吸煙與心血管疾病33

1、吸煙與心血管疾病吸煙是中國人心血管疾病的重要危險(xiǎn)因素高血壓 160M血脂異常 160M 糖尿病 20MIFG 20M肥胖 60M超重 200M吸煙 350M被動(dòng)吸煙 540M中國NEHNS IV冠心病是吸煙致死疾病的前三位之一由吸煙引起死亡的前三位疾?。簢赓Y料為：COPD冠心病肺Ca國內(nèi)資料為：COPD肺Ca冠心病1. Surgeoen Generals Report. Health Consequences of Smoking; 2004. 2. J Natl Cancer Inst. 1993;85(24):1994. 3. Crane. Cancer Epidemiol Biomar

2、kers Prev. 1996;5(8):639. 4. Miligi. Am J Ind Med. 1999;36(1):60. 5. Roman. Cerebrovasc Dis, 2005;20(Suppl 2):91. 6. Willigendael. J Vasc Surg. 2004;40:1158. 7. Yang. BMJ. 1999;319:143內(nèi)皮功能紊亂血栓生成增加炎癥反響加強(qiáng)氧化修飾Lavi et al. Circulation. 2007;115:2621-2627; :/ /HIC/Topics/Diag/diangi

3、o.cfm. Accessed June 14, 2007.右冠狀動(dòng)脈粥樣硬化吸煙促發(fā)心血管疾病的發(fā)病機(jī)理組織因子TF在動(dòng)脈粥樣硬化斑塊有高表達(dá)，這可能在血栓形成中發(fā)揮重要作用TF 水平以 Xa因子 (FXa)進(jìn)行評價(jià)吸煙者與非吸煙者比，循環(huán)中TF活性遠(yuǎn)高于后者Sambola et al. Circulation. 2003;107:973-977.Factor Xa (FXa) pmol/L/minP=.0032172830100200300400吸煙者吸煙前2支煙吸煙者吸煙后(2支煙)吸煙使血栓生成增加Barua et al. Circulation. 2001;104:1905-1910

4、.50000不吸煙者吸煙者4000300020001000NO濃度 (nmol/L)P.000112663613吸煙使一氧化氮生物合成減少Zeiher et al. Circulation. 1995;92:1094-1100.020304060501010P.01P.001P.01吸煙者P.01不吸煙者P.01與不吸煙者相比，吸煙者根據(jù)流量調(diào)節(jié)的內(nèi)皮血管舒張功能明顯減弱動(dòng)脈造影正常的吸煙者動(dòng)脈造影不正常的吸煙者動(dòng)脈造影正常的不吸煙者動(dòng)脈造影不正常的不吸煙者流量調(diào)節(jié)的內(nèi)皮血管舒張功能吸煙使血管內(nèi)皮舒張功能受損Lavi et al. Circulation. 2007;115:2621-2627

5、.與不吸煙者相比，吸煙者更容易發(fā)生心外膜內(nèi)皮功能障礙P=.03604530150不吸煙者戒煙者吸煙者46%34%35%內(nèi)皮功能障礙吸煙致心外膜血管內(nèi)皮功能障礙白細(xì)胞計(jì)數(shù)升高與更高心血管事件風(fēng)險(xiǎn)相關(guān)與不吸煙者相比，吸煙者的白細(xì)胞計(jì)數(shù)明顯升高Lavi et al. Circulation. 2007;115:2621-2627; Stewart et al. Circulation. 2005;111:1756-176286420P.0001P=.03P.0001P.0001吸煙者戒煙者白細(xì)胞中性粒細(xì)胞淋巴細(xì)胞單核細(xì)胞不吸煙者細(xì)胞計(jì)數(shù)109/L吸煙使白細(xì)胞計(jì)數(shù)升高ns=not significan

6、t. a Unless marked as “ns, differences for each value between groups were statistically significant at a level of P.05. Schmid et al. Thromb Res. 1996;81:451-460.不吸煙者吸煙者pg/mLa36.834.832.830.828.826.824.822.8123451211-脫氫血栓烷素B2 nsnsnsMin/10 Plateletsa1234512丙二醛天3.64.0nsnsnsnsnsnsnsns

7、nsns天被動(dòng)吸煙的人血小板聚集功能與吸煙者接近吸煙使血小板聚集功能增強(qiáng)異構(gòu)前列腺素F2 水平是體內(nèi)脂質(zhì)過氧化反響的指標(biāo)The dots representing subjects who smoked are each connected to a dot representing a nonsmoker matched to the subject for age and sex.Adapted from Morrow et al. N Engl J Med. 1995;332(18):1198-1203.64056048040032024016080吸煙者不吸煙者100090080070

8、0600500400300吸煙者不吸煙者自由異構(gòu)前列腺素F2pmol/L酯化異構(gòu)前列腺素F2pmol/L吸煙增加氧化修飾吸煙與心血管疾病的流行病學(xué)吸煙流行10年后出現(xiàn)吸煙相關(guān)疾病的流行吸煙與冠心病 (CAD)Waters et al. Circulation. 1996;94:614-621. 已有病變加重的發(fā)生率吸煙者非吸煙者新病變發(fā)生率吸煙者P=.002P=.00757373620非吸煙者患者百分率患者百分率吸煙加重動(dòng)脈粥樣硬化aThe probability of an event (developing a disease) occurring in exposed people co

