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Starting ACS patients on varenicline in the hospital.

ORLANDO--Starting varenicline in smokers while hospitalized for an acute coronary syndrome (ACS) resulted in substantially higher smoking abstinence rates than with placebo at all time points through 6 months of follow-up in the double-blind, randomized EVITA trial.

"The ACS population is typically older, they're long-term smokers, and they come into the hospital with a life-threatening condition. Their family is all around them. They've had angioplasty or CABG [coronary artery bypass graft] surgery. So they have pressure on them to stop smoking. This is a teachable moment, a window of opportunity. The public health benefit for smoking cessation in this population is huge. You can cut their risk of death and significant morbidity in half if you can get them to stop," Dr. MarkJ. Eisenberg said in presenting the EVITA results at the American Heart Association scientific sessions.

EVITA (Evaluation of Varenicline in Smoking Cessation for Patients Post-Acute Coronary Syndrome) was an investigator-initiated, 40-center study involving 302 smokers hospitalized for ACS. They'd smoked for an average of 36 years and were puffing 22 cigarettes per day at enrollment. More than 90% of them had an acute MI just several days before starting on varenicline (Chantix) at 1 mg twice daily or placebo for 12 weeks.

"To our knowledge, this is the highest-risk population that's been exposed to varenicline," said Dr. Eisenberg, professor of medicine at McGill University and director of the cardiovascular health services research program at Jewish General Hospital in Montreal.

The primary study endpoint was continuous self-reported abstinence since baseline backed by biochemical confirmation in the form of an exhaled carbon monoxide level of 10 ppm or less at week 24 as well as at all the earlier follow-up visits. The rate was 47.3% in the varenicline group, compared with 32.5% in placebo-treated controls. That placebo response rate is in line with numerous prior studies that have shown that less than one-third of smokers with ACS remain abstinent after leaving the hospital.

"Most cardiologists would say, All my patients stop smoking.' But in the clinic if you look in the patients' pockets, you find a pack of cigarettes. They stop smoking while in hospital, but as soon as they're discharged, the relapse rate is almost immediate. Most patients are smoking the day they get out of hospital," according to Dr. Eisenberg.

In EVITA, the number needed to treat with varenicline for 12 weeks in order to produce 1 extra nonsmoker at 6 months was 6.8 patients.

The secondary endpoint of at least a 50% reduction in the number of cigarettes per day from baseline to 6 months was met by 67.4% of the varenicline group and 55.6% of controls, with a number needed to treat of 8.5, he continued.

No safety issues emerged in the study, although as Dr. Eisenberg noted, EVITA wasn't sufficiently powered to look at safety. The only side effect more common in varenicline-treated patients was abnormal dreams, with a 12-week incidence of 15%, threefold higher than in controls, a phenomenon seen in other, larger varenicline studies as well.

The EVITA investigators plan to follow participants out to 12 months. "If we see someone who at 1 year post MI is still smoking, maybe it's time to go after them again, perhaps with another medication or behavioral therapy," he said.

There are no randomized clinical trials demonstrating that starting nicotine patches or bupropion in the hospital is effective for smoking cessation in the ACS population, according to the cardiologist.

Dr. Eisenberg predicted this study will change clinical practice. In much the same way physicians now routinely start ACS patients on a statin, beta-blocker, and aspirin before they leave the hospital, physicians will capitalize on this opportunity to help ACS patients quit smoking as well, he said.

In an interview, Dr. David C. Goff, who wasn't involved in EVITA, called the trial "a game changer" in preventive cardiology.

"The use of varenicline in ACS patients before they leave the hospital is a very important step forward. Cardiologists are increasingly comfortable with the idea of starting secondary prevention medications in the hospital, and there's very little more important for a person with heart disease who smokes cigarettes than to help them quit smoking. It's probably the No. 1 priority. So evidence that we can start a medication in the hospital and get more people who smoke cigarettes to quit smoking is definitely game changing, I think," said Dr. Goff, professor of epidemiology and dean of the Colorado School of Public Health in Aurora.

Dr. Eisenberg reported receiving funding from Pfizer to perform the EVITA trial. He has also gotten honoraria from the company for providing continuing medical education talks on smoking cessation.



Caption: DR. GOFF

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Title Annotation:CARDIOLOGY
Author:Jancin, Bruce
Publication:Family Practice News
Article Type:Report
Date:Dec 1, 2015
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