What is the first-line medication for a 67-year-old female patient with stable cardiovascular disease (CV) and no contraindications for smoking cessation treatment?

First-Line Medication for Smoking Cessation in Cardiovascular Disease

According to the 2018 American College of Cardiology Expert Consensus Decision Pathway on Tobacco Cessation Treatment, varenicline is the first-line medication that should be recommended for this 67-year-old female patient with stable cardiovascular disease and no contraindications.

Evidence-Based Rationale

Varenicline is the most effective smoking cessation pharmacotherapy for patients with cardiovascular disease for several reasons:

• Varenicline has 25% higher cessation rates compared to nicotine replacement therapy (NRT) and 39% higher cessation rates compared to bupropion 1
• It works as a partial agonist at nicotinic acetylcholine receptors (particularly α4β2), which both reduces withdrawal symptoms and blocks the rewarding effects of continued smoking 1, 2
• The American College of Cardiology guidelines specifically recommend varenicline as first-line therapy for patients with cardiovascular disease who have no contraindications 1

Mechanism and Efficacy

Varenicline's dual mechanism of action provides two key benefits:

• Reduces nicotine withdrawal symptoms through partial receptor stimulation
• Blocks the pleasurable effects of smoking by occupying receptor sites that would otherwise bind to nicotine

This dual action makes varenicline particularly effective, with clinical trials showing continuous abstinence rates of 47% during weeks 9-12 in patients with cardiovascular disease compared to only 14% with placebo 3.

Safety in Cardiovascular Disease

The FDA label for varenicline specifically addresses its use in cardiovascular disease:

• A randomized, double-blind, placebo-controlled study of subjects with stable cardiovascular disease showed superior CO-confirmed abstinence rates with varenicline (47%) compared to placebo (14%) 3
• While there were initial concerns about cardiovascular events, the FDA notes that "all-cause and CV mortality was lower in patients treated with varenicline" 3

Optimal Treatment Approach

For this 67-year-old female patient:

1. Initiate varenicline therapy:

   • Start 1 week before the quit date
   • Begin with dose titration: 0.5 mg once daily for days 1-3, then 0.5 mg twice daily for days 4-7, then 1 mg twice daily
   • Continue treatment for 12 weeks minimum 1

2. Combine with behavioral counseling:

   • Schedule at least 4 counseling sessions during the 12-week treatment course
   • Focus on problem-solving skills, coping strategies, and identifying smoking triggers 1

3. Monitor for side effects:

   • Most common: nausea (30-40%), insomnia, abnormal dreams, headache 3, 4
   • Schedule follow-up within 2 weeks of the quit date 1

Potential Pitfalls and Considerations

• Nausea management: If nausea occurs, recommend taking medication with food and a full glass of water
• Neuropsychiatric symptoms: While initial concerns existed, recent evidence shows lower risk than previously thought 1, 5
• Treatment duration: Extending treatment beyond 12 weeks may be beneficial for relapse prevention in successful quitters 1
• Combination therapy: If varenicline alone is insufficient, consider adding NRT (combination NRT is more effective than single NRT) 1

While bupropion and NRT are also effective options, the evidence clearly supports varenicline as the most efficacious first-line treatment for smoking cessation in patients with stable cardiovascular disease who have no contraindications.