Smoking cessation in European patients with coronary heart disease. Results from the EUROASPIRE IV survey: A registry from the European Society of Cardiology

Sex-specific predictive factors of smoking cessation in subjects at high cardiovascular risk

Smoking is a major risk factor for cardiovascular diseases (CVD), in particular in women, but smoking cessation (SC) reduces or even cancels the risk for both sexes. Using a nationwide SC services database, we aimed to determine the predictive factors of SC in men and women smokers with CV risk factors (CVRF) or CVD. A retrospective study from the French CDTnet database was conducted. Inclusion criteria were age ≥18years, and≥1 CVRF (Body Mass Index ≥25kg/m2, hypertension, diabetes, hypercholesterolemia) or CVD (myocardial infarction (MI) or angina pectoris, stroke, peripheral arterial disease [PAD]). Self-reported smoking abstinence (≥28 consecutive days) was confirmed by exhaled carbon monoxide<10ppm. Logistic regression analysis assessed the association between SC and sociodemographic, medical characteristics, and smoking profile. Among the 36,864 smokers at high CV risk, abstinence rate was slightly lower in women than in men, (52.6% [n=8,102] vs 55.0% [n=11,848], P<0.001). For both sexes, factors associated with the lowest abstinence rates were diabetes, respiratory and psychiatric diseases, anxiolytic/antidepressant use, and cannabis consumption. In women, the factors associated with smoking abstinence were suffering from MI or angina and taking contraceptive pill and the factors associated with persistent smoking were alcohol disorder and high cigarette consumption. In men, there was a positive relationship between overweight and abstinence while being dual users of cigarettes and electronic cigarettes at first visit, having tobacco-related diseases (cancer and PAD) and taking opioid substitution treatment were associated with persistent smoking. Finally, in both sexes, the factors associated with abstinence were: age≥65years, having a diploma, being employed, self-referred or encouraged by entourage, ≥1 previous quit attempt, ≤20 cigarettes per day consumption, benefiting from SC medication prescription and ≥4 follow-up visits. In conclusion, our results suggest the relevance of SC intensive management in smokers at high CV risk, based on sociodemographic, medical, and smoking behaviour characteristics, as well as a gender-specific SC approach.

Efficacy of a Mobile Health App (eMOTIVA) Regarding Compliance With Cardiac Rehabilitation Guidelines in Patients With Coronary Artery Disease: Randomized Controlled Clinical Trial

BACKGROUND

Cardiac rehabilitation is fundamental among patients recovering from a coronary event, and mHealth technology may constitute a useful tool that provides guidelines based on scientific evidence in an entertaining, attractive, and user-friendly format.

OBJECTIVE

This study aimed to compare the efficacy of an mHealth intervention involving the eMOTIVA app and that of usual care regarding compliance with cardiac rehabilitation guidelines in terms of lifestyle, cardiovascular risk factors, and satisfaction among patients with acute coronary syndrome.

METHODS

A randomized controlled clinical trial with a parallel group design was conducted. It included 300 patients (mHealth group, 150; control group, 150) who underwent percutaneous coronary intervention for acute coronary syndrome. Both groups underwent evaluations initially (during hospitalization) and after 3 and 6 months (face-to-face consultations). The eMOTIVA app incorporates a virtual classroom providing audio and video information about a healthy lifestyle, a section for self-recording cardiovascular risk factors, and a section for feedback messages and gamification. The primary outcome variables were (1) adherence to the Mediterranean diet and the frequency of consumption of food; (2) physical activity level, sedentary time, and exercise capacity; (3) smoking cessation and nicotine dependence; (4) level of knowledge about cardiovascular risk factors; and (5) app satisfaction and usability.

