Some of my young patients who suffered heart attacks in their 30s to 40s did not think that they would have a heart attack. Most of these young patients were smokers who did not realise that smoking was such a strong risk factor for heart attacks.

By Dr Huang Zijuan, Consultant, Department of Cardiology

Smoking causes damage to the arteries, blocking heart or brain arteries which can lead to heart attacks or strokes.

I have seen many patients who were smokers, in the clinic, seeking help to know if they have heart problems and whether they will get a heart attack. Is finding out if one has heart problems sufficient to prevent a heart attack?

If a cardiac scan of a patient revealed severe blockages, he or she will often be quickly treated with a coronary angioplasty and stenting (Fig. 1) or even a coronary artery bypass surgery (Fig. 2). Notwithstanding that all these procedures and surgeries also have accompanying risks of stroke and heart attacks.

Fig. 1 – A stent is a tube that surgeon uses to insert into a blocked artery to keep it open.


Fig. 2 – A bypass surgery is a major operation where a surgeon has to stop the heart using a bypass machine and remove a blood vessel from another part of your body to bypass the blocked artery.

Unfortunately, it sometimes takes an ordeal like that to convince a patient to quit smoking.

However, there are still some patients who still fail to quit smoking even after the procedure. These patients are at a high risk of recurrent heart attacks with possibly dangerous consequences like cardiac arrest.

There are also many times, when the scans of patients who were smokers only show minor deposits in the heart arteries. In such cases, no stenting or bypass surgery is necessary, as these procedures carry risks and would not eradicate the minor deposits. However, patients may not realise that heart attack could still happen if one continues to smoke.

Studies show that a large proportion of heart attacks are caused by blockages that were non-obstructive, or arteries that had only minor deposits1, 2. The small deposits of plaque in these arteries may rupture any time, if triggered by the effect of toxins in cigarette smoke. The ruptured plaque or minor deposit can then rapidly progress into complete blockage of the artery (Fig. 3), causing a heart attack.

Plaque forming
Fig. 3 – Plaque forming over time and causing serious blockage.


Ted*, in his 50s, saw my colleague with a complaint of chest pain. He was a typical patient who would get a heart attack. He was a middle-aged man who did not exercise regularly, and worse of all, he was a heavy smoker. A cardiac scan done showed that even though there were some minor deposits or plaque in two of his heart arteries, the blood flow in his heart arteries was still good, thus no procedure was required. He was advised to quit smoking to avoid getting a heart attack. Ted's health was now in his own hands.

Barely four months later, Ted was rushed into the emergency department because of a major heart attack. One of his coronary arteries which was earlier found to have only minor deposits, was 100% blocked. The plaque had ruptured, blocked the entire artery and affected blood supply to the heart. It turned out that Ted did not heed the advice to quit smoking.

In Singapore, about eight people die every day from out-of-hospital cardiac arrest3. A common reason for cardiac arrest is heart attack. Fortunately for Ted, he was rushed to the hospital in time and received stenting to unblock his artery. However, the episode has damaged his heart muscles and weakened his heart. After this hard lesson, Ted decided to quit smoking. He has been doing it slowly but surely, setting goals and cutting down on the number of cigarettes he takes each day.

Strategies to Quit Smoking

A common reason given by patients on why they smoke is that they feel stressed and smoking could relieve their stress. Every one of us, inevitably will be faced with stress in the course of our work or in our daily lives. Instead of smoking, there are many ways of relieving stress such as doing exercises like taking a brisk walk. This would also help improve mental wellbeing and health.

Family support is important. Many patients succeed in quitting smoking with the encouragement of their family. To start off, set a target for the number of cigarettes to cut down by per week, stick to the targets and set a date to completely quit. Getting your family members involved in the quitting process can be a good way to motivate yourself to achieve the goals. 

It is never too late nor too old to quit. It is not true that if you quit now, something worse will happen. Although there may be withdrawal symptoms when you attempt to quit, these symptoms vary from person to person. Speak to your doctor to manage these symptoms. Nicotine causes a form of addiction and there are medical treatments like nicotine replacement patches to help ease it. There are also smoking cessation counsellors who can support you to quit smoking.

I have many patients who have successfully quit smoking. They are doing well and in better health when they come for their follow-ups, years after their bypass surgery or stenting procedure. Patients who failed to quit smoking usually fare worse, with recurrent blockages that even coronary interventions cannot help much anymore. Some of them feel breathless with just taking a few steps, due to accumulated lung damage. You do not want to get to that stage. It is far better to try to quit smoking for better quality of life and to spend time with those 
you care about. Your health and life is in your own hands.

Take the first step by asking your doctor for help to quit smoking. If many can succeed in quitting, you can do it as well!

*Name has been changed to protect the identity.

Giroud D, Li JM, Urban P, Meier B, Rutishauer W. Relation of the site of acute myocardial infarction to the most severe coronary arterial stenosis at prior angiography. Am J Cardiol. 1992;69(8):729–732. 
2 Ambrose JA, Tannenbaum MA, Alexopoulos D, Hjemdahl-Monsen CE, Leavy J, Weiss M, et al. Angiographic progression of coronary artery disease and the development of myocardial infarction. J Am Coll Cardiol. 1988;12(1):56–62.
3 Singapore’s Out-of-Hospital Cardiac Arrest Data Report (2011-2018). Published 2020. Accessed June 12, 2021.

This article is from Murmurs Issue 39 (Jan – Apr 2021). Click here to read the full issue.