Trends in smoking cessation counseling: experience from American Heart Association-get with the guidelines

Smoking and Provision of Smoking Cessation Interventions among Inpatients with Acute Coronary Syndrome in China: Findings from the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome Project

Highlights

Over half of male acute coronary syndrome patients were smokers in China.

Smoking was associated with higher risk of critical cardiac symptoms at admission.

Only 35.3% of smoking patients received smoking cessation interventions in China.

Background:

Smoking cessation is recognized as an effective and cost-effective strategy for improving the prognosis of patients with coronary heart disease. Despite this, few studies have evaluated the smoking prevalence and provision of smoking cessation interventions among patients with acute coronary syndrome (ACS) in China.

Objectives:

To evaluate the smoking prevalence, clinical conditions and in-hospital outcomes associated with smoking, and the provision of smoking cessation interventions among ACS patients in China.

Methods:

This registry study was conducted using data from the Improving Care for Cardiovascular Disease in China project, a collaborative nationwide registry of the American Heart Association and the Chinese Society of Cardiology. Our study sample comprised 92,509 ACS inpatients admitted between November 2014 and December 2018. A web-based data collection platform was used to report required data.

Results:

Smoking prevalence among male and female ACS patients was 52.4% and 8.0%, respectively. Patients younger than 45 years had the highest smoking rate (men: 68.0%; women: 14.9%). Compared with non-smokers, smokers had an earlier onset age of ACS and a greater proportion of severe clinical manifestations at admission, including ST-elevation myocardial infarction (67.8% versus 54.8%; p < 0.001) and substantially elevated myocardial injury markers (86.1% versus 83.0%; p < 0.001). After multivariable adjustment, smoking was associated with higher risk of critical cardiac symptoms at admission (OR = 1.14, 95% CI: 1.08–1.20; p < 0.001) and had no direct association with in-hospital outcomes (OR = 0.93, 95% CI: 0.84–1.02; p = 0.107) of ACS patients. Of 37,336 smokers with ACS, only 35.3% received smoking cessation interventions before discharge. There was wide variation in provision of smoking cessation interventions across hospitals (0%–100%).

Conclusions:

Smoking is highly prevalent among ACS patients in China. However, smoking cessation interventions are not widely adopted in clinical practice in China as part of formal treatment strategies for ACS patients, indicating an important target for quality improvement.

Clinical Trial Registration:

URL: http://www.clinicaltrials.gov. Unique identifier: NCT02306616.

The American Heart Association's Get With the Guidelines (GWTG)-Stroke development and impact on stroke care

The American Heart Association’s Get With the Guidelines (GWTG)-Stroke programme has changed stroke care delivery in the USA since its establishment in 2003. GWTG is a voluntary registry and continuous quality improvement initiative that collects data on patient characteristics, hospital adherence to guidelines and inpatient outcomes. Implementation of the programme saw increased provision of evidence-based care and improved patient outcomes. This review will describe the development of the programme and discuss the impact on stroke outcomes and transformation of stroke care delivery that followed its implementation.

Outcomes of Middle Eastern Patients Undergoing Percutaneous Coronary Intervention: The Primary Analysis of the First Jordanian PCI Registry

Aim:

This is a prospective multicenter registry designed to evaluate the incidence of adverse cardiovascular events in Middle Eastern patients undergoing percutaneous coronary interventions (PCI). The registry was also designed to determine the predictors of poor outcomes in such patients.

Methods and Results:

We enrolled 2426 consecutive patients who underwent PCI at 12 tertiary care centers in Jordan between January 2013 and February 2014. A case report form was used to record data prospectively at hospital admission, discharge, and 12 months of follow-up. Mean age was 56 ± 11 years, females comprised 21% of the study patients, 62% had hypertension, 53% were diabetics, and 57% were cigarette smokers. Most patients (77%) underwent PCI for acute coronary syndrome. In-hospital and 1-year mortality rates were 0.78% and 1.94%, respectively. Definite or probable stent thrombosis occurred in 9 patients (0.37%) during hospitalization and in 47 (1.94%) at 1 year. Rates of target vessel repeat PCI and coronary artery bypass graft surgery at 1 year were 3.4% and 0.6%, respectively. The multivariate analysis revealed that cardiogenic shock, congestive heart failure, ST-segment deviation, diabetes, and major bleeding were significantly associated with higher risk of 1-year mortality.