9、mpared with the probability of the event in nonexposed people. Adjusted for age.Willett et al. N Engl J Med. 1987;317(1):1303-1309.1.01-14/日非吸煙者15-24/日25/日吸煙者每日吸煙量相對風(fēng)險(xiǎn)可信區(qū)間95吸煙增加心絞痛風(fēng)險(xiǎn)與非吸煙者相比，吸煙者發(fā)生急性非致死性心梗的風(fēng)險(xiǎn)增加3倍。aThe ratio of the odds of development of disease in exposed persons to the odds

10、of development of disease in nonexposed persons.Teo. Lancet. 2006;368:647-658.109876543210年齡70 y 支/日20非吸煙者戒煙者1-19支/日風(fēng)險(xiǎn)比可信區(qū)間95吸煙增加急性非致死性心梗的風(fēng)險(xiǎn)Y usuf S et al . Lancet. 2004;364:937-52OR (99% CI)每日吸煙量與心肌梗死發(fā)生有量效關(guān)系a The probability of an event (developing a disease) occurring in exposed people compared wi

11、th the probability of the event in nonexposed people. Adjusted for age.Willett et al. N Engl J Med. 1987;317(21):1303-1309.致死冠心病的相對風(fēng)險(xiǎn)1-14/日非吸煙者15-24/日25/日吸煙者每日吸煙量相對風(fēng)險(xiǎn)可信區(qū)間95吸煙增加冠心病死亡風(fēng)險(xiǎn)aThe probability of an event (developing a disease) occurring in exposed people compared with the probability of the

12、event in nonexposed people. Adjusted for age.Wannamethee et al. Circulation. 1995;91:1749-1756.1.02.30.01.02.03.04.0不吸煙者吸煙者相對風(fēng)險(xiǎn)可信區(qū)間95吸煙增加心源性猝死的風(fēng)險(xiǎn)aThe probability of an event (developing a disease) occurring in exposed people compared with the probability of the event in nonexposed people. Adjusted f

13、or the baseline variables significantly associated with each end point.Hasdai et al. N Engl J Med. 1997;336:755-761.Q波心梗 (MI)1.01.282.08相對風(fēng)險(xiǎn)可信區(qū)間950.01.02.03.04.0不吸煙者戒煙者吸煙者吸煙使冠脈介入治療后發(fā)生Q波心梗的風(fēng)險(xiǎn)增高被動(dòng)吸煙與冠心病Adjusted for age, systolic blood pressure, diastolic blood pressure, total cholesterol, HDL choleste

14、rol, FEV, height, preexisting CAD, body mass index, triglycerides, white cell count, diabetes, physical activity, alcohol intake, and social class. aLight active refers to men smoking 1-9 cigarettes a day. bHeavy passive refers to upper three quarters of cotinine concentration combined (0.8 to 14.0

15、ng/mL). cLight passive refers to lowest quarter of cotinine concentration among nonsmokers (0-0.07 ng/mL). Whincup et al. BMJ. 2004;329:200-205.被動(dòng)吸煙發(fā)生心臟疾病的風(fēng)險(xiǎn)比不吸煙者增加30隨訪時(shí)間（年）0510152000.00輕度主動(dòng)吸煙a重度被動(dòng)吸煙b輕度被動(dòng)吸煙c嚴(yán)重冠心病發(fā)生比例被動(dòng)吸煙增加冠心病發(fā)生風(fēng)險(xiǎn)aThe ratio of the odds of development of disease in exposed

16、 persons to the odds of development of disease in nonexposed persons. Adjusted for age, sex, region, physical activity, and consumption of fruits, vegetables, and alcohol. Adapted from Teo et al. Lancet. 2006;368:647-658.被動(dòng)吸煙暴露持續(xù)時(shí)間小時(shí)/周無1-78-1415-21224210.75被動(dòng)吸煙使發(fā)生非致死性心梗的風(fēng)險(xiǎn)量級增加比值比可信區(qū)間95被動(dòng)吸煙增加急性心梗發(fā)生風(fēng)險(xiǎn)

17、吸煙與腦卒中大量吸煙后急性作用：腦血管急性血栓形成腦核磁共振像 急性缺血性腦卒中Goldstein et al. Stroke. 2006;37:1583-1633; :/ /stroke/whatisastroke.shtml. Accessed October 19, 2007.吸煙增加急性缺血性卒中風(fēng)險(xiǎn)無論是主動(dòng)還是被動(dòng)吸煙都會(huì)加快頸動(dòng)脈粥樣硬化aAdjusted for demographic characteristics, cardiovascular risk factors, and lifestyle variables (risk factor m

18、odel and Keys score, education, leisure activity, body mass index, and alcohol use). bTo environmental tobacco smoke.Howard et al. JAMA. 1998;279(2):119-124.吸煙者不吸煙者且無被動(dòng)吸煙b43.038.831.632.825.9不吸煙者但有被動(dòng)吸煙b戒煙者且無被動(dòng)吸煙b戒煙者有被動(dòng)吸煙b頸動(dòng)脈內(nèi)膜中層厚度增加m/3年吸煙促進(jìn)頸動(dòng)脈粥樣硬化進(jìn)展aThe probability of an event (developing a disease)

19、 occurring in exposed people compared with the probability of the event in nonexposed people. Adjusted for age, follow-up period, history of diabetes, hypertension, high cholesterol levels, and relative weight (in 5 categories).Colditz et al. N Engl J Med. 1988;318(15):937-941.1-1415-24不吸煙者25吸煙者每日吸煙

20、量（支）相對風(fēng)險(xiǎn)可信區(qū)間95青年、中年女性，發(fā)生腦卒中的風(fēng)險(xiǎn)可能與吸煙量相關(guān)吸煙增加致命性和非致命性