the propensity score. Active smokers had a significantly lower in-hospital (p < 0.001) and 30-day (p < 0.001) mortality compared with non-smokers and previous smokers; this was confirmed after adjustment for all baseline and procedural confounders, and the propensity score. In conclusion, in our population, active smoking was significantly associated with improved epicardial recanalization and lower in-hospital and 30-day mortality compared with previous and non-smoking history.

Azienda Ospedaliero Universitaria Ospedali Riuniti 34142 Trieste Italy

Cardiology Azienda Ospedaliera 16033 Lavagna Italy

Cardiology Center Hospitalier d'Antibes Juan Les Pins 06600 Antibes France

Cardiology Complexo Hospetaliero Universitario La Coruna 15001 La Coruna Spain

Cardiology Department Hospital Garcia de Orta 2805 267 Almada Portugal

Cardiology Division Department of Internal Medicine National Taiwan University Hospital Tapei 8865600 Taiwan

Cardiology Hospital Clínico Universitario Virgen de la Victoria 29000 Malaga Spain

Cardiology Hospital Germans Triasi Pujol 8918 Badalona Spain

Cardiology Institute Instanbul University 34000 Instanbul Turkey

Cardiology Iraklion University Hospital 70001 Crete Greece

Cardiology Maastricht University Medical Center 6229 Maastricht The Netherlands

Cardiology University Hospital Prague 12808 Prague Czech Republic

Cardiovascular Department Siloam Lippo Village Hospital Heart Center Pelita Harapan University Tangerang 15810 Indonesia

Center for Cardiovascular Diseases 6000 Ohrid North Macedonia

Central Hospital of Medical University of Lodz 90 008 Lodz Poland

Centre for Intensive Internal Medicine University Medical Centre 1000 Ljubljana Slovenia

Clinic Emergency Hospital of Bucharest 010001 Bucharest Romania

Department of Cardiology and Cardiovascular Interventions Instituto Nacional de Cirugía Cardíaca Montevideo 11700 Uruguay

Department of Cardiology and Vascular Medicine National Cardiovascular Center Harapan Kita University of Indonesia Jakarta 11420 Indonesia

Department of Cardiology Bezmialem Vakif University Hospital 34093 Istanbul Turkey

Department of Cardiology Medisch Spectrum Twente Thoraxcentrum Twente 7541 Enschede The Netherlands

Department of Cardiology National Heart Center Singapore 169609 Singapore

Department of Cardiology National University Hospital Singapore 117597 Singapore

Department of Cardiology Queen Elizabeth Hospital University of Hong Kong Hong Kong 999077 China

Department of Cardiology Queen Mary Hospital University of Hong Kong Hong Kong 999077 China

Department of Cardiology University Hospital Centre University of Zagreb 10000 Zagreb Croatia

Department of Heart and Vascular Surgery State Research Institute for Complex Issues of Cardiovascular Diseases 650000 Kemerovo Russia

Department of Internal Medicine Ospedale Riuniti 25121 Brescia Italy

Department of Statistical Sciences University of Padova 35121 Padova Italy

Department of Teaching and Research Instituto de Cardiología de Corrientes Juana F Cabral Corrientes W3400CDS Argentina

Division of Cardiology Alexandra Hospital 10431 Athens Greece

Division of Cardiology Assiut University Heart Hospital Assiut University Asyut 71511 Egypt

Division of Cardiology Attikon University Hospital 10431 Athens Greece

Division of Cardiology AUSL IRCCS Reggio Emilia 42121 Reggio Emilia Italy

Division of Cardiology Azienda Ospedaliera Ospedali Riuniti Marche Nord 61121 Pesaro Italy

Division of Cardiology Blida University Hospital Blida 09000 Algeria

Division of Cardiology Bursa City Hospital 16000 Bursa Turkey

Division of Cardiology Center Hospitalier Universitaire de Lille 59000 Lille France

Division of Cardiology CHU Lariboisière AP HP INSERM UMRS 942 Paris 7 University 75010 Paris France

Division of Cardiology Clinica Villa dei Fiori 80011 Acerra Italy

Division of Cardiology Clinical and Experimental Interventional Cardiology University of Saarland 66421 Homburg Germany

Division of Cardiology Complejo Hospitalario de Toledo 45001 Toledo Spain

Division of Cardiology Faculty of Medicine Eskisehir Osmangazi University 02640 Eskisehir Turkey

