Smoking and CVD.what role for the Cardiologist? Dr Sandeep Gupta, MD, FRCP Consultant Cardiologist Whipps Cross/BartsHealth NHS Trusts Hospitals, London, UK
Therapeutic Advances in the Treatment of Cardiovascular Disease 50 45 40 10% 50% Total Mortality Risk Reduction in Post-MI Patients (%) 35 30 25 20 15 23% 20% 7% 27% 22% 30% 10 5 Thrombolysis PPCI/ 1 4 Antiplatelet 2,5 β-blockers 6 ACEI/ARB Inhibitor 7 11 Statins 12,13 thrombolysis Therapy Class 1. GISSI. Lancet.1986, 1987; 2. ISIS Lancet.1988; 2. 3. AIMS. Lancet.1988, 1990; 4. ASSET. Lancet.1988, 1990; 5. Antiplatelet Trialists Collaboration. BMJ.1994; 6. Yusuf et al. ProgCardiovasc Dis.1985;27:335 371; 7. SAVE. N Engl J Med.1992; 8. AIRE. Lancet. 1993; 9. GISSI 3. J Am Coll Cardiol.1996; 10. ISIS 4. Lancet.1995; 11. TRACE. N Engl J Med.1995; 12. 4S. Lancet. 1994;13. LIPID. N Engl J Med.1998.
Post-MI setting Intervention Risk reduction (%) Event rate (%) Stopping smoking, None - 8 36% Asp/Clop 25 6 B-Blockers 25 4.5 Statins 30 3 ACEI 25 2.3
Effects of smoking cessation in secondary prevention Meta analysis of 20 studies (1978 to 2000) - 12,603 smokers with coronary heart disease - Follow-up: 3 to 7 years Sustained quitters Continuing smokers n = 5,659 n = 6,944 1,044 deaths 1,884 deaths 18.4% 27.1% RR = 0.64 (CI 95%, 0.58 0.71) Deaths - 36% Non fatal myocardial reinfarction: - 32% RR = 0.68 (CI 95%, 0.57-0.82) Critchley JA, Capewell S JAMA 2003: 290: 86-97
May 2004
65% of the world s smokers live in 10 countries
The young
Tobacco Is a Risk Factor for 6 of the World s 8 Leading Causes of Death Hatched areas indicate proportions of deaths related to tobacco use.
SMOKING: EFFECT ON CORONARY ARTERY DISEASE 1 Progression of existing lesions after 2 years 57% Formation of new lesions after 2 years 50 p=0.002 50 p=0.007 Patients (%) 40 30 20 37% Patients (%) 40 30 20 20% 36% 10 10 0 Non-smokers Current smokers 0 Non-smokers Current smokers 1. Waters D et al. Circulation 1996;94:614 21
Effects of smoking cessation in secondary prevention After CABG Risk of reoperation x 2.5 at 1 year for non quitters 1 After angioplasty Risk of mortality x 1.4 at 4.5 years for non quitters 2 1. Voors AA et al Circulation 1996; 93: 42-7 2. Hasdai D et al N Engl J Med 1997; 336: 755-61
Smoking: a particular risk factor The essential and often unique risk factor for acute coronary syndromes in young adults 6,448 patients with STEMI The prevalence of smoking is very important in myocardial infarction under 50 years.with the same prevalence among men and women % of smokers by age and gender 0.97 0.94 0.74 0.83 0.55 0.60 0.68 0.40 0.18 0.25 Global Female/Male prevalence = 0.38 Thomas D et al. Étude ALLIANCE Journées Européennes de la SFC Janvier 2007
Worldwide burden of disease from exposure to second-hand smoke: a retrospective analysis of data from 192 countries Second-hand smoke = 603,000 deaths worldwide Nearly 2/3 of these deaths are caused by ischaemic heart disease in adult non-smokers Lower respiratory infections in children <5 years Otitis media in children <3 years Asthma in children <15 years Asthma in adults Lung cancer in adults Ischaemic heart disease in adults TOTAL 165,000 71 1,150 35,800 21,400 379,000 603,000 Öberg M et al. Lancet, 2011, 377, 139-146.
