The Role of Smoking Cessation in Vascular Disease Management

Podcast Transcript

Announcer:

Welcome to Cardiac Consult, brought to you by the Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute at Cleveland Clinic. This podcast will explore the latest innovations, medical and surgical treatments, diagnostic testing, research, technology and practice improvements.

Lee Kirksey, MD:

Welcome to Cardiac Consult. My name's Lee Kirksey. I'm the Vice Chair of Vascular Surgery here at Cleveland Clinic. When I say here at Cleveland Clinic, I mean Cleveland Clinic, which is within the northeast section of Ohio, but also within the eastern corridor of Florida, within Las Vegas, London, Abu Dhabi, 23 hospitals enterprise-wide. We have, frankly, the largest academic vascular surgery group in the nation, numbering 31 academic vascular surgeons within Northeast Ohio. We're across eight hospitals in Northeast Ohio, and so we have a considerable presence here. I'm here with...

Eduardo Corso, MD:

Hey, I'm Eduardo Corso. I'm a staff vascular surgeon here at Cleveland Clinic in Cleveland, Ohio. I'm the leader of the west side group, which is a group of six vascular surgeons covering two hospitals and vein clinic, et cetera. Thank you, Lee.

We're here today to talk about, from a clinician's standpoint, how to help people stop smoking. I think one of the things that I always try to do is establish that rapport with patients. I walk in the clinic door and I'm greeted with an overwhelming odor of nicotine, and I know I'm going to need to address it. But I don't want to put people off. I want to try to help them understand why they're there to see me as a vascular surgeon about their PAD or their carotid or their AAA disease, but also establish that clinical relationship with the patient so they gain my trust and I can also work on smoking cessation, which is critical to having good outcomes and long-term care.

Lee Kirksey, MD:

Absolutely. I think for clinicians, there are a lot of data which support that, in general, with peripheral artery disease or PAD, we don't do as good of a job as we should. Relatively speaking, when we talk about PAD versus coronary artery disease, our rates of statin utilization, especially high-intensity statin utilization, are lower for PAD. We all understand that PAD is a more severe, advanced disease state relative to CAD. Our rates of smoking cessation and attempts at smoking cessation, whether it's through nihilism or frustration or apathy, I don't think that's the case for most of us, we don't do as good of a job.

Within our recent PAD American Heart Association guidelines, there is very robust evidence and a lot of focus on how we can improve our implementation. For physicians who are burdened with time challenges, what do you do within your practice? Of course, you have 25, 30 minutes to evaluate a new patient with peripheral artery disease, PAD. How do you suggest they go about systematically addressing this issue?

Eduardo Corso, MD:

A lot of times, once I'm seeing someone in my office, they have a problem that may need surgery. But if they're a new patient, I definitely talk about the modifiable risk factors. I'll pull up their latest LDL cholesterol. We measure their blood pressure. We talk about diabetes, but also any nicotine use or abuse. I think it's important to ask patients again and again. They might've quit before, but just kind of like, "Hey, you haven't started smoking again, have you?" Because sometimes they won't volunteer that information, but it's so critical to what we do. We’ve talked about certain patients with mild disease that maybe need to stop smoking before they have an intervention to treat them well. I usually shoot for LDL, I think 70 in these patients is recommended, normotensive, controlling the diabetes. But also I tell patients of all these factors, and they have a synergistic effect, if they could only pick one thing to do, it's stop using nicotine.

Lee Kirksey, MD:

The epidemiologic evidence is very clear that smoking is the most potent driver of the development of PAD and coronary artery disease. A four times greater odd risk of developing peripheral artery disease, going to amputation. Diabetes is short of that, three times greater risk. Interestingly, hypertension, which is quite prevalent with all groups within the US, is two times greater risk. But to your point, collectively, for our patients that suffer from hypertension, diabetes, elevated cholesterol and smoke, one sees how they're at greater risk of developing complications. I would suggest, and I think what we do within our practice, and we do it very well, we'll provide digital links to our resources, but we have a handout that we provide to patients.

We have our advanced practice nurses that will participate in tobacco cessation discussions. We'll provide those resources for patients. I think in this day and age, as physicians that are burdened with a lot of documentation requirements, it's very important to have some systematic, standardized process. Within our electronic medical record, we always provide, because many patients have a MyChart, we always provide links to all of these resources so they can review at their discretion after the visit.

Eduardo Corso, MD:

The other thing that I always do is, regardless of why I'm seeing a patient, if they've ever been a smoker, I'm going to, based on guidelines, recommend that they get a screening aortic ultrasound to look for aneurysmal disease. One of the things – as you mentioned, the electronic medical record is there – is I will always go back and look and see if they've had an old CT scan or some other imaging, so that even I might be meeting them in their mid-70s and if they've ever been a smoker, it's important to look for that aneurysmal disease because it is completely without symptoms sometimes until it's an emergency.

Lee Kirksey, MD:

That's very important that smoking, just like it's the most preventable and modifiable of risk factors for athero-occlusive disease, it’s the most preventable risk factor for aneurysmal related disease. I think we underutilize our screening in understanding the patients at risk. Maybe you can run down real quickly for the viewers and listeners, what are the risk factors for aneurysmal disease that you consider within your practice?

