A multicenter tobacco cessation program in acute coronary syndrome PD Nicolas Rodondi, MD, MAS Research Fellow: Reto Auer, MD Head of the Cardiovascular Prevention & Lipid Clinic Department of Ambulatory Care and Community Medicine, University of Lausanne Congress Europrevent, Geneva April 14 2011 1
Event rate Efficacy of in-hospital multidimensional interventions of secondary prevention after acute coronary syndrome (ACS) 25% 21,3% 20% 19,1% * 15% 11,6% 11,1% Control 10% 8,7% * Intervention 4,8% * * p 0.0001 5% 0% Mortality Recurrent MI Readmission Auer R et al. Circulation 2008 2
Secondary Outcomes Outcome Nbr of studies Smoking cessation rate 12 (11 CCT) RR (95% CI) 1.29 (1.02-1.64) Increase in prescription rate of proven efficacious drug therapy at discharge Nbr of studies RR (95% CI) -β blockers 5 (BAS) 1.48 (1.05-2.09) -ACE-Inhibitors 6 (BAS) 1.41 (1.11-1.78) -Lipid lowering drug 4 (BAS) 1.72 (1.31-2.25) -Antiplatelet agents 6 (BAS) 1.14 (0.92-1.41) CCT: Clinical Controlled Trial, BAS, Before and After Study Auer R et al. Circulation 2008 3
Smoking and acute coronary syndrome (ACS) (1) High risk of recurrence of ACS: about 15-20% 1 Smokers: recurrence, 2x higher than non smokers or those who stopped smoking. 2 Smoking cessation: 50% risk of recurrence, as well as long-term mortality. 2,3 Hospitalization following a CHD event: smoking cessation Teachable moment for patients, receptivity to educational measures. 4 1 PG Steg et al., JAMA 2007; 2 TD Rea et al., Ann Intern Med 2002 3 LE Daly et al., Br Med J (Clin Res Ed) 1983; 4 CM McBride et al., Health Educ. Res. 2003 4
Smoking and acute coronary syndrome (ACS) (2) Patients with ACS in Switzerland: Neither systematic educational intervention during hospitalization nor ambulatory follow-up Ambulatory follow-up by phone: efficient to improve smoking cessation rates. 1 1 Rigotti NA, et al.,cochrane Database Syst Rev 5
Efficacy of interventions for smoking cessation in hospitalized patients 1 33 studies identified Interventions to help smoking cessation are efficient with ambulatory follow-up at least 1 month OR at 6 months: 1.65 (95% CI, 1.44-1.90) Addition of nicotine replacement therapy cessation rate Should be provided at least to patients with withdrawal symptoms during hospitalization 1 Rigotti et al, Cochrane systematic review, 2007 6
Examples of smoking cessation Chouinard, Nursing research, 2005 Froehlicher, Circulation, 2004 interventions and impact N Intervention vs Control group Quit rate % at 6 mo (12mo) RR 168 25 13 1.48 277 Smith, CMAJ, 2009 276 52 (48) 67 (57) 41 (42) 49 (39) 1.20 (1.12) 1.27 (1.32) Outcomes Continuous abstinence at 6 mo 7 day point prev at 6 mo (12mo) Self reported abstinence at 6 (12) mo Phone calls 6 5 7 Patients: Smokers hospitalized with a heart disease Froehlicher et al, 2004: only highly motivated patients by smoking cessation Intervention: Intervention based on stage of change (Chouinard et al) Interview with behaviorial counseling strategies (Froehlicher et al; Smith et al, 2009) 7
Possible large margin for smoking cessation: pre-elips preliminary results from Lausanne 23 first patients included in pre-elips phase 11 STEMI, 10 NSTEMI, 2 unstable angina 1 woman; 22 men 8 smokers (35%) 8
Hospital discharged medications and Treatment interventions Prescription rate Aspirin: 23/23 - Reason for non-prescription Clopidogrel: 20/23 3 CABG: no indication β blocker: 20/23 Bradycardia: 2 No reason reported: 1 IECA/ARB 16/23 Prescription controversial: 1 Renal insufficiency: 2 Not prescribed, but suggested to PCP: 1 No reason reported: 3 Statin 23/23 - Smoking cessation intervention 4/8 Patient refusal reported: 1 No reason reported: 3 9
Objectives of the Swiss smoking cessation study in ACS 1 objective: does systematic intervention, within a multidimensional intervention, quit rates at one year in patients hospitalized with ACS? 2 objectives: Which patient groups benefit most from intervention (according to age, gender, and SES) rate of re-admission and recurrent MI? Cost-effectiveness analysis of smoking cessation intervention 10
Systematic smoking cessation intervention offered to ELIPS patients with a motivational interviewing Follow-up by phone for 2 months Before-after study Methods 240 patients included in the pre-elips phase 70 patients included in the Elips intervention phase in LA and GE until today, 240 target Swiss Federal Office of Public Health Project supported by the Swiss Tobacco Prevention Fund 11
Ambulatory follow-up by telephone 48h, 1 week, 1 month and 2 months Average effective duration : 5-15 min / patient Intervention based on patient s stage of change Motivational counseling Undetermination Intention Preparation/Action Cognitive Behaviourial Counseling 12
Baseline data collection Tobacco use: past pack-years, current quantity Motivation to smoking cessation (visual scale from 1 to 10) Patients of STOP-tabac consultation (in LA + GE): Stage of change Fagerströhm Past smoking cessation attemps Nicotine replacement therapies 13
Outcome To compare pre- and post-elips: I : 7-day point prevalence smoking cessation at 1 year II : Continuous abstinence at 12 months Attempt to quit >24 hours during the past year Change on the motivation scale Smoking cessation levels validated by expired CO and serum cotinine 14
Preliminary results of pre-elips phase (n=207) 1 Before systematic smoking cessation interventions % smokers at baseline 36% % smokers at 1-year follow-up 27%! Successful smoking cessation 27%! - Lower than in control group of several previous studies - Large margin for improvement in intervention phase 1 Preliminary data from Lausanne site 15
Potential impact Inpatient counseling with ambulatory follow-up by telephone for smoking cessation support: innovative intervention in Switzerland Large margin for improvement in ACS patients Each smoker should benefit from best care to recurrence of ACS and life duration in a healthy state. If efficient program: widespread systematic intervention on smoking cessation for patients with ACS in all Swiss hospitals 16
Thank you for your attention Nicolas.Rodondi@hospvd.ch 17
Rationale Acute events, such as myocardial infarction, have been shown to be very effective teachable moments when smoking habits are particularly susceptible to interventions for smoking cessation. 18
Established within 24 hours at CHUV, or obtained from addressing hospital Lipid profile 6/12 Measured, but only after 24 hours 3/9 Nitrates Regular therapy 1/23 Optional 2/23 Cardiac rehabiliation Rehabilitation suggested 9/23
Intensity of intervention: 1. Single contact in hospital lasting <= 15 minutes, no follow-up support. 2. One or more contacts in hospital lasting in total > 15 minutes, no follow-up support. 3. Any hospital contact plus follow-up <=1 month. 4. Any hospital contact plus follow-up > 1 month. Rigotti NA, et al. Cochrane Database Syst Rev 2007:CD001837 20