For every one cigarette smoked you will lose 11 minutes of life
Q: How many cigarettes needed to cause a heart attack?
10 th Dec 2010
Q: How quickly does a cigarette cause harm?
Q: How does a cigarette cause harm?
Q: How long does it take to quit smoking?
25 th January 2011
Q: What CV benefits with smoking cessation?
CARDIOVASCULAR BENEFITS OF SMOKING CESSATION Short-term benefits HDL; decreased LDL Arterial pressure Heart rate Improved arterial compliance Risk of arrhythmic death after myocardial infarction (MI) Platelet volume Long-term benefits reduced risk of: Stroke Recurrent coronary events after MI Arrhythmic death after MI Secondary cardiovascular disease (CVD) events 1. Terres et al. Am J Med 1994; 97: 242 9. 2. Wannamethee et al. JAMA 1995; 274: 155 60. 3. Nilsson et al. J Int Med 1996; 240: 189 94. 4. Oren et al. Angiology 2006; 57: 564 8. 5. Peters et al. J Am Coll Cardiol 1995; 26: 1287 92. 6. Rea et al. Ann Intern Med 2002; 137: 494 500. 7. Twardella et al. Eur Heart J 2004; 25: 2101 8.
The cycle of nicotine addiction Nicotine binding causes an increase in release of Dopamine 1,2 Dopamine gives feelings of pleasure and calmness 1 The smoker craves Nicotine to Nicotine release more Dopamine to restore pleasure and calmness 1 Competitive binding of Nicotine to nicotinic acetylcholinergic receptors causes prolonged activation, desensitization, and upregulation 2 As Nicotine levels decrease, receptors revert to an open state causing hyperexcitability leading to cravings 1,2 Dopamine 1. Jarvis MJ. BMJ. 2004; 328:277-279. 2. Picciotto MR, et al. Nicotine and Tob Res. 1999: Suppl 2:S121-S125.
Partial Antagonist 1,4 Because CHAMPIX is bound to the receptor, it prevents the binding of nicotine 1. Hays JT et al. Am J Med 2008;121(4A):S32-S42 4. Foulds J. Int J Clin Pract. 2006; 60(5):571-6. CHAMPIX reduces the pleasurable and reinforcing effects of smoking
Q: Is smoking cessation safe to use in Cardiac patients?
January 2010 January 2010
Cardiovascular events and all deaths Varenicline (n = 353) Placebo (n = 350) n % n % Any adjudicated cardiovascular event* 26 7.4 23 6.6 Coronary artery disease Non-fatal MI 7 2.0 3 0.9 Need for coronary revascularization 8 2.3 3 0.9 Hospitalization for angina pectoris 8 2.3 8 2.3 No different to placebo Hospitalization for congestive heart failure 0 0.0 2 0.6 Cerebrovascular disease Non fatal stroke 2 0.6 1 0.3 Transient ischemic attack 1 0.3 1 0.3 Peripheral vascular disease (PVD) New diagnosis or admission for a procedure to treat PVD 5 1.4 3 0.9 Death all causes 2 0.6 5 1.4 Cardiovascular death 1 0.3 2 0.6 Non cardiovascular death 1 0.3 3 0.9 *Reported or observed cardiovascular events or deaths from any cause were reviewed separately and adjudicated under blinded conditions by an independent event committee
SMOKING REDUCES BENEFITS ASSOCIATED WITH ANTIHYPERTENSIVE TREATMENT Hypertensive smokers have higher cardiovascular risk despite treatment for blood pressure Journath G et al. Blood Pressure 2005;14:144 50
SMOKING REDUCES SOME OF THE BENEFITS OF STATINS Up to a 63% higher risk of vascular events in smokers vs nonsmokers despite treatment with statins Statin Milionis HJ et al. Angiology 2001;52:575 87
Evidence from the UK Real Price and Consumption of Cigarettes in the UK, 1971-96 17000 16000 15000 CONSUMPTION 2.65 2.45 14000 13000 12000 11000 2.25 2.05 1.85 1.65 Price ( ) 1994 value 10000 PRICE 1.45 9000 1971 1974 1977 1980 1983 1986 1989 1992 1995 Source: Townsend J 1998, Central Statistical Office (UK) (1965-93) Year 1.25
Cost effectiveness
A Brief Intervention (?) Ask about smoking status Advise to quit Assess willingness to quit Assist by offering treatment Arrange follow up Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. US Department of Health and Human Services. Public Health Service; May 2008. Available at: www.surgeongeneral.gov/tobacco/default.htm
ABC is a reminder of what to do A = Ask about smoking B = Brief advice to be smokefree C = Cessation support Ministry of Health. 2007. New Zealand Smoking Cessation Guidelines. Wellington: Ministry of Health.
