Recomendacionesparaayudaradejardefumaralpacientecardiolgicoentresminutos. ElaboradoporelGrupodeTrabajodetabacodelaSociedadEspaoladeCardiologa,Seccin deCardiologaPreventivayRehabilitacin.

27deMarzode2011 Jaime Fernndez de Bobadilla, Regina Dalmau, Jos Antonio Casasnovas, Manuel Abeytua, Javier Balaguer, Ramn Bover, Jos Antonio Carbonell, Leticia Fernndez, Ramn Fito, Juana Freire,ngelGarca,MarcosGarca,JosMaraGarciadeAndoain,XavierGarcaMoll,Vctor JosepGirbes,LuisGonzlez,CatherineGraupner,EstebanLpezdeS,SusanaMartnez,Juan Morales, Marco Antonio Paz, Francisco Roncales, Juan Carlos Sevilla, Juana Umaran, Juan CarlosYez. Introduccinyobjetivosdeldocumento Aunque los cardilogos seamos conscientes de la importancia terica del tabaquismo, pocas vecesemprendemosaccionesconcretasenlaprcticaclnicaparatratarlodeformaeficaz.No soloenEspaa,tambinenlamayoradelospasesdenuestroentorno.Lafaltadeinterspor el tabaquismo puede estar en relacin con el atractivo tcnico y cientfico de los procedimientos de alta tecnologa utilizados en cardiologa, con la limitada formacin en tabaquismodeloscardilogos,conlalimitacinderecursoshumanosyfinancierosdedicados aestereayconlapercepcindequeelfumadoresenparteresponsabledesuenfermedad. Laausenciadefinanciacindelosmedicamentosparadejardefumarreflejaeldesintersde laAdministracin,poreltratamientodeltabaquismo.Porltimo,elcardilogoyelmdicoen generalvivenlarecadacomounfracaso,queresultadesmotivadorparafuturostratamientos. El objetivo de este documento es suministrar una directriz muy simple con los mnimos necesarios para ayudar a dejar de fumar a nuestros pacientes, con idea de promover un abordajesistemticodeltabaquismoencardiologa.El90%delosconsumidoresregularesde tabacosonadictosalanicotina,unadelasdrogasconmscapacidaddegeneraradiccin.Esto convierteeltabaquismoenunfactorderiesgocardiovasculardetratamientomuycomplejo.El diagnsticoytratamientoptimoestfueradenuestroalcance,dadalaaltaprevalencia.Pero estonopuedeserunaexcusaparadejardetratarunfactorderiesgocardiovascularquees, adems,laprimeracausademuerteevitableennuestroentorno. Lamayoraestamosdeacuerdoenqueeltabaquismoesunaadiccingravecuyotratamiento ptimo requiere la mayora de las veces un abordaje complejo y multidisciplinar. Como este abordajeidealesimposibleypuedeconduciralaconclusinequivocadadequenosepuede hacernada,enlaprctica,resultamuchomsoperativoconsiderarlounfactorderiesgocomo cualquier otro y dedicarle al menos el mismo tiempo que dedicamos al tratamiento de la hipertensin arterial, la dislipemia y la diabetes. Hay extensa evidencia cientfica que demuestra que el consejo breve 1, y la utilizacin de medicamentos, consiguen ndices de abstinenciamuchomsaltosquelosintentosdedejardefumarsinayuda.