Division of Cardiology Groupe Hospitalier Mutualiste de Grenoble 38000 Grenoble France

Division of Cardiology Heart Centre Turku 20521 Turku Finland

Division of Cardiology Hopital Erasmus Universitè Libre de Bruxelles 1070 Bruxelles Belgium

Division of Cardiology Hospiatl Cordoba Cordoba 5000 Argentina

Division of Cardiology Hospital Cabueñes 33201 Gijon Spain

Division of Cardiology Hospital Clinico Universitario de Valencia 46010 Valencia Spain

Division of Cardiology Hospital de Santa Cruz CHLO Nova Medical School Centro de Estudos de Doenças Crónicas 1000 Lisbon Portugal

Division of Cardiology Hospital de Santo António 4099 001 Porto Portugal

Division of Cardiology Hospital Puerta de Hierro Majadahonda 28222 Madrid Spain

Division of Cardiology Hospital Puerta del Mar 11001 Cadiz Spain

Division of Cardiology Hospital Universitario de Canarias 38001 Santa Cruz de Tenerife Spain

Division of Cardiology Kontantopoulion Hospital 104 31 Athens Greece

Division of Cardiology Medical University of Silezia 40 002 Katowice Poland

Division of Cardiology Northwest Clinics 1811 Alkmaar The Netherlands

Division of Cardiology Odense Universitets Hospital 5000 Odense Denmark

Division of Cardiology Ospedale A Manzoni 23900 Lecco Italy

Division of Cardiology Ospedale Civico Arnas 90100 Palermo Italy

Division of Cardiology Ospedale Degli Infermi ASL Biella 13900 Biella Italy

Division of Cardiology Ospedale del Mare 00156 Napoli Italy

Division of Cardiology Ospedale F Spaziani 03100 Frosinone Italy

Division of Cardiology Ospedale G Moscati 81031 Aversa Italy

Division of Cardiology Ospedale Maggiore Bologna 40100 Bologna Italy

Division of Cardiology Ospedale S Maurizio 39100 Bolzano Italy

Division of Cardiology Ospedale San Giovanni di Dio e Ruggi d'Aragona 84070 Salerno Italy

Division of Cardiology Ospedale Sant'Anna 44121 Ferrara Italy

Division of Cardiology Ospedale Santa Chiara di Trento 38014 Trento Italy

Division of Cardiology Ospedale Santa Maria delle Grazie 80078 Pozzuoli Italy

Division of Cardiology Ospedale Santa Maria Goretti Latina 04100 Latina Italy

Division of Cardiology Otamendi Hospital Buenos Aires 1001 Argentina

Division of Cardiology Oulu University Hospital 90220 Oulu Finland

Division of Cardiology Radboud University Medical Center 6525 Nijmegen The Netherlands

Division of Cardiology St Antonius Hospital 3434 Nieuwegein The Netherlands

Division of Cardiology UMC Utrecht 3584 CX Utrecht The Netherlands

Division of Cardiology Universidad UPB CES Medellin 050001 Colombia

Division of Clinical and Experimental Cardiology AOU Sassari University of Sassari 07100 Sassari Italy

H Universitario y Politécnico La Fe 46001 Valencia Spain

Instituto Cardiovascular de Buenos Aires Buenos Aires 1428 Argentina

Instituto de Cardiologia de Santa Catarina Praia Comprida Sao Jose 88100 000 Brazil

Instituto de Cardiologia do Rio Grande do Sul Porto Alegre 90000 00 Brazil

Instituto de Cardiologia Integral Montevideo 11700 Uruguay

Interventional Cardiology Unit Azienda Ospedaliera Sanitaria 43121 Parma Italy

Interventional Cardiology Unit Azienda Ospedaliero Universitaria Ospedali Riuniti 60100 Ancona Italy

Interventional Cardiology Unit Heart Disease Institute Hospital Universitari de Bellvitge 08016 Barcelona Spain

Invasive Cardiology and Congenital Heart Disease Patras University Hospital 26221 Patras Greece

Pronto de Socorro Cardiologico Prof Luis Tavares Centro PROCAPE Federal University of Pernambuco Recife 50000 000 Brazil

Tyumen Cardiology Research Center 625026 Tyumen Russia

University Clinic for Cardiology Medical Faculty Ss' Cyril and Methodius University 1000 Skopje North Macedonia

University Hospital Brno Medical Faculty of Masaryk University Brno 60200 Brno Czech Republic

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