Nicotine replacement therapy … - Carlos A ... - Entretiens du Carla

Table 2.
In practice
Based on all these experimental and
clinical findings, what approach should be
adopted regarding the use of NRT in
patients with coronary heart disease?
In France, given the efficacy of NRT in
smoking cessation and the fact that the
experimental and clinical studies available
at the time demonstrated its safety, the
AFSSAPS (French Health Products Safety
Agency) issued the following guidelines in
May 2003 (27-28):
- Nicotine replacement therapies are
well tolerated by patients with coronary
artery disease and do not exacerbate
coronary heart disease or arrhythmias
(level 2).
- Nicotine replacement therapies are
recommended in smokers with coronary
artery disease (Grade B).
- Nicotine replacement therapy can be
prescribed as soon as the patient is
discharged from the intensive care unit
immediately after myocardial infarction
(Grade C).
- However, the prescribing physician
must consider the loss of nicotine
tolerance if the patient has not recently
smoked (consensus agreement).
Early prescription of NRT right from
hospital admission is an important
component of successful cessation after
myocardial infarction. Indeed, studies
show that half of patients who were
smokers at the time of their infarct resume
smoking within six months of the event,
and usually relapse during the early weeks
(29). Delaying the prescription of NRT
therefore increases the risk of relapse.
Furthermore, patients lose their nicotine
tolerance and may not tolerate NRT so
well.
Prescribing NRT early after a coronary
event therefore appears free of risk and
guarantees better tolerance and better
long-term results.
To summarize
• Media reports of rare clinical cases
of cardiovascular events occurring in
patients treated with nicotine
replacement therapy (NRT) worried the
population for a long time and led doctors
to be cautious and to avoid prescribing
NRT for cardiovascular patients.
• In fact, the experimental studies
have shown that NRT has no effect on
thrombosis, probably has none on
endothelial function and its potential
sympathomimetic effects are highly
attenuated due to the pharmacokinetics
of NRT and the nicotine tolerance
acquired by smokers.
• Moreover, the clinical studies show
no excess of cardiovascular events with
NRT in either the general population of
smokers or in patients with stable
coronary artery disease.
• Although we have no randomized
studies on the use of NRT immediately
after an acute coronary syndrome, the
absolute risk of using NRT in this situation
is most probably much lower than the risk
of continuing to smoke.
• Taken together, these data have led
to the use of NRT in smokers with
coronary artery disease being
recommended, including immediately
after an acute coronary event such as
myocardial infarction. ■
45 Cardiovascular safety of NRTs - Daniel Thomas
(27) AFSSAPS (Agence
Française de Sécurité
Sanitaire des Produits de
Santé). Les stratégies
thérapeutiques
médicamenteuses et non
médicamenteuses de
l’aide à l’arrêt du tabac.
Recommandations de
bonne pratique.
Mai 2003
(http://afssaps.sante.fr/ht
m/10/tabac/sommaire.ht
m)
(28) B. Le Foll, Melihan-
Cheinin P, Rostoker G,
Lagrue G for the working
group of AFSSAPS.
Smoking cessation
guidelines: evidencebased
recommendations
of the French Health
Products Safety Agency
European Psychiatry 2005;
20: 431-41.
(29) Kotseva K. Wood D,
De Backer G et al.
Cardiovascular prevention
guidelines in daily
practice: a comparison of
EUROASPIRE I, II ans III
surveys in eight European
countries. Lancet 2009;
373: 929-40
29-kotseva 27-
AFSSAPS (Agence
Française de Sécurité
Sanitaire des Produits de
Santé). Les stratégies
thérapeutiques
médicamenteuses et non
médicamenteuses de
l’aide à l’arrêt du tabac.
Recommandations de
bonne pratique. Mai 2003
(http://afssaps.sante.fr/ht
m/10/tabac/sommaire.ht
m) 28-B. Le Foll, Melihan-
Cheinin P, Rostoker G,
Lagrue G for the working
group of AFSSAPS.
Smoking cessation
guidelines: evidencebased
recommendations
of the French Health
Products Safety Agency
European Psychiatry 2005;
20:431-41.
29-Scholte op Reimer W,
de Swart E, De Bacquer D
et al. Smoking behaviour
in European patients with
established coronary
heart disease. Eur Heart J.
2006; 27:35-41.