El objetivo de este documento es que los cardilogos dediquemos de forma sistemtica y eficiente 3 minutos de nuestro tiempo a ayudar a dejar de fumar a nuestros pacientes cardiovasculares. Si pasamos de la casi completa pasividad actual a dedicar 3 minutos de tiempo bien aprovechados y articulamos mecanismos para un seguimiento aceptable del tratamientofarmacolgico,habremosdadounpasoimportanteenelmanejodeestefactorde riesgocardiovascular. A continuacin exponemos una estrategia de tratamiento sencilla que consumira, una vez automatizada, apenas 3 minutos de tiempo por cada fumador. No aspiramos a que sea la estrategiamseficazperoslamseficienteteniendoencuentalosrecursosdisponibles. Distinguimosdostiposdepacientes:eldeconsultaexternayelpacientehospitalizado. Elaboracindeldocumento. Este documento se ha elaborado partiendo de un texto que fue discutido en la reunin del grupo de trabajo de tabaco que tuvo lugar el da 10 de marzo de 2011 en la Sede de la Sociedad Espaola de Cardiologa. Como resultado de la discusin se elabor un documento quefuemodificadohastaobtenerunaversinfinalconsensuada. TodoslosmiembrosdelgrupodetrabajodetabacodelaSECyladirectivadelaSeccinde Cardiologa Preventiva y Rehabilitacin fueron informados del proyecto e invitados a participar. Usodeldocumento. El documento incluye un Mensaje Verbal estndar con una serie de ideas que el cardilogo deberaintentartransmitiralpacientefumador.Cadaprofesionalutilizarsupropiolenguajey adaptar el mensaje a cada circunstancia. En segundo lugar, una Hoja de Seguimiento/Texto para el Informe de Alta diseada para potenciar el esfuerzo realizado por el clnico. Existe evidencia cientfica que demuestra que el seguimiento del paciente aumenta significativamente la abstinencia continuada al ao 2. Por ltimo, se facilitar al paciente MaterialdeApoyoImpreso,quedeberasersuficientementeclaro,comoparaqueelpaciente promediopuedayquieraleerloyasimilarlo.Ademsselefacilitarladireccindelapgina web de la Sociedad Espaola de Cardiologa para que pueda acceder a material extra disponibleenlaweb. MensajeVerbalparaelpaciente La estrategia para el paciente hospitalizado es similar a la de la consulta, con los siguientes matices: a) La mayora de los pacientes consideran que ya han dejado de fumar, por lo que, asumiremosquelafechaparadejardefumaryahapasado,lesfelicitaremosporsudecisiny

reforzaremossudeterminacindenovolverafumarcuandosalgadelhospitalb)Lahojade seguimientosesustituir(siesposible)poruntextoenelinformedealta. Sepresentaacontinuacinlaestrategiaestndarparaelpacienteenconsultasdiseadapara hacerseen3minutos. 1) Fumaygradodedependencia?Formulamos3preguntassencillas: a. Fuma? b. Desdecundo,cuntoycundofumaelprimercigarrillodelda? c. Haintentadodejardefumarantesycuntotiempoestuvosinfumar? 2) Quieredejardefumar? Aunque el paciente diga que quiere dejar de fumar, daremos el consejo estndar para reafirmar su decisin. Es importante, informar, empatizar y motivar y evitar reir al paciente. A continuacin los mensajes que recomendamos que se incluyan en la conversacinconelpaciente: Lomsimportantequepuedehacerporsusalud:msquelascosasquelehemoshecho enelhospitalolasmedicinasqueesttomando. Dejardefumaresposible:muchagenteloconsigue Consecuenciassisiguefumando:laprobabilidaddemorirenlosprximos2aoses12%. Beneficiossilodejaahora:laprobabilidaddeseguirvivodentrode2aosescasiladeun no fumador: 98% 3. Adems, evitar cncer, enfermedad pulmonar grave y tendr ms capacidad para hacer las cosas que le gustan y ejercicio fsico y una vida sexual ms satisfactoria4.Sesentirmsjoven:suorganismorejuvenecerenmuchosaspectos. Reducirelconsumonoessuficiente.Lanicotinaesunadrogaylamayoradelasveceshay que elegir todo o nada. Es difcil mantener una disminucin del consumo y, adems, consumosdeunsolocigarrillo/dasonmuynegativosparalasaluddesucorazn5.
Si le paciente no quiere dejar de fumar: Le damos el consejo estndar, le suministramos materialyleinvitamosaquereconsideresudecisinyaque,almenos,intentereducirel consumocomopuenteadejarlodefinitivamente. Pacientesconintentosfallidosprevios:Enlospacientesrefractarios,enlosquehahabido intentos fallidos, adems de dar todos los pasos previos detallados ms arriba y pautar tratamiento farmacolgico, si tenemos acceso a unaunidad de tabaquismo especializada sinlistadeesperaimportante,loremitiremosadichaunidad.

3) Cmovoyaayudarleaquedejedefumar? Fijemoshoymismounafechaydgaleatodosquevaadejardefumar Evitesituacionesderiesgoyelimineelementosdetuentorno. Cuandosientasdeseosdefumar,debesaberquepasarn,nodniunasolacalada Nuncapiensequecontrolaeltabaco:eltabacoesunadrogaysivuelveafumarunsolo cigarrillo,esmuyprobablequeenpocotiempoestfumandocomoantes. Nodejequeotrosfumenentucasaoentutrabajo,elhumoperjudicasusalud.

