REPLY
Smoking while Wearing a Nicotine Patch
James G. Warner Jr and
William C. Little
15 March 1995 | Volume 122 Issue 6 | Pages 476-477
IN RESPONSE:
We appreciate Dr. Mittleman's comments and agree with his summary of the limitations of interpreting causation from a single clinical observation.
In addition to our patient [1], several other patients whose cardiac events were temporally related to smoking while wearing a nicotine patch have been described [2]. The combination of smoking and transdermal nicotine can produce high nicotine levels [3, 4]. Because nicotine produces vasoconstriction, catecholamine release, and platelet aggregation, it may also trigger plaque rupture, leading to the formation of an occlusive thrombus and resulting in myocardial infarction. Although our observation and physiologic plausibility do not establish that smoking while wearing a nicotine patch can trigger cardiac events, we believe that patients with established coronary artery disease should avoid nicotine from any source. Further, all users of nicotine patches should be warned of the additional potential risks associated with smoking.
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Author and Article Information
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Institute for Prevention of Cardiovascular Disease, New England Deaconess Hospital, Boston, MA 02215. The Bowman Gray School of Medicine, Winston-Salem, NC 27157.
1. Warner JG Jr, Little WC. Myocardial infarction in a patient who smoked while wearing a nicotine patch (Letter). Ann Intern Med. 1994; 120:695.
2. Orleans CT, Ockene JK. Routine hospital-based quit-smoking treatment for the postmyocardial infarction patient: an idea whose time has come. J Am Coll Cardiol. 1993; 22:1703-5.
3. Benowitz NL. Pharmacologic aspects of cigarette smoking and nicotine addiction. N Engl J Med. 1988; 319:1318-30.
4. Gorsline J, Gupta SA, Dye D, Rolf CN. Steady-state pharmacokinetics and dose relationship of nicotine delivered from Nicoderm (Nicotine Transdermal System). J Clin Pharmacol. 1993; 33:161-8.
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