Silver Acetate Other Pharmacotherapies

and฀cotinine฀monitorings฀were฀compared฀ [156] ฀in฀self-reported฀ex-smokers:฀While฀cotinine฀ monitoring฀detected฀17฀smokers,฀CO฀monitoring฀detected฀smokers฀in฀only฀9.8฀of฀the฀ reported฀non-smokers฀ [156] .฀In฀a฀recently฀published฀smoking฀cessation฀study,฀the฀eficacy฀ of฀the฀three฀parameters฀was฀compared฀at฀three฀time฀points฀9,฀26,฀and฀52฀weeks฀from฀treat- ment฀initiation฀ [157] .฀The฀results฀suggested฀the฀cotinine฀analyses฀in฀urine฀may฀lead฀to฀more฀ accurate฀but฀lowered฀measured฀abstinence฀rates฀49,฀29,฀and฀26฀vs.฀38,฀26,฀and฀25,฀self- report฀plus฀CO฀vs.฀self-report฀plus฀cotinine,฀respectively฀ [157] . ETS฀and฀other฀environmental฀factors฀trafic฀pollution,฀fog฀may฀also฀be฀possible฀expla- nations฀for฀elevated฀CO.฀If฀an฀ex-smoker฀has฀not฀smoked฀for฀7฀days฀previously,฀plasma฀ cotinine฀levels฀should฀not฀exceed฀20฀ngml;฀neither฀do฀cotinine฀determinations฀in฀plasma,฀ saliva฀or฀urine฀indicate฀previous฀cigarette฀smoking.

11.5 Special Therapeutic Situations

11.5.1 Ischaemic Heart Disease

The฀two฀controlled฀studies฀conducted฀to฀date฀in฀patients฀with฀stable฀angina฀point฀to฀a฀favour- able฀inluence฀on฀progression฀or฀on฀the฀course฀of฀the฀disease.฀In฀smokers฀20฀cigarettes day฀with฀coronary฀heart฀disease,฀blood฀low฀in฀various฀myocardial฀regions฀is฀improved฀as฀ a฀sign฀of฀“smoking฀reduction”฀where฀cigarette฀consumption฀is฀replaced฀in฀part฀by฀nicotine฀ patches฀14฀and฀21฀mg฀strengths฀ [158] .฀With฀falling฀CO฀content฀of฀expired฀air,฀the฀under- perfused฀myocardial฀regions฀were฀reduced฀in฀size฀and฀the฀patients’฀exercise฀capacity฀was฀ increased฀despite฀higher฀nicotine฀levels฀compared฀with฀controls฀because฀cigarette฀con- sumption฀had฀fallen.฀One฀study฀indicated฀that฀nicotine฀had฀a฀“minimally฀harmful”฀effect฀on฀ the฀circulation,฀because฀even฀years฀of฀smokeless฀tobacco฀use฀did฀not฀increase฀either฀the฀risk฀ factors฀for฀the฀development฀of฀coronary฀heart฀disease฀or฀the฀atherogenic฀index฀ [159] . When฀cigarette฀consumption฀in฀patients฀with฀stable฀angina฀using฀nicotine฀patches฀14฀ and฀21฀mg฀was฀gradually฀reduced฀from฀20฀to฀7฀cigarettesday,฀only฀3฀out฀of฀77฀smokers฀ in฀the฀active฀treatment฀group฀compared฀with฀8฀out฀of฀79฀smokers฀in฀the฀placebo฀group฀had฀ to฀ discontinue฀ treatment฀ because฀ of฀ cardiovascular฀ events฀ [64] .฀ Transdermal฀ nicotine฀ administration฀does฀not฀increase฀either฀the฀frequency฀of฀angina฀attacks฀or฀the฀occurrence฀of฀ nocturnal฀attacks,฀arrhythmias฀or฀episodes฀with฀ECG฀evidence฀of฀ST-segment฀depression฀ [64] .฀Smoking฀cessation฀was฀achieved฀in฀36฀and฀22฀of฀patients฀active฀treatment฀vs.฀pla- cebo฀ [64] .฀Thus,฀the฀usefulness฀of฀NRT฀has฀been฀conirmed฀in฀smokers฀with฀stable฀angina.฀ Recommendations฀have฀now฀also฀been฀published฀concerning฀the฀treatment฀of฀ischaemic฀ heart฀disease฀ [160] ,฀indicating฀that฀nicotine฀patches฀clearly฀reduce฀the฀primary฀endpoints฀ death,฀ myocardial฀ infarction,฀ cardiac฀ arrest,฀ hospital฀ admission,฀ cardiac฀ arrhythmias฀ or฀ heart฀failure฀in฀CHD฀patients฀within฀14฀weeks฀5.4฀vs.฀7.9,฀active฀treatment฀vs.฀placebo฀ [160] .฀Nicotine฀treatment฀may฀thus฀be฀initiated฀as฀early฀as฀2–3฀days฀after฀an฀acute฀myocar- dial฀infarction,฀and฀NRT฀is฀indicated฀for฀smoking฀cessation฀in฀all฀patients฀with฀angina฀pec- toris฀and฀cardiac฀arrhythmias.฀Dosage฀recommendations฀are฀available฀for฀nicotine฀patches฀