 4) Prescribirmedicacin Esimportantequeusemoslosmedicamentosquemultiplicanlaprobabilidaddequedeje defumar,mejorandomuchosusexpectativas.Quizahoracreaquepuedesolo,perolos estudiosdemuestranqueconmedicamentoslaprobabilidaddexitoseduplicaotriplica2. Enestemomento,losmedicamentosnoestnfinanciados,peronopiensequesoncaros. Haga cuentas de lo que gasta en tabaco y de la cantidad de dinero que ahorrar en los prximosaosdejandodefumar6. El cardilogo puede prescribir el medicamento ms oportuno en cada caso, teniendo en cuentaque: Las guas internacionales recomiendan medicacin a todos los pacientes 2 y que existentresmedicamentosqueseconsiderandeprimeraeleccin:Vareniclina,Terapia SustitutivadeNicotinayBupropion7. Vareniclinaeselmedicamentomseficazenensayosclnicosenpoblacingeneral8. Vareniclina, en metanlisis y ensayos head to head es ms eficaz que Bupropion y queParchesdenicotina9. Vareniclinaeselmedicamentoconmsevidenciaencardiopataisqumica10. Sielpacientehatenidounintentoprevioexitoso(lograbstinenciacontinuadurante1 ao):considerarrepetirlaopcinutilizada. 5) Seguimiento Unodelosproblemasprincipalesparalospacienteseselseguimiento.Loidealesqueel primerseguimientoserealiceelprimermesdespusdelalta.Aprovecharemoslaocasin paraintentarestablecerunespaciolibredehumoenlaviviendadelpacientequeayudar alpacienteadejardefumary,adems,disminuirsuriesgodeeventos. El modelo de carta para suministrar al paciente, dirigido a su mdico de AP, cuando el pacienteestsiendovistoenconsultaseselsiguiente: Estimadocolega,Elpaciente___________________________________________________ condiagnsticode___________________________________________________________ Fumadorde___paquetesaldadesdehace___aosyquefumaelprimercigarrilloalas ______horasdelevantarse,haestablecidolasiguientefechaparadejardefumar_______ yestrecibiendotratamientocon___________desdeelda___________adosisde____ Teruegoque,enlamedidadeloposible,realiceselseguimientodelpacientedentrode2 y 12 semanas para su seguimiento. Es importante para la salud del paciente que sus familiares,amigosycompaerosnofumenensuentorno,yaqueelhumodeloscigarrillos inhaladodeformapasivaaumentaelriesgodeunnuevoepisodiocardiovascular11. Cuando el paciente est hospitalizado, si es posible, aadiremos al informe de alta, el siguientetexto: El paciente, fumador de ___ paquetes al da desde hace___ aos y que fuma el primer cigarrilloalas______horasdelevantarse,hadejadodefumareldadesuingresoenel hospital,yestrecibiendotratamientocon___________adosisde_________________ Teruegoque,enlamedidadeloposible,realiceselseguimientodelpacientedentrode2 y 12 semanas para su seguimiento. Es importante que sus familiares, amigos y

compaerosnofumenensuentorno,yaqueelhumodeloscigarrillosinhaladodeforma pasivaaumentaelriesgodeunnuevoepisodiocardiovascular. 6) Materialdeayuda Materialparasuministrarapacientes Pendientedeelaborar MaterialenlapginawebdelaSEC: Calculadora de costes: http://www.fundaciondelcorazon.com/informacionpara pacientes/prevencionsecundaria/calculadoratabaco.html Materialpendientedeelaborareinsertar Referenciasdepublicaciones:guas,ensayos,estudiosdecosteefectividad 7) Siguientespasoseideasparamejorar Elaborarprogramadeseguimientoymotivacinatravsdecorreoelectrnico. Invitaralaenfermeracardiovascularalasprximasreunionesdelgrupo. Aumentarladisponibilidadyelusodecooxmetrosenlasconsultas. Referencias
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HJAubin,ABobak,JRBritton,COncken,CBBillingJr,JGong,KEWilliams,KRReeves.Varenicline versustransdermalnicotinepatchforsmokingcessation:resultsfromarandomisedopenlabeltrial ThoraxOnlineFirst,publishedonFebruary8,2008as10.1136/thx.2007.090647

10NancyA.Rigotti,MD;AndrewL.Pipe,CM,MD;NealL.Benowitz,MD;CarmenArteaga,PhD;Dahlia Garza,MD;SerenaTonstad,MD,PhD,MPHEfficacyandSafetyofVareniclineforSmokingCessationin PatientsWithCardiovascularDisease.ARandomizedTrial.Circulation.2010;121:221229

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