RESULTS

The study analyzed 287 patients (mHealth group, 145; control group, 142). Most participants were male (207/300, 69.0%), and the mean age was 62.53 (SD 8.65) years. Significant improvements were observed in the mHealth group compared with the control group at 6 months in terms of (1) adherence to the Mediterranean diet (mean 11.92, SD 1.70 vs 8.92, SD 2.66 points; P<.001) and frequency of eating foods (red meat [≤1/week]: 141/143, 97.9% vs 96/141, 68.1%; industrial pastries [<2/week]: 129/143, 89.6% vs 80/141, 56.8%; oily fish [≥2/week]: 124/143, 86.1% vs 64/141, 41.4%; vegetables [≥2/day]: 130/143, 90.3% vs 78/141, 55.3%; fruit [≥2/day]: 128/143, 88.9% vs 85/141, 60.2%; all P<.001); (2) physical activity (mean 2112.66, SD 1196.67 vs 1372.60, SD 944.62 metabolic equivalents/week; P<.001) and sedentary time (mean 8.38, SD 1.88 vs 9.59, SD 2.09 hours; P<.001); (3) exercise capacity (distance: mean 473.49, SD 102.28 vs 447.25, SD 93.68 meters; P=.04); and (4) level of knowledge (mean 117.85, SD 3.83 vs 111.00, SD 7.11 points; P<.001). App satisfaction was high (mean 42.53, SD 6.38 points), and its usability was excellent (mean 95.60, SD 4.03 points).

CONCLUSIONS

With the eMOTIVA app, favorable results were obtained in the intervention group in terms of adherence to the Mediterranean diet, frequency of eating certain foods, physical activity, sedentary time, exercise capacity, knowledge level, systolic blood pressure, heart rate, and blood sugar level. Furthermore, participants reported high app satisfaction and rated its usability as excellent. Thus, this innovative tool is very promising.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05247606; https://clinicaltrials.gov/study/NCT05247606.

Smoking behaviour in post-acute myocardial infarction patients: cross-sectional study

Introduction

Heart disease remains the leading cause of death in developed countries, and cigarette smoking contributes to a significant proportion of cardiovascular-related deaths. Abstaining from tobacco use is associated with a significant reduction in the risk of recurrent myocardial infarctions.

Methodology

In this cross-sectional study, 384 participants post-acute myocardial infarction (MI) were recruited through random sampling to explore the associations between smoking status and intention to quit smoking. Data collection took place over a 6-month period at a tertiary care hospital, Islamabad, Pakistan.

Results

The majority of participants were male (59.9%) and fell into the age category of 46-50 years (37.5%). Heavy daily smokers comprised the largest smoking group (41.6%), and non-ST-elevated MI was the most common subtype (40.1%). Intention to quit smoking varied among participants, with the pre-contemplation stage having the highest representation (19.3%), followed by contemplation (25.8%). Notably, a significant proportion of participants expressed no intention to quit smoking (35.4%).

Conclusion

Multinomial logistic regression analysis identified current smoking as a significant predictor of intention to quit in the preparation and contemplation stages. Overall, this study underscores the importance of considering smoking behaviour when evaluating the intention to quit smoking post-MI and highlights the need for tailored interventions and support strategies to address smoking cessation in this population. These findings offer valuable insights for the development of effective strategies aimed at reducing persistent smoking following MI and improving patient outcomes.

Organizational and patient-level predictors for attaining key risk factor targets in cardiac rehabilitation after myocardial infarction: The Perfect-CR study

BACKGROUND

Benefits of cardiac rehabilitation (CR) programme components on attaining risk factor targets post-myocardial infarction (MI) and their predictive strength relative to patient characteristics remain unclear. We aimed to identify organizational and patient-level predictors of risk factor target attainment at one-year post-MI.

METHODS

In this observational study data on CR organization at 78 Swedish CR centres was collected and merged with patient-level registry data (n = 7549). Orthogonal partial least squares discriminant analysis identified predictors (Variables of Importance for the Projection (VIP) values >0.8) of attaining low-density lipoprotein-cholesterol (LDL-C) <1.8 mmol/L, blood pressure (BP) <140/90 mmHg and smoking abstinence.

