What is the management for a 60-year-old female smoker with elevated hemoglobin (Hgb) level?

Management of Elevated Hemoglobin (19 g/dL) in a 60-Year-Old Female Smoker

A 60-year-old female smoker with a hemoglobin of 19 g/dL requires urgent smoking cessation intervention and evaluation for secondary polycythemia, with particular focus on ruling out cardiopulmonary causes and potential myeloproliferative disorders.

Initial Assessment and Diagnosis

• Elevated hemoglobin (Hgb) of 19 g/dL in a female smoker indicates secondary polycythemia, which significantly increases risk of thrombotic events and cardiovascular mortality 1
• Smoking directly contributes to elevated hemoglobin through several mechanisms:
  • Carbon monoxide exposure leading to increased carboxyhemoglobin formation 2
  • Compensatory erythrocytosis due to chronic tissue hypoxia 1
  • Smoking increases plasma fibrinogen levels and enhances platelet aggregation, further increasing thrombotic risk 3, 4

Immediate Management Priorities

1. Smoking Cessation (Highest Priority)

• Immediate smoking cessation counseling using the 5 A's approach (Ask, Advise, Assess, Assist, Arrange) 2
• Pharmacotherapy options should be offered:
  • Nicotine replacement therapy (patches, gum)
  • Bupropion (starting at 100 mg daily, increasing to 300 mg daily)
  • Varenicline (first-line option as a nicotine acetylcholine receptor partial agonist) 2
• Smoking cessation can normalize hemoglobin levels within weeks to months and significantly reduces cardiovascular risk 2

2. Diagnostic Workup

• Complete blood count with peripheral smear to evaluate all cell lines 5
• Arterial blood gas to assess oxygen saturation and rule out hypoxemia 2
• Erythropoietin level to differentiate between primary and secondary polycythemia 5
• Pulmonary function tests to evaluate for COPD (common in smokers) 4
• Echocardiogram to assess for cardiac causes of secondary polycythemia 2
• Consider JAK2 mutation testing to rule out polycythemia vera if other causes are not evident 5

Treatment Approach

1. Address Underlying Causes

• Smoking cessation is the cornerstone of treatment and should be emphasized at every visit 2
• Evaluate and treat any underlying cardiopulmonary disease that may be contributing to hypoxemia 2
• Monitor blood pressure closely, as hypertension often coexists and compounds cardiovascular risk 2

2. Reduce Thrombotic Risk

• Consider phlebotomy if hemoglobin remains >18 g/dL despite smoking cessation, to reduce blood viscosity and thrombotic risk 6
• Low-dose aspirin (81-325 mg daily) should be offered to reduce thrombotic risk if no contraindications exist 2
• Target blood pressure <140/80 mmHg to further reduce cardiovascular risk 2

3. Follow-up and Monitoring

• Repeat hemoglobin measurement 4-6 weeks after smoking cessation to assess improvement 1
• Regular monitoring of complete blood count every 3 months until hemoglobin normalizes 5
• Continued smoking cessation support with regular follow-up visits 2

Common Pitfalls and Considerations

• Avoid attributing elevated hemoglobin solely to smoking without ruling out other serious causes 5
• Don't underestimate the additive cardiovascular risk of smoking, elevated hemoglobin, and increased blood viscosity 6
• Recognize that smoking increases both white blood cell count and hemoglobin, creating a hypercoagulable state 1
• Be aware that smoking cessation may be challenging but is essential; success rates improve with combined pharmacological and behavioral approaches 2
• Elderly patients with elevated hemoglobin have significantly higher cardiovascular mortality risk compared to those with normal hemoglobin levels 5