Heart Disease and Smoking Are Locked in an Ongoing Battle Against Patient Health

There are more than 36 million smokers in the United States today, and most (70%) admit they want to quit. Individuals who decide to quit see a smaller risk of heart disease within 1 to 2 years, along with reduced risks of stroke and peripheral vascular disease. However, annual deaths from smoking still exceed 480,000 in the United States, where over 16 million live with smoking-related diseases that include infertility, lung cancer, and chronic obstructive pulmonary disease.¹

Two studies that recently appeared in the Journal of the American Heart Association used data from the National Cardiovascular Data Registry (NCDR) of the American College of Cardiology (ACC) to illustrate the ongoing health consequences patients with heart disease face in the long term, both those who continue smoke and those who express a desire to quit.

In the first study, health status and mortality rates were compared as they related to smoking status among patients who underwent transcatheter aortic valve replacement (TAVR) for aortic stenosis.² The investigators reviewed data on 72,165 patients who underwent TAVR between November 2011 and June 2016 at 457 sites in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. They had a median age of 83 years, and 48% were women.³ In 2016, the procedure was estimated to cost $70,000.⁴

Smokers comprised 5.6% (4063) of this group, and these patients underwent the procedure at a younger age compared with nonsmokers: 75 years (range 68-81) versus 83 years (range, 77-88), respectively. Those who smoked also had more incidences of atherosclerosis and lung diseases among smokers compared with nonsmokers (51% vs 26%), lower in-hospital survival, and worse long-term health status. And in the 30 days following the procedure, smokers had significantly higher mean aortic valve gradient (10.6 vs 9.8 mm Hg; P <.001); this measure remained high at 1 year (11.1 vs 10.2 mm Hg; P <.001). However, smoking status also was not associated with postdischarge mortality or heart failure.³

The authors determined, “While the younger age allows smokers to survive the initial procedure, the associated comorbidities impact long&#8208;term recovery. Further studies are needed to understand the effect of smoking cessation on outcomes in patients undergoing TAVR, especially as TAVR is being offered to a wider and potentially younger population.”

In the second study, investigators looked into the rates of smoking cessation assistance among cardiology practices in the PINNACLE Registry, part of the NCDR,² on the heels of survey results showing healthcare providers feel uncomfortable referring patients to smoking cessation services. They measured provided smoking cessation assistance and its predictors, as well as provider-level variation in this patient service.⁵

Knowing that “smoking cessation leads to 2&#8208; to 3&#8208;fold reduction in the risk for incident CVD [cardiovascular disease] and mortality within 5 years of smoking cessation,” they reviewed data on 328,749 smokers who visited 348 NCDR-affiliated cardiology practices from January 1, 2013, to March 31, 2016. The mean patient age was 57 years + 16, 54% were male, close to one-third had a coronary artery disease, and 3 cardiovascular risk factors predominated: hypertension (61%), dyslipidemia (54%), and diabetes (20%).⁵

Their results show that just 34% (112,884) received documented smoking cessation assistance. Of this group, a scant 10% (11,223) received a pharmacotherapy prescription (eg, bupropion, nicotine replacement therapy, or varenicline). And men were more likely to receive this service, as well as patients with “hypertension, dyslipidemia, diabetes mellitus, coronary artery disease, peripheral arterial disease, ischemic stroke/TIA, prior vascular intervention, heart failure, and atrial fibrillation or flutter.”⁵

Cardiology practices in the Midwest, Northeast, and West Census regions also offered smoking cessation services more frequently—although this measure also varied among the providers themselves. For example, women (odds ratio [OR], 1.18; 95% CI, 1.16-1.21) in the Midwest were more likely to be given smoking cessation assistance (OR, 1.61 vs the West; 95% CI, 1.18-2.21), but older age (OR, 0.88 per 10-year increase, 95% CI, 0.88-0.89) and having a history of diabetes (OR, 0.84, 95% CI, 0.82-0.87) meant patients were less likely to be offered help quitting smoking in the South (OR, 0.48 vs the West; 95% CI, 0.37-0.63).⁵

The authors concluded, “Our findings suggest a significant deficit and opportunity for improvement, especially when one considers the fact that a large number of patients included in the PINNACLE registry were presenting for a cardiology visit because of a preexisting CVD. Some of the potential methods that can be leveraged to address this deficit are provider training, patient education, provision of adequate reimbursement, and, potentially, provider incentive for smoking cessation assistance.”

References

1. Iliades C. The best and worst ways to quit smoking. Everyday Health website. everydayhealth.com/stop-smoking-pictures/the-best-and-worst-ways-to-quit-smoking.aspx. Published January 11, 2018. Accessed February 10, 2020.

2. Glenn K. ACC Registry data used to examine cognitive impairment in heart attack patients, smoking and TAVR outcomes [press release]. Washington, DC: American College of Cardiology; January 30, 2020. acc.org/about-acc/press-releases/2020/01/30/16/08/acc-registry-data-used-to-examine-cognitive-impairment-in-heart-attack-patients-smoking-and-tavr-outcomes. Accessed February 10, 2020.

3. Qintar M, Li Z, Vemulapalli S, et al. Association of smoking status with long&#8208;term mortality and health status after transcatheter aortic valve replacement: insights from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. J Am Heart Assoc. 2019;8(16):e011766. doi: 10.1161/JAHA.118.011766.

4. Celia D. TAVR: a potential lifesaver that comes at a cost. Population Health Learning Network website. managedhealthcareconnect.com/article/tavr-potential-lifesaver-comes-cost. Published December 2016. Accessed February 10, 2020.

5. Sardana M, Tang Y, Magnani JW, et al. Provider&#8208;level variation in smoking cessation assistance provided in the cardiology clinics: insights from the NCDR PINNACLE Registry. J Am Heart Assoc. 2019;8(13):e011412. doi: 10.1161/JAHA.118.011307.