Conclusions:

In this first large Jordanian registry of Middle Eastern patients undergoing PCI, patients treated were relatively young age population with low in-hospital and 1-year adverse cardiovascular events. Certain clinical features were associated with worse outcomes and may warrant aggressive therapeutic strategies.

Smoker's Paradox in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

BACKGROUND

Prior studies have found that smokers undergoing thrombolytic therapy for ST-segment elevation myocardial infarction have lower in-hospital mortality than nonsmokers, a phenomenon called the "smoker's paradox." Evidence, however, has been conflicting regarding whether this paradoxical association persists in the era of primary percutaneous coronary intervention.

METHODS AND RESULTS

We used the 2003-2012 National Inpatient Sample databases to identify all patients aged ≥18 years who underwent primary percutaneous coronary intervention for ST-segment elevation myocardial infarction. Multivariable logistic regression was used to compare in-hospital mortality between smokers (current and former) and nonsmokers. Of the 985 174 patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention, 438 954 (44.6%) were smokers. Smokers were younger, were more often men, and were less likely to have traditional vascular risk factors than nonsmokers. Smokers had lower observed in-hospital mortality compared with nonsmokers (2.0% versus 5.9%; unadjusted odds ratio 0.32, 95% CI 0.31-0.33, P<0.001). Although the association between smoking and lower in-hospital mortality was partly attenuated after baseline risk adjustment, a significant residual association remained (adjusted odds ratio 0.60, 95% CI 0.58-0.62, P<0.001). This association largely persisted in age-stratified analyses. Smoking status was also associated with shorter average length of stay (3.5 versus 4.5 days, P<0.001) and lower incidence of postprocedure hemorrhage (4.2% versus 6.1%; adjusted odds ratio 0.81, 95% CI 0.80-0.83, P<0.001) and in-hospital cardiac arrest (1.3% versus 2.1%; adjusted OR 0.78, 95% CI 0.76-0.81, P<0.001).

CONCLUSIONS

In this nationwide cohort of patients undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction, we observed significantly lower risk-adjusted in-hospital mortality in smokers, suggesting that the smoker's paradox also applies to ST-segment elevation myocardial infarction patients undergoing primary percutaneous coronary intervention.

Adherence to process of care quality indicators after percutaneous coronary intervention in Ontario, Canada: a retrospective observational cohort study

Background

Public reporting of percutaneous coronary intervention (PCI) outcomes has been established in many jurisdictions to ensure optimal delivery of care. The majority of PCI report cards examine in-hospital mortality, but relatively little is known regarding the adherence to processes of care.

Methods

A modified Delphi panel comprising cardiovascular experts was assembled to develop a set of PCI quality indicators. Indicators such as prescription of aspirin, dual antiplatelet therapy, statins and smoking cessation counselling were identified to represent high-quality PCI care. Chart abstraction was performed at 13 PCI hospitals in Ontario, Canada from 2009 to 2010 with at least 200 PCI patients randomly selected from each hospital.

Results

Our study sample included 3041 patients, of whom 18% had stable coronary artery disease (CAD) and 82% had an acute coronary syndrome (ACS). Their mean age was 63±12.4 years and 29% of patients were female. Prior to PCI, 89% were prescribed aspirin, and after PCI 98.7% were prescribed aspirin, 95.1% were prescribed dual antiplatelet therapy for 12 months after drug-eluting stents, and 94.9% were prescribed statins. The lowest performing quality indicator was smoking cessation counselling, observed in only 42% of current and past smokers (18% in patients with stable CAD and 47% in ACS).

Conclusions

Our study demonstrates high levels of adherence to most quality indicators for patients undergoing PCI procedures in Ontario. In conclusion, smoking cessation counselling was not consistently performed across hospitals and represents an opportunity for future quality improvement efforts.