Advising to quit versus offer of treatment 70 % increase in quit attempts 60 50 40 30 20 10 0 Advice Offer of treatment 42 Aveyard P. Keeping smoking cessation interventions brief and effective. Smoking Cessation Rounds 2009; Vol 3, Issue 2.
Potential algorithm for smoking in the cardiac setting Step 1: ASK 1 On admission to A&E or CCU, ASK if patient is a smoker and RECORD it if they are This can be done by any member of the multi-disciplinary team Smoker: No Smoker: Yes Suggestion: Use self adhesive coloured labels on the notes or patient chart to identify smoking status Step 2: ADVISE 2 When the patient s condition has been stabilised, ADVISE the patient that they should stop smoking in order to reduce their risk of further CV complications. Ask if they are willing to try to stop. Willing: No Willing: Yes Step 3: REFER and/or TREAT Ask that they think about the benefits of stopping and that they ask for help if they want to try in the future 3 Reinforce their decision and give the patient some reading material on the benefits of stopping smoking REFER the patient to a specialised clinic for smoking cessation support and/or, if appropriate, supply an initial prescription Clinic in same hospital: No Clinic in same hospital : Yes Ask the clinic staff to visit the patient while they are in hospital Write to the patient s GP regarding their smoking status and actions that have been taken. Request GP follow up. Ministry of Health. 2007. New Zealand Smoking Cessation Guidelines. Wellington: Ministry of Health
What about electronic cigarettes? A solution that could lead to the end of tobacco? Or A huge gamble that will harm health and lead young people to smoking? Better Lung Health For All
Will e-cigarettes encourage children to start smoking? Most UK children have heard of e-cigarettes In one 2015 survey by ASH: 13% of 11-18 year olds had tried them at least once 2.4% had used them regularly (once a month or more) Better Lung Health For All Source: ASH (2015)
What are the benefits of e-cigarettes? Better Lung Health For All
What are the benefits of e-cigarettes? Less harmful than conventional cigarettes Far fewer harmful components Better Lung Health For All
Are e-cigarettes safe? Image: Mikael Häggström, from Wikipedia Better Lung Health For All
Mechanisms by which nicotine may contribute to Coronary Heart Disease Hyperlipididemia Benowitz, 1991 Endothelial Injury Premature Atherosclerosis NICOTINE Platelet Activation Thrombosis Sympathoadrenal Activation Coronary Vasoconstriction Increased Heart Rate Myocardial Contractility Hemodynamic Stress T X A 2 Vascular Stenosis or Occlusion CARBON MONOXIDE Decreased Oxygen Transport MECHANISMS Possible Increased Circulating Catecholamines Myocardial Ischemia or Infarction Probable Definite Arrhythmias Sudden Death Benowitz, 1991
Referrals to stop smoking service
Brief advice works You advise just one smoker every day to quit (time taken = 30 seconds) Over 40 days this would have taken up 20 minutes of your time, but one of those 40 people will quit long term* Over 1 year and you will have prompted six people to stop smoking, using about 2 hours effort from you Consider that by investing 2 hours of your time in that year, you ve saved 3 of those people s lives! *Lancaster T & Stead L. (2004) Physician advice for smoking cessation, Cochrane Database Syst Rev, CD000165