Smoking and CVD ….what role for the Cardiologist?

Dr Sandeep Gupta, MD, FRCP

Consultant Cardiologist Whipps Cross/BartsHealth NHS Trusts Hospitals, London, UK

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1. GISSI. Lancet.1986, 1987; 2. ISIS 2. Lancet.1988; 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.

5

10

15

20

25

30

35

40

45

50

ThrombolysisPPCI/ thrombolysis

1–41–4 AntiplateletAntiplatelet2,52,5 ββ-Blockers-Blockers66 ACE Inhibitor ACEI/ARB 7–117–11 StatinsStatins12,1312,13

10%–50%10%–50%

23%23%20%20%

7%–27%7%–27%22%–30%22%–30%

Therapy ClassTherapy Class

Therapeutic Advances in theTherapeutic Advances in theTreatment of Cardiovascular DiseaseTreatment of Cardiovascular Disease

InterventionRisk

reduction (%)

Event rate (%)

None - 8

Asp/Clop 25 6

B-Blockers 25 4.5

Statins 30 3

ACEI 25 2.3

Post-MI setting

Stopping smoking, 36%

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 yearsSustained quitters Continuing smokers

n = 5,659 n = 6,9441,044 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 in10 countries

The young

Hatched areas indicate proportions of deaths related to tobacco use.

Tobacco Is a Risk Factor for 6 of the World’s 8 Leading Causes of Death

SMOKING: EFFECT ON CORONARY ARTERY DISEASE1

1. Waters D et al. Circulation 1996;94:614–21

Progression of existing lesions after 2 years

Formation of new lesions after 2 years

37%

57%

p=0.00250

40

30

20

10

0

Patie

nts

(%)

Non-smokers Currentsmokers

50

40

30

20

10

0

p=0.007

Patie

nts

(%)

20%

36%

Currentsmokers

Non-smokers

After CABG Risk of reoperation x 2.5 at 1 year for non quitters1

After angioplastyRisk of mortality x 1.4 at 4.5 years for non quitters2

1. Voors AA et al Circulation 1996; 93: 42-72. Hasdai D et al N Engl J Med 1997; 336: 755-61

Effects of smoking cessation in secondary prevention

Smoking: a particular risk factorThe 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

Thomas D et al. Étude ALLIANCE Journées Européennes de la SFC Janvier 2007

% 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

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-smokersLower

respiratoryinfectionsin children<5 years

Otitismedia inchildren<3 years

Asthmain

children<15 years

Asthmain adults

Lungcancer in

adults

Ischaemicheart

disease inadults

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?

10th 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?

25th 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 Dopamine1,2

• Dopamine gives feelings of pleasure and calmness1

• The smoker craves Nicotine to release more Dopamine to restore pleasure and calmness1

• Competitive binding of Nicotine to nicotinic acetylcholinergic receptors causes prolonged activation, desensitization, and upregulation2

• As Nicotine levels decrease, receptors revert to an open state causing hyperexcitability leading to cravings1,2

1. Jarvis MJ. BMJ. 2004; 328:277-279. 2. Picciotto MR, et al. Nicotine and Tob Res. 1999: Suppl 2:S121-S125.

Dopamine

Nicotine

• Because CHAMPIX is bound to the receptor, it prevents the binding of nicotine

• CHAMPIX reduces the pleasurable and reinforcing effects of smoking

1. Hays JT et al. Am J Med 2008;121(4A):S32-S424. Foulds J. Int J Clin Pract. 2006; 60(5):571-6.

Partial Antagonist 1,4

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 6.6Coronary artery diseaseNon-fatal MI 7 2.0 3 0.9Need for coronary revascularization 8 2.3 3 0.9Hospitalization for angina pectoris 8 2.3 8 2.3Hospitalization for congestive heart failure 0 0.0 2 0.6

Cerebrovascular diseaseNon–fatal stroke 2 0.6 1 0.3Transient 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 1.4Cardiovascular death 1 0.3 2 0.6Non–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

No different to placebo

Hypertensive smokers have higher cardiovascular risk despite treatment for blood pressure

SMOKING REDUCES BENEFITS ASSOCIATED WITH ANTIHYPERTENSIVE TREATMENT

Journath G et al. Blood Pressure 2005;14:144–50

Up to a 63% higher risk of vascular events in

smokers vs non-smokers despite

treatment with statins

SMOKING REDUCES SOME OF THE BENEFITS OF STATINS

Milionis HJ et al. Angiology 2001;52:575–87

Statin

Evidence from the UK

Real Price and Consumption of Cigarettesin the UK, 1971-96

9000

10000

11000

12000

13000

14000

15000

16000

17000

1971 1974 1977 1980 1983 1986 1989 1992 1995

Year

£ 1.25

£ 1.45

£ 1.65

£ 1.85

£ 2.05

£ 2.25

£ 2.45

£ 2.65

Pric

e (£)

1994

valu

e

PRICE

CONSUMPTION

Source: Townsend J 1998, Central Statistical Office (UK) (1965-93)

Cost effectiveness

A Brief Intervention (?)

Ask

Advise

Assess

Assist

Arrange

… about smoking status

… to quit

… willingness to quit

… by offering treatment

… 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.

42

0

10

20

30

40

50

60

70

Advice Offer of treatment

% in

crea

se in

qui

t atte

mpt

sAdvising to quit versus offer of treatment

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 3:REFER and/orTREAT

REFER the patient to a specialised clinic for smoking cessation support and/or, if appropriate, supply an initial prescription

Step 1:ASK

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

Step 2:ADVISE

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.

1Smoker: No Smoker: Yes

Suggestion: Use self adhesive coloured labels on the notes or patient chart to identify smoking status

Willing: No Willing: Yes

Reinforce their decision and give the patient some reading material on the benefits of stopping smoking

Ask that they think about the benefits of stopping and that they ask for help if they want to try in the future

2

3Clinic in same hospital:

NoClinic 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

Better Lung Health For All

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-cigarettesIn 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)

Source:ASH (2015)

Better Lung Health For All

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

MECHANISMS

Possible

Probable

Definite

Mechanisms by which nicotine may contribute to Coronary Heart Disease

Benowitz, 1991Hyperlipididemia

Endothelial Injury

Platelet Activation Thrombosis

Coronary Vasoconstriction

Increased Heart RateMyocardial Contractility

Hemodynamic Stress

Increased Circulating Catecholamines

Sudden Death

Premature Atherosclerosis

Vascular Stenosis or Occlusion

Myocardial Ischemia or Infarction

Arrhythmias

Sympathoadrenal Activation

NICOTINE

CARBON MONOXIDE

Decreased Oxygen

Transport

TXA2

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