Chronic stable angina treatment smoking cessation

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [mailto:mgibson@perfuse.org] Phone:617-632-7753; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan. M.B.B.S.

Overview
The 1989 Surgeon General’s report, which assessed numerous case-control and cohort studies, reported that smoking increased cardiovascular disease mortality by 50%. Cigarette smoking, likely due to the hemodynamic consequences of sympathetic neural stimulation and systemic catecholamine release, plays an important role in the pathogenesis of coronary artery disease. Cigarette smoking also forms a major risk factor for acute cardiovascular events as it relates to an associated increase in blood coagulability. Hence, cigarette smoking is an important reversible risk factor in the pathogenesis of CAD and cessation of which improves prognosis and is associated with a substantial decrease in the risk of mortality. In patients with stable angina pectoris, nicotine replacement therapy has shown to be potentially beneficial despite the associated cardiovascular risks of nicotine, such as increase in heart rate with a small rise in blood pressure. Nicotine replacement therapy may be initiated as early as 2–3 days after acute myocardial infarction or cardiac arrhythmias. Additionally, nicotine patches have been used successfully in high-risk patients without any adverse effects such as aggravation of MI or arrhythmia.

Smoking Cessation: The 5A Step-wise Strategy

 * A: Ask Systematic identification of all smokers at every opportunity.


 * A: Assess Determine the patient’s degree of addiction and his/her willingness to stop smoking.


 * A: Advise Strongly encourage all smokers to quit smoking.


 * A: Assist Provide a smoking cessation strategy that includes behavioral counseling, nicotine replacement therapy and/or pharmacological intervention.


 * A: Arrange Offer help to schedule follow-up visits.

Supportive trial data

 * The Cochrane database, a meta-analysis of 20 studies that aimed to estimate the magnitude of risk reduction associated with smoking cessation, reported that there was a 36% reduction in the overall mortality (crude RR 0.64, 95% CI 0.58 to 0.71) and a significant reduction in the rate of non-fatal MI (crude RR 0.68, 95% CI 0.57 to 0.82).


 * Based on a placebo-controlled, randomized study that assessed the cardiovascular safety of nicotine patches in patients with coronary artery disease who tried to quit smoking, there were no observed changes in the resting heart rate and blood pressure between the screening and follow-up phases. There were also no significant changes observed in the number and duration of ischemic episodes or in the frequency of arrhythmias. However, exercise tolerance and time to 1-mm ST segment depression increased in both groups. Thus, the study concluded the use of nicotine patches to promote smoking cessation was safe in patients with high-risk for CAD. Similar results were observed in another study that assessed the safety of transdermal nicotine for smoking cessation in patients with coronary artery disease.

==ACC/AHA Guidelines- Cardiovascular Risk Factor Reduction- Smoking Cessation (DO NOT EDIT)  == {{cquote|

Class I
1. Smoking cessation and avoidance of exposure to environmental tobacco smoke at work and home is recommended. Follow-up, referral to special programs, and/or pharmacotherapy (including nicotine replacement) is recommended, as is a stepwise strategy for smoking cessation (Ask, Advise, Assess, Assist, Arrange). (Level of Evidence: B)}}

Vote on and Suggest Revisions to the Current Guidelines

 * The Chronic Stable Angina Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Guidelines Resources

 * The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina


 * The ACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina


 * The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina


 * Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology