p.25 抽出テキスト
CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e9–e119. DOI: 10.1161/CIR.0000000000001168 August 29, 2023 Virani et al 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Chronic Coronary Disease Guideline in patients with CCD.39,40 Mindfulness-based and psychotherapy interventions (eg, meditation, yoga, cognitive-behavioral therapy) improve depression, anxiety, stress, social support, and cardiovascular risk factors in patients with CCD but not all-cause or cardiovascular mortality, QOL, recurrent MI, or revascularization.41–44 Pharmacological treatment of depression in patients with CCD is reasonable with consideration of adverse effects.4,45 4.2.3 Tobacco Products Recommendations for Tobacco Products Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations 1 A 1 In patients with CCD, tobacco use should be assessed at every health care visit to facilitate identification of those who may benefit from behavioral or pharmacologic interventions.*1–3 1 A 2. Patients with CCD who regularly smoke tobacco should be advised to quit at every visit.*4 1 A 3. In patients with CCD who regularly smoke tobacco, behavioral interventions are recommended to maximize cessation rates in combination with pharmacotherapy, including bupropion, varenicline, or combination long- and short-acting nicotine replacement therapy (NRT).*5–7 2b B-R 4. In patients with CCD who regularly smoke tobacco, varenicline may be considered versus bupropion or NRT to increase cessation rates.6 2b B-R 5. In patients with CCD who regularly smoke tobacco, the short-term use of nicotine-containing e-cigarettes may be considered to aid smoking cessation, although the risk of sustained use and unknown long-term safety may outweigh the benefits.8–10 3: Harm B-NR 6 Patients with CCD should avoid secondhand smoke exposure to reduce risk of cardiovascular events.*11,12 *Modified from the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease.13 Synopsis Tobacco smoke exposure, in particular cigarette smoking, is a leading cause of CVD and cardiovascular events in persons with CCD.14–18 Cigarette smoke adversely affects endothelial function, promotes atherosclerosis, and is prothrombotic.19 Beneficial short-term effects of smoking cessation include a decrease in heart rate and BP and improved endothelial function.20,21 Prospective cohort studies of patients with CCD show that smoking cessation is associated with a 36% reduction in death and a 32% reduction in MI.22 Pharmacotherapy and behavioral therapy in combination can increase the success of smoking cessation. Observational studies on smokeless tobacco (including snuff, snus, and chewing tobacco) and cardiovascular risk have found mixed results, but an increased risk of coronary heart disease events may be observed, albeit to a lesser degree than cigarette smoking.23–26 Recommendation-Specific Supportive Text 1 Most persons who smoke report they want to quit smoking, although annual quit rates among those who smoke are <10%.2 Systematic assessment of tobacco and e-cigarette use is the first step to facilitating smoking cessation, but clinicians often do not screen for tobacco use.3 Routine screening for smoking status by clinicians has been shown to increase the rate of clinician intervention to promote smoking cessation. Screening for smoking can also allow clinicians to reinforce continued abstinence among those who have successfully quit and identify patients who may have relapsed. Electronic health record-based interventions that include a means to document smoking status and other tools such as clinician prompts or decision support, can improve process outcomes, such as referral to smoking cessation programs or documentation of smoking cessation counseling, although electronic health record-based documentation of smoking status alone has not improved quit rates.27,28 Data are unavailable on the effect of screening and most other tobacco cessation interventions on quit rates for persons who use smokeless tobacco and e-cigarettes. Nicotine-containing e-cigarette use is increasing, including among never-smokers, and many cigarette smokers have become “dual users,” using both e-cigarettes and cigarettes.29 Meta-analyses suggest that smokeless tobacco use is associated with increased risk of CHD events, albeit to a lesser degree than cigarette smoking.23–25 E-cigarettes may increase the risk of CHD and cardiovascular events, and long-term risks of e-cigarettes are unknown.8,30–37 Given these risks, screening for use as part of comprehensive risk assessment may be reasonable. 2. Even brief advice to quit tobacco smoking provided by a clinician increases the rate of quitting in persons who smoke (relative risk, 1.66 [95% CI, 1.42- 1.94]).4 Other members of the care team, including nurses, community pharmacists, and oral health professionals, can also effectively provide behavioral support for smoking cessation.7 Messages to patients should be clear, personalized, nonjudgmental, and focus on the benefits of smoking cessation, such as: “Quitting smoking is the most important thing you can do for your heart health.”38 3 Behavioral therapy is also effective for smoking cessation including group and individual in-person counseling, telephone-based support, interactive internet-based interventions, and text message– based interventions.7 A meta-analysis of 37 RCTs of behavioral interventions for smoking cessation in persons with CCD found a 22% increase Downloaded from http://ahajournals.org by on October 7, 2026