Summary of recommendations from The American College of Cardiology Guideline 2018 for smoking cessation in patients with CVD16)
| Outpatient with stable CVD | Inpatient with ACS | |
|---|---|---|
| 1st line |
Varenicline OR combination NRT |
In-hospital to relieve nicotine withdrawal: Nicotine patch OR combination NRT At discharge: Combination NRT OR varenicline |
| 2nd line |
Bupropion OR single NRT product |
At discharge: Single NRT product |
| 3rd line |
Nortriptyline |
Bupropion |
| If single agent is insufficient to achieve abstinence |
Combine categories of FDA-approved drugs: Varenicline+NRT (single agent) Varenicline+Bupropion Bupropion+NRT (single agent) |
NA |
ACS, acute coronary syndromes; CVD, cardiovascular disease; FDA, U.S. Food and Drug Administration; MI, myocardial infarction; NRT, nicotine replacement therapy; NA, not applicable.
aCombination NRT comprises a nicotine patch plus the patient’s choice of nicotine gum or lozenge or inhaler or spray. bSome committee members planning to use varenicline would start it in-hospital; others would not start until discharge. Regardless, continue nicotine patch or short-acting form for 1 week to manage nicotine withdrawal symptoms during up-titration of varenicline dose. cNortriptyline is not FDA-approved for smoking cessation indication and there are few data on use in patients with CVD. dBupropion is listed as 3rd line because of no evidence of efficacy when started during hospitalization for acute ACS or acute MI. However, there are no special safety concerns for bupropion in this setting.
Revised from the article of Barua et al. (J Am Coll Cardiol 2018; 72: 3332-65).16)