Chronic stable angina treatment smoking cessation

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [3] Phone:617-632-7753; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan. M.B.B.S.


The 1989 Surgeon General’s report, which assessed numerous case-control and cohort studies, reported that smoking increased cardiovascular disease mortality by 50%.[1] 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.[2] 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.[3][4][5] 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.[2] Additionally, nicotine patches have been used successfully in high-risk patients without any adverse effects such as aggravation of MI or arrhythmia.[6][7]

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).[5]

2012 Chronic Angina Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT)[8][9][10]

Smoking Cessation (DO NOT EDIT)[8]

Class I
"1. Smoking cessation and avoidance of exposure to environmental tobacco smoke at work and home should be encouraged for all patients with SIHD. Follow-up, referral to special programs, and pharmacotherapy are recommended, as is a stepwise strategy for smoking cessation (Ask, Advise, Assess, Assist, Arrange, Avoid). (Level of Evidence: B) "


  1. Centers for Disease Control (CDC) (1989) The Surgeon General's 1989 Report on Reducing the Health Consequences of Smoking: 25 Years of Progress. MMWR Morb Mortal Wkly Rep 38 Suppl 2 ():1-32. PMID: 2494426
  2. 2.0 2.1 Benowitz NL, Gourlay SG (1997) Cardiovascular toxicity of nicotine: implications for nicotine replacement therapy. J Am Coll Cardiol 29 (7):1422-31. PMID: 9180099
  3. Bartecchi CE, MacKenzie TD, Schrier RW (1994) The human costs of tobacco use (1) N Engl J Med 330 (13):907-12. DOI:10.1056/NEJM199403313301307 PMID: 8114863
  4. MacKenzie TD, Bartecchi CE, Schrier RW (1994) The human costs of tobacco use (2) N Engl J Med 330 (14):975-80. DOI:10.1056/NEJM199404073301406 PMID: 8121461
  5. 5.0 5.1 Critchley J, Capewell S (2003) Smoking cessation for the secondary prevention of coronary heart disease. Cochrane Database Syst Rev (4):CD003041. DOI:10.1002/14651858.CD003041 PMID: 14583958
  6. 6.0 6.1 Tzivoni D, Keren A, Meyler S, Khoury Z, Lerer T, Brunel P (1998) Cardiovascular safety of transdermal nicotine patches in patients with coronary artery disease who try to quit smoking. Cardiovasc Drugs Ther 12 (3):239-44. PMID: 9784902
  7. 7.0 7.1 (1994) Nicotine replacement therapy for patients with coronary artery disease. Working Group for the Study of Transdermal Nicotine in Patients with Coronary artery disease. Arch Intern Med 154 (9):989-95. PMID: 8179456
  8. 8.0 8.1 Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP; et al. (2012). "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 126 (25): 3097–137. doi:10.1161/CIR.0b013e3182776f83. PMID 23166210.
  9. Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007)2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation 116 (23):2762-72.[1] PMID: 17998462
  10. Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). Circulation 107 (1):149-58.[2] PMID: 12515758

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