''SAMIKSHA HEART AND DIABETIC CARE''
The Framingham study found an 18% increase in coronary events for males and a 31% increase
for females for every 10 cigarettes smoked per day. There is more of an association between
smoking and myocardial infarction than between smoking and stable angina. Smoking increases
the risk of stroke, coronary heart disease and peripheral vascular disease through a number of
mechanisms (Table 1.11). Smoking is a major factor in the increased risk of coronary heart
disease for women using oestrogen-containing contraceptive pills
Some effects of smoking
1 Increased atherogenesis, probably by toxic injury to endothelial cells
2 Hypoxia, resulting in intimal proliferation
4 Reduction in HDL
5 Oxidation of lipids
6 Increase in fibrinogen levels
Smoking cessation is associated with a rapid decline in death rates from coronary disease,
probably because of smoking’s thrombogenic effects. Smoking seems less important as a risk
factor in populations with low LDL levels
Many strategies are available to help patients to give up smoking. These should all begin with an
explanation of the reasons smoking cessation is worthwhile. Some explanation of the mechanism
of its deleterious effects may be helpful. Patients who have recently presented with possible
cardiac symptoms may be amenable to advice of this nature. It is also especially important to
give strong advice about smoking to patients with multiple existing coronary risk factors.
The rapidity at which benefits begin to occur, and the risks and difficulties involved in further
cardiac treatment (e.g. coronary surgery) for smokers, should be emphasised. The postoperative
risk is considerably higher for smokers, particularly for serious chest infections. This risk falls
quickly (within four weeks) once smoking is stopped.
Nicotine replacement patches may be helpful and appear safe even for patients with
ischaemic heart disease. The drug bupropion, which is a non-tricyclic antidepressant, is now
available for patients who wish to stop smoking. This drug seems safe for patients with cardiac
disease, at least for those without unstable symptoms. It does not cause conduction abnormalities
or increase the risk of ventricular arrhythmias. Patients should be advised to continue
smoking when they first start the drug but plan to stop on a particular day after about a week of
treatment. The drug is usually continued for at least seven weeks. The starting dose is 150 mg
daily and then 150 mg twice a day.
It is important to discuss strategies for smoking cessation with the patient and to try to
establish a treatment plan that suits the individual.
Evidence of an increased cardiovascular risk from environmental smoke has been available for
some years.20 Legislation is gradually reducing the risk for people in occupations associated with
smoking (e.g. serving in bars and restaurants) but patients with existing ischaemic heart disease
should be advised to avoid exposure.