ACS patients who are smoking and already depressed at the time of their hospitalization may need additional support for smoking cessation. Clinicians should consider using smoking cessation medication that also has beneficial effects on depressed mood. Clinicians treating post-ACS patents who smoked at the time of their event should screen for and be vigilant of post-ACS development of depression symptoms.
Clinical practice guidelines state that nicotine replacement products should be used with caution in the 2 weeks post-ACS, and there is a lack of comprehensive safety data for using nicotine replacement therapy in this population. This has significant implications for ACS patients that are depressed and smoking. Both depressed smokers in general and depressed smokers with ACS appear to experience stronger nicotine withdrawal than non-depressed smokers [5
]. Thus, reluctance to recommend nicotine replacement to ACS patients may be particularly harmful for depressed smokers with ACS. Thus, establishing the safety of nicotine replacement therapy or finding an alternative may be particularly important for this population. Prescribing varenicline currently has similar limitations; There is concern regarding increased cardiac events in both stable CVD and non-CVD samples, it has not been tested for safety in ACS patients, and there is some concern that it may have negative psychiatric side effects [25
]. Thus, even if varenicline is found to be generally safe in post-ACS smokers, it may not be an appropriate 1st
line treatment for post-ACS smokers with depression or with a significant psychiatric history.
It appears that treatments or combinations of treatments that effect both depression and smoking may be needed for those smokers who are depressed or at risk for depression (e.g., history of major depression) at the time of ACS hospitalization. Bupropion has promise as such a treatment as it 1) is an antidepressant, 2) is effective for smoking cessation and recommended for depressed smokers in the general population [25
], and 3) reduces nicotine withdrawal [62
]. In addition, a recent post-hoc analysis of a large RCT indicates that bupropion may increase long-term cessation among depressed, post-ACS smokers [53
]. However, these results are preliminary and await replication. Note that another antidepressant, Nortriptyline, has been shown to be efficacious for smoking cessation but is not considered a first line treatment and may have cardiovascular side effects [25
Counseling treatments that have added mood management strategies to smoking cessation treatment have been developed [63
]. However, results have been surprisingly mixed, indicating that these treatments are only more effective than standard treatments in smokers with a history of recurrent major depression [64
]. Thus the development of novel treatments for depressed, post-ACS smokers is needed. Any new treatment for this population should be integrated, to the extent possible, into existing medical visits. For example, newly developed intensive treatments might be integrated into the cardiac rehabilitation setting.
Behavioral Activation (BA) is a well-established empirically supported treatment for depression that has recently shown promise in a pilot trial for both reducing depressed mood and smoking cessation in a sample of depressed smokers [65
]. BA purports to improve mood and facilitate smoking cessation by increasing pleasant, goal directed, and valued activities through repeated between appointment homework assignments. There are several reasons BA may be ideal for smoking cessation and mood improvement post-ACS: 1) Although BA is not an exercise treatment, completing between appointment goals is often incompatible with remaining sedentary, and sedentary lifestyle is predictive of mortality in CVD patients [66
]; 2) BA has been successfully integrated with other health behavior change interventions [67
]; 3) BA is thought to be simpler and easier to train than other empirically supported counseling treatment packages [68
]; and 4) BA directly seeks to increase positive affect rather than targeting reduction of negative affect; thus, BA may be particularly effective for anhedonic patients, which is notable given the role of anhedonia in both smoking cessation and post-ACS health outcomes [18