Cardiac adverse effects of nicotine replacement therapy

Smoking markedly increases the risk of cardiovascular disease. Nicotine replacement therapy is available to assist in smoking cessation. To assess the cardiac adverse effects of nicotine replacement therapy, we conducted a review of the literature using the standard Prescrire methodology. A meta-analysis of 21 randomised, placebo-controlled trials published in early 2014 included a total of 11 647 patients, including 828 patients at high risk of cardiovascular events and 187 patients with acute coronary disorders. It showed that nicotine replacement therapy was associated with an increased risk of cardiac disorders, particularly palpitations, which are a known adverse effect of smoking. Among patients at high cardiovascular risk, 1.2% experienced a serious cardiovascular event, with no statistically significant difference versus placebo. Bupropion and varenicline both have serious adverse effects and have been less extensively evaluated in patients at high cardiovascular risk. In practice, when a drug is needed to assist in smoking cessation, nicotine appears to be a reasonable choice. Nicotine replacement therapy exposes patients to a risk of palpitations but rarely to serious cardiac disorders, even in individuals with a cardiovascular history. In addition, these adverse effects are better documented than those of bupropion and varenidine in such patients. Nonetheless, the cardiac effects of nicotine call for prudent use of nicotine replacement therapy: the minimum effective dose should be sought, and the goal should be total nicotine withdrawal.