Eduardo Corso, MD:

Really, number one is nicotine use. Another one is family history of aneurysmal disease because there are some genetic predispositions, whether it's Ehlers-Danlos or Loeys-Dietz, that can run in families. We tend to see those patients when they're on the younger side. I always ask about the family history of aneurysm and if they did have an aneurysm, say in their father or grandfather, at what age to consider looking for that. What about you?

Lee Kirksey, MD:

I'll just tack on male gender. Men are much more likely in a six to eight to one ratio of having aneurysmal disease. I think that's really important. It's worth underscoring what you've described about the onset of both PAD and aneurysmal disease in patients in whom smoking behavior is present. Those patients are much more likely to present at an earlier age. Many times when we're young, we have the myopia of not believing that we're going to be affected by one of these disease states. But for people who have risk factors, all these risk factors, but including smoking, are more likely to present at an earlier age, late 40s, early 50s with one of these manifestations. That's critically important.

Eduardo Corso, MD:

Some patients with aortoiliac disease may present with buttock claudication that may not be immediately recognized by clinicians as a disease of circulation.

Lee Kirksey, MD:

So, I think the other point to touch on for referring providers, I've gotten calls from referring doctors about a patient with intermittent claudication, non-limb threatening peripheral arterial disease, intermittent claudication, pain with exertion in their legs, or patients with a carotid stenosis. I've told that patient that we're going to work on smoking cessation. They don't need a procedure, an intervention or surgery immediately or early on, we need to really focus on smoking cessation. I've literally gotten a call from a referring provider questioning why that strategy is being pursued.

Eduardo Corso, MD:

Absolutely. It's not because we want to withhold or deny care to anyone. When we intervene early on mild disease, we can actually do a disservice to patients with mild claudication, especially if we haven't addressed their modifiable risk factors or put them through supervised walking because when their disease inevitably returns, now they've got a stent and that stent now is occluded and it can come back with a vengeance and be a much worse disease than if we had never operated on the patient. Making people understand that we may not be operating on claudication as an indication is important. We don't want us then to send to somebody else who will do that intervention because that may be actually a disservice to the patient.

Lee Kirksey, MD:

100% correct. When we think about it objectively, for lower extremity interventions, infrainguinal interventions, if we perform an endovascular procedure with angioplasty or stent in the superficial femoral artery, we can generally , depending upon lesion, expect patency of two years at about 60%, 70%, and in best case for a reasonable length of a lesion. For patients that are smoking and they undergo an infrainguinal intervention, I routinely tell them that their likelihood of having a recurrent lesion within one year is greater than 70%. Those are dramatically different outcomes for a patient in whom we proceed with an intervention in the face of smoking. It's definitely worth our time. It's in their best interest if we can postpone, delay, optimize their medical status. I don't consider that, to your point, as denying therapy. I consider that as enhancing the management of that patient. I think that's an important point for people to understand.

Eduardo Corso, MD:

At the Cleveland Clinic, we offer every possible intervention and adjunct. We have been leaders in clinical trials for peripheral artery disease. We use the most cutting-edge technology, atherectomies, drug-coated balloons and stents, in addition to percutaneous bypass and other really cutting-edge and advanced things, but all of those adjuncts really don't have as much of an effect as the effect of stopping smoking.

Lee Kirksey, MD:

That's right.

Eduardo Corso, MD:

So that's why we go on and on about it.

Lee Kirksey, MD:

I would just say that for referring physicians, sometimes doctors want to know what are the options for their patient type, the patient that sits in front of them. We're always available. I like getting calls from referring docs that want to discuss a patient they're going to send. I'm happy to discuss that patient, what we can do for them, what options that we have for them. This Cardiac Consult podcast and the print material is a way to communicate with our valued referring physicians. I think we're both always happy to hear from them, and certainly we'll follow up with them when we see their patients.

Eduardo Corso, MD:

We continue to follow our patients over very long periods of time with repeat ultrasounds and things like that, so that we can continue to do the best care. If we've noticed that there's a recurrent disease developing, we can intervene before the clot happens. Longitudinal care is also incredibly important and something that we pride ourselves on.

Lee Kirksey, MD:

That point is so important because it sits at the heart of who we are as vascular surgeons. We see patients over the longitudinal. Typically, Ed, I think you agree that when we see a patient with peripheral artery disease, my first conversation is that me, you and I, the patient, we are going to have a long-term relationship. To your point, that's because peripheral artery disease, I consider it as in remission when we treat it with a procedure or a surgery. I consider it in maintenance. If we treat it over time, it's maintenance surveillance. When we treat it over time, we want to reduce the rates of progression, but it can always return. It's very important that we're not one-off itinerant physicians and that we follow these patients over time. That's why our vascular lab is so important in participating in that surveillance.

Eduardo Corso, MD:

We're confirming that they're taking their medications. Like I mentioned before, I celebrate my patients when they quit smoking. I think it's very important. It's a very difficult thing to do, for a person to quit smoking. I celebrate it and then I check in with them at their visits and make sure that they haven't relapsed.

Lee Kirksey, MD:

That's great. That's wonderful. Dr. Corso and myself, Lee Kirksey, we appreciate you tuning in, listening, viewing Cardiac Consultation. We'd love to help you take care of your patients to achieve the best outcomes for smoking cessation, PAD, cardiovascular disease. Thank you so much.

Eduardo Corso, MD:

Thank you.

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