RESULTS

The strongest predictors (VIP [95% CI]) for attaining LDL-C and BP targets were offering psychosocial management (2.14 [1.78-2.50]; 2.45 [1.91-2.99]), having a psychologist in the CR team (1.62 [1.36-1.87]; 2.05 [1.67-2.44]), extended opening hours (2.13 [2.00-2.27]; 1.50 [0.91-2.10]), adequate facilities (1.54 [0.91-2.18]; 1.89 [1.38-2.40]), and having a medical director (1.70 [0.91-2.48]; 1.46 [1.04-1.88]). The strongest patient-level predictors of attaining LDL-C and/or BP targets were low baseline LDL-C (3.95 [3.39-4.51]) and having no history of hypertension (2.93 [2.60-3.26]), respectively, followed by exercise-based CR participation (1.38 [0.66-2.10]; 1.46 [1.14-1.78]). For smoking abstinence, the strongest organizational predictor was varenicline being prescribed by CR physicians (1.88 [0.95-2.80]) and patient-level predictors were participation in exercise-based CR (2.47 [2.07-2.88]) and group education (1.92 [1.43-2-42]), and no cardiovascular disease history (2.13 [1.78-2.48]).

CONCLUSIONS

We identified multiple CR organizational and patient-level predictors of attaining risk factor targets post-MI. These results may influence the future design of comprehensive CR programmes.

Correlation Analysis Between Required Surgical Indexes and Complications in Patients With Coronary Heart Disease

A total of 215 patients with coronary heart disease (CHD) were analyzed with SPSS. Samples of different genders showed significance in the obtuse marginal branch of the left circumflex branch × 1, the diagonal branch D1 × 1, and the ms PV representation. Patients with left circumflex branch occlusion are more male and tend to be younger. Age displayed a positive correlation with left intima-media thickness (IMT) and right IMT. This indicated that as age increases, the values of left IMT and right IMT increase. Samples of different CHD types showed significance in the obtuse marginal branch of the left circumflex branch × 1, the middle part of RCA × 1, and the middle part of the left anterior descending branch × 1.5. For non-ST-segment elevation angina pectoris with acute total vascular occlusion, the left circumflex artery is the most common, followed by the right coronary artery and anterior descending branch. Ultrasound of carotid IMT in patients with CHD can predict changes in left ventricular function, but no specific correlation between left and right common carotid IMT was found. Samples with or without the medical history of ASCVD showed significance in the branch number of coronary vessel lesions. The value of the branch number of coronary vessel lesions in patients with atherosclerotic cardiovascular disease (ASCVD) was higher than in those without ASCVD. The occurrence of complication is significantly relative with the distance of left circumflex branch × 1, the middle segment of left anterior descending branch × 1.5, and the distance of left anterior descending branch × 1. For patients without complications, the values in the distal left circumflex branch × 1, the middle left anterior descending branch × 1.5, and the distal left anterior descending branch × 1 were higher than those for patients with complications. The VTE scores showed a positive correlation with the proximal part of RCA × 1, the branch number of coronary vessel lesions, the posterior descending branch of left circumflex branch × 1, the distal part of left circumflex branch × 1, and the middle part of left anterior descending branch × 1.5.

Improving smoking cessation after myocardial infarction by systematically implementing evidence-based treatment methods

We compared the odds of smoking cessation at 2-months post-myocardial infarction (MI), before and after implementing routines optimizing use of evidence-based smoking cessation methods, with start during admission. The following routines were implemented at six Swedish hospitals: cardiac rehabilitation nurses offering smokers consultation during admission, optimizing nicotine replacement therapy and varenicline prescription, and contacting patients by telephone during the 1st week post-discharge. Using logistic regression, odds for smoking cessation at 2-months before (n smokers/n admitted = 188/601) and after (n = 195/632) routine implementation were compared. Secondary outcomes included adherence to implemented routines and assessing the prognostic value of each routine on smoking cessation. After implementation, a larger proportion of smokers (65% vs. 54%) were abstinent at 2-months (OR 1.60 [1.04-2.48]). Including only those counselled during admission (n = 98), 74% were abstinent (2.50 [1.42-4.41]). After implementation, patients were more often counselled during admission (50% vs. 6%, p < 0.001), prescribed varenicline (23% vs. 7%, p < 0.001), and contacted by telephone post-discharge (18% vs. 2%, p < 0.001). Being contacted by telephone post-discharge (adjusted OR 2.74 [1.02-7.35]) and prescribed varenicline (adjusted OR 0.39 [0.19-0.83]) predicted smoking cessation at 2-months. In conclusion, readily available methods for aiding smoking cessation can be implemented effectively in routine practice, with beneficial effects for post-MI patients.

