Parsing The Updated 2018 Acute Ischemic Stroke Guidelines: Smoking Cessation

The 2018 International Stroke Conference was headlined by the practice-changing results of DEFUSE 3 and related acute stroke care guideline updates. Having returned to our institutions, neurologists are parsing the updated 2018 acute ischemic stroke guidelines¹ and wondering how best to operationalize the latest data.
 
Overshadowed by updated guidelines regarding the extended window and buried among changes regarding the utility of indiscriminate use of routine diagnostic testing, was a change regarding smoking cessation.
 
While the guidelines committee did not find any randomized trials of pharmacological smoking cessation aides specifically for stroke patients, they cite a randomized trial in acute coronary patients:² patients randomized to receive a pharmacological cessation aide had a significant improvement in abstinence. In terms of observational data, a recent study found that patients with stroke who quit smoking had a reduced rate of cardiovascular disease and mortality over 5 years.³ Based partially on such evidence, the updated guidelines provide a IIb recommendation that “for smokers with an acute ischemic stroke, in-hospital initiation of varenicline might be considered”.¹
 
A class I recommendation to “strongly advise every patient with acute ischemic stroke who has smoked in the past year to quit” remains in place and is buttressed with a IIb option to consider “interventions that incorporate both pharmacotherapy and behavioral support”.¹
 
While Get With the Guidelines-Stroke has seen a substantial improvement in “appropriate” smoking cessation interventions at the time of hospital discharge,⁴ a distinction between counselling and pharmacotherapy was not made. Therefore, whether effective smoking cessation interventions are being initiated is unknown.
 
Whereas the extended window guidelines influence care for a small group of acute stroke patients, the smoking cessation guidelines apply to every single acute stroke and TIA patient who is an active smoker. Neurologists, particularly stroke neurologists and hospitalists, should familiarize themselves with the updated guidelines, the relevant data, and pharmacological interventions. 
 
References:

1. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. 2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke. Stroke 2018. DOI: 10.1161/STR.0000000000000158.
2. Eisenberg MJ, Windle SB, Roy N, Old W, Grondin FR, Bata I, et al. Varenicline for Smoking Cessation in Hospitalized Patients with Acute Coronary Syndrome. Circulation. 2016:133;21-30.
3. Epstein KA, Viscoli CM, Spence JD, Young LH, Inzucchi SE, Gorman M, et al. Smoking cessation and outcome after ischemic stroke or TIA. Neurology. 2017:89;1723-1729. 
4. Ormseth CH, Sheth KN, Saver JL, Fonarow GC, Schwamm LH. The American Heart Association’s Get With the Guidelines (GWTG)-Stroke development and impact on stroke care. Stroke and Vascular Neurology 2017;2:doi:10.1136/svn-2017-000092

Neal S. Parikh, MD, earned his MD from Weill Cornell Medical College and completed residency training in neurology at the same institution. He is now an NIH T32 neuro-epidemiology and vascular neurology fellow at New York-Presbyterian Hospital/Columbia University Medical Center. He tweets @NealSParikhMD and contributes to Blogging Stroke as a blogger.