Lifestyle management to prevent atherosclerotic cardiovascular disease: evidence and challenges

Lifestyle management is the cornerstone of both primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD) and the importance of lifestyle management is emphasised by all major guidelines. Despite this, actual implementation of lifestyle management is poor. Lifestyle modification includes smoking cessation, weight loss, dietary change, increasing physical inactivity, and stress management. This review summarises evidence-based opportunities and challenges for healthcare professionals to promote healthy lifestyles at an individual level for the prevention of ASCVD.

Active Ingredients and Mechanisms of Change in Motivational Interviewing for Smoking Cessation in Patients With Coronary Artery Disease: A Mixed Methods Study

Background: For patients with coronary artery disease (CAD), smoking is an important risk factor for the recurrence of a cardiovascular event. Motivational interviewing (MI) may increase the motivation of the smokers to stop smoking. Data on MI for smoking cessation in patients with CAD are limited, and the active ingredients and working mechanisms of MI in smoking cessation are largely unknown. Therefore, this study was designed to explore active ingredients and working mechanisms of MI for smoking cessation in smokers with CAD, shortly after a cardiovascular event.

Methods: We conducted a qualitative multiple case study of 24 patients with CAD who participated in a randomized trial on lifestyle change. One hundred and nine audio-recorded MI sessions were coded with a combination of the sequential code for observing process exchanges (SCOPE) and the motivational interviewing skill code (MISC). The analysis of the cases consisted of three phases: single case analysis, cross-case analysis, and cross-case synthesis. In a quantitative sequential analysis, we calculated the transition probabilities between the use of MI techniques by the coaches and the subsequent patient statements concerning smoking cessation.

Results: In 12 cases, we observed ingredients that appeared to activate the mechanisms of change. Active ingredients were compositions of behaviors of the coaches (e.g., supporting self-efficacy and supporting autonomy) and patient reactions (e.g., in-depth self-exploration and change talk), interacting over large parts of an MI session. The composition of active ingredients differed among cases, as the patient process and the MI-coaching strategy differed. Particularly, change talk and self-efficacy appeared to stimulate the mechanisms of change “arguing oneself into change” and “increasing self-efficacy/confidence.”

Conclusion: Harnessing active ingredients that target the mechanisms of change “increasing self-efficacy” and “arguing oneself into change” is a good MI strategy for smoking cessation, because it addresses the ambivalence of a patient toward his/her ability to quit, while, after the actual cessation, maintaining the feeling of urgency to persist in not smoking in the patient.

Is Weight Gain Inevitable for Patients Trying to Quit Smoking as Part of Cardiac Rehabilitation?

The literature is uncertain about the extent to which those who attend cardiac rehabilitation (CR) gain weight while trying to quit smoking. This study aimed to determine the extent of CR-based smoking cessation provision and whether CR, as delivered in routine practice, is associated with helping patients quit smoking and avoid weight gain. Data from the UK National Audit of Cardiac Rehabilitation database, between April 2013 and March 2016, were used. Smoking status is categorised as smokers and quitters assessed by patient self-report. Outcomes included body weight, blood pressure, depression, and physical activity. A multiple linear regression model was constructed to understand the effect of continuing smoking or quitting smoking on CR outcomes. CR outcome scores were adjusted by the baseline CR score for each characteristic. An e-survey collected information about the smoking cessation support offered to patients attending CR. A total of 2052 smokers (58.59 ± 10.49 years, 73.6% male) and 1238 quitters (57.63 ± 10.36 years, 75.8% male) were analysed. Overall, 92.6% of CR programmes in the United Kingdom (UK) offer smoking cessation support for CR attenders. Quitting smoking during CR was associated with a mean increase in body weight of 0.4 kg, which is much less than seen in systematic reviews. Quitters who attended CR also had better improvements in physical activity status and psychosocial health measures than smokers. As delivered in routine practice, CR programmes in the UK adhere to the guideline recommendations for smoking cessation interventions, help patients quit smoking, and avoid weight gain on completion of CR.

Determinants of persistent smoking after acute myocardial infarction: an observational study

Background

Smoking cessation is one of the most effective secondary prevention measures after acute myocardial infarction (AMI). However, around 50% of smokers do not quit smoking after AMI. The aim of the present study is to estimate the proportion of patients quitting smoking and to identify determinants of persistent smoking after AMI in a region with increased cardiovascular mortality. We also assessed the time of smoking cessation after AMI.

Methods

We used follow-up data of patients registered with the Regional Myocardial Infarction Registry in Saxony-Anhalt (RHESA) in Germany. We assessed smoking status and determinants of persistent smoking six weeks after discharge from hospital after AMI. Information on smoking, sociodemographic characteristics, risk factors for AMI, experienced symptoms of AMI, and clinical care were gathered in a computer-assisted telephone interview and questionnaires filled out by study subjects and physicians or study nurses.

Results

Out of 372 smokers at the time of AMI, 191 (51.3%) reported that they quit smoking within six weeks after discharge from hospital after AMI. Strongest determinant of persistent smoking was a previous AMI before the current one (OR = 2.19, 95%CI 1.10–4.38) and strongest determinants of smoking cessation were experiencing complications in the hospital (0.37, 95%CI 0.12–1.12) and having a life partner (0.56, 95%CI 0.34–0.95). Most individuals who stopped smoking did so during the initial stay in the hospital, before the cardiac rehabilitation (CR).

Conclusions

Persistent smoking after AMI and its determinants were similar in our region to previous studies. CR cannot be viewed as determinant of smoking cessation – more likely the same teachable moment induces behavioural change with regard to smoking and participation in CR.

The scientific basis for secondary prevention of coronary artery disease: recent contributions from the Netherlands

While the beneficial effects of secondary prevention of cardiovascular disease are undisputed, implementation remains challenging. A gap between guideline-mandated risk factor targets and clinical reality was documented as early as the 1990s. To address this issue, research groups in the Netherlands have performed several major projects. These projects address innovative, multidisciplinary strategies to improve medication adherence and to stimulate healthy lifestyles, both in the setting of cardiac rehabilitation and at dedicated outpatient clinics. The findings of these projects have led to changes in prevention and rehabilitation guidelines.

Mediating effects of lipids on the association between smoking and coronary artery disease risk among Chinese

Objective

The mechanism between smoking and coronary artery disease (CAD) remains unclear. It is likely that lipid (including triglycerides (TG), total cholesterol (TC), low density lipoprotein-cholesterol (LDL-C), high density lipoprotein-cholesterol (HDL-C)) have been functioning as one of the mediators between smoking and the CAD occurrence. The study aimed to investigate the mediating effect of lipid on the relationship between smoking and CAD risk.

Methods

The case-control study included 2048 subjects. General linear regression analysis was used to corroborate the association between smoking and lipid levels. Univariate and multivariate logistic regression analysis were performed to reveal the relationship between smoking, lipid and the risk of CAD. Mediation analysis was used to investigate whether the association between smoking and CAD risk was mediated by lipid.

Results

Smoking was found to be associated with the risk of CAD (odds ratio (OR) = 1.34, 95% confidence interval (CI): 1.05–1.71, P = 0.019). Regression analysis showed that TG, TC and HDL-C were associated with CAD (OR = 2.69, 95%CI: 2.12–3.40, P < 0.001; OR = 0.34, 95%CI: 0.29–0.43, P < 0.001; OR = 0.37, 95%CI: 0.30–0.47, P < 0.001). Moreover, the ratio of TG to HDL-C (TG/HDL-C) was also related to CAD (OR = 4.45, 95%CI: 3.52–5.64, P < 0.001). Mediation analysis showed that among the effects of smoking on CAD, 17.52% was mediated by lipid, in which HDL-C accounted for 11.16% and TG accounted for 6.36%. Further analysis showed that the effect was also partially mediated by TG/HDL-C, which was accounted for 28%.

Conclusions

Lipid plays a partial mediation on the association between smoking and CAD risk. The study provides a clue on the mediation effect of lipids on the relationship between smoking and CAD risks, which is a novel insight to the progression of CAD.

Association of Silica Dust Exposure and Cigarette Smoking With Mortality Among Mine and Pottery Workers in China

Importance

The joint association of long-term silica dust exposure and cigarette smoking with mortality has not been well established.

Objective

To evaluate the joint association of silica dust exposure and cigarette smoking with mortality in a large cohort of workers at mines and factories in China.

Design, Setting, and Participants

This cohort study included 44 708 adults who were employed in 20 metal mines and 9 pottery factories in central and southern China for at least 1 year between January 1, 1960, and December 31, 1974. Participants were retrospectively followed up to January 1, 1960, and prospectively followed up to December 31, 2003. Data analysis was conducted from April 5, 2019, to October 26, 2019.

Exposures

Cumulative respirable silica dust exposure was estimated by linking a job-exposure matrix to participants' personal work histories. Cigarette smoking data were collected through participant questionnaires.

Main Outcomes and Measures

The main outcome was mortality, with codes from the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) used to categorize diseases associated with mortality.

Results

Among 44 708 participants, 38 221 (85.49%) were men, with a mean (SD) age at cohort entrance of 26.9 (8.1) years. A total of 13 700 deaths were observed during 1 534 005 person-years of follow-up, with a median follow-up period of 34.9 years (range, 4.8-43.9 years). Silica exposure was associated with a higher risk of mortality among individuals with all diseases, lung cancer, respiratory tuberculosis, cardiovascular diseases, and diseases of the respiratory system; cigarette smoking was associated with an increased risk of mortality among individuals with all diseases, lung cancer, respiratory tuberculosis, cerebrovascular diseases, and diseases of the respiratory tract. The hazard ratios for the joint association of silica dust exposure and cigarette smoking with mortality were 4.51 (95% CI, 3.23-6.29) for lung cancer, 3.21 (95% CI, 2.53-4.08) for certain infectious and parasitic diseases, 3.93 (95% CI, 2.99-5.15) for respiratory tuberculosis, 6.27 (95% CI, 4.83-8.15) for diseases of the respiratory system, and 12.52 (95% CI, 7.92-19.80) for pneumoconiosis, with a significant additive interaction (P < .001). The proportions of the joint association for the additive interaction of silica dust exposure and cigarette smoking were 21.63% for lung cancer, 42.12% for certain infectious and parasitic diseases, 42.25% for respiratory tuberculosis, 29.55% for diseases of the respiratory system, and 36.46% for pneumoconiosis.

Conclusions and Relevance

These findings suggest that cigarette smoking is associated with an increased risk of mortality in individuals exposed to silica dust. Smoking cessation and the control of silica dust concentrations may be important for reducing the risk of mortality among individuals exposed to silica.

Factors associated with smoking cessation in patients with coronary heart disease: a cohort analysis of the German subset of EuroAspire IV survey

Background

Tobacco smoking is one of the most important risk factors of coronary heart disease (CHD). Hence, smoking cessation is considered pivotal in the prevention of CHD. The current study aimed to evaluate smoking cessation patterns and determine factors associated with smoking cessation in patients with established CHD.

Methods

The fourth European Survey of Cardiovascular Disease Prevention and Diabetes investigated quality of CHD care in 24 countries across Europe in 2012/13. In the German subset, smoking cessation patterns and clinical characteristics were repetitively assessed a) during index event due to CHD by medical record abstraction, b) as part of a face-to-face interview 6 to 36 months after the index event (i.e. baseline visit), and c) by telephone-based follow-up interview two years after the baseline visit. Logistic regression analysis was performed to search for factors determining smoking status at the time of the telephone interview.

Results

Out of 469 participants available for follow-up, 104 (22.2%) had been classified as current smokers at the index event. Of those, 65 patients (62.5%) had quit smoking at the time of the telephone interview, i.e., after a median observation period of 3.5 years (quartiles 3.0, 4.1). Depressed mood at baseline visit and higher education level were less prevalent amongst quitters vs non-quitters (17.2% vs 35.9%, p = 0.03 and 15.4% vs 33.3%, p = 0.03), cardiac rehabilitation programs were more frequently attended by quitters (83.1% vs 48.7%, p < 0.001), and there was a trend for a higher prevalence of diabetes at baseline visit in quitters (37.5% vs 20.5%, p = 0.07). In the final multivariable model, cardiac rehabilitation was associated with smoking cessation (OR 5.19; 95%CI 1.87 to 14.46; p = 0.002).

Discussion

Attending a cardiac rehabilitation program after a cardiovascular event was associated with smoking cessation supporting its use as a platform for smoking cessation counseling and relapse prevention.

Lifestyle modification in older versus younger patients with coronary artery disease

Objective

To compare the treatment effect on lifestyle-related risk factors (LRFs) in older (≥65 years) versus younger (<65 years) patients with coronary artery disease (CAD) in The Randomised Evaluation of Secondary Prevention by Outpatient Nurse SpEcialists 2 (RESPONSE-2) trial.

Methods

The RESPONSE-2 trial was a community-based lifestyle intervention trial (n=824) comparing nurse-coordinated referral with a comprehensive set of three lifestyle interventions (physical activity, weight reduction and/or smoking cessation) to usual care. In the current analysis, our primary outcome was the proportion of patients with improvement at 12 months follow-up (n=711) in ≥1 LRF stratified by age.

Results

At baseline, older patients (n=245, mean age 69.2±3.9 years) had more adverse cardiovascular risk profiles and comorbidities than younger patients (n=579, mean age 53.7±6.6 years). There was no significant variation on the treatment effect according to age (p value treatment by age=0.45, OR 1.67, 95% CI 1.22 to 2.31). However, older patients were more likely to achieve ≥5% weight loss (OR old 5.58, 95% CI 2.77 to 11.26 vs OR young 1.57, 95% CI 0.98 to 2.49, p=0.003) and younger patients were more likely to show non-improved LRFs (OR old 0.38, 95% CI 0.22 to 0.67 vs OR young 0.88, 95% CI 0.61 to 1.26, p=0.01).

Conclusion

Despite more adverse cardiovascular risk profiles and comorbidities among older patients, nurse-coordinated referral to a community-based lifestyle intervention was at least as successful in improving LRFs in older as in younger patients. Higher age alone should not be a reason to withhold lifestyle interventions in patients with CAD.

Heavy Smoking is Associated with Low Depression and Stress: a Smokers' Paradox in Cardiovascular Disease?

INTRODUCTION

Smoking, anxiety and depression constitute predisposing factors of coronary artery disease.

AIM

The aim of this study was to investigate the degree of nicotine dependence in coronary patients and its relationship to anxiety and depression.

METHODS

The study population consisted of 208 coronary patients, 131 men and 77 women, who were hospitalized in a hospital in Attica and were all smokers. The degree of nicotine dependence was measured by the Fagerstrom scale, while depression and anxiety intensity were assessed with the Zung SDS and SAS scales respectively.

RESULTS

158 participants (75.9%) were moderately to highly dependent on nicotine, 108 participants (51.9%) reported moderate to severe depression intensity levels while 91 participants (43.8%) reported moderate to severe anxiety intensity levels. The degree of dependence on nicotine was negatively related to the intensity of anxiety and depression experienced by coronary patients. Additionally, the degree of nicotine dependence, anxiety and depression was associated with various sociodemographic and clinical factors such as educational level, social support, and information on their condition and treatment.

CONCLUSION

Overall, the findings of this study point to an inverse relationship of nicotine dependence, depression and anxiety. However, this paradoxical association could be a product of shared risk factors or confounding. Nonetheless, the development of individualized educational and supportive interventions to quit smoking in coronary patients should primarily focus on the assessment of depression and stress.

[Smoking cessation: A challenge for cardiologists and pulmonologists]

In addition to public health measures that need to be strongly supported politically, smoking is also a major medical issue. Tobacco dependence is a chronic disease, and, given its extremely addictive nature, treatment for tobacco dependence must be addressed actively by all health professionals. Because smoking is a major contributor to many of the pathologies their specialties address, cardiologists and pulmonologists must be at the forefront of this care. In this review we analyse the current state of smoking cessation treatment and its inadequacies, the limiting impact that doctors' own smoking has, as well as the misconceptions held by smokers and sometimes by doctors as well, which act as brakes on smoking cessation. Smoking cessation must become a treatment delivered in real clinical practice and any doctor must know how to manage it fluently. Do not be satisfied with simply advising smokers to quit. Learn how to approach the subject with smokers effectively, know how the various pharmacotherapies are used and know how to organize smoking cessation follow-up, an essential guarantee of success. If optimal management of this major pathological factor is a role for all doctors, it is of course especially so for our two specialties. It's up to us, cardiologists and pulmonologists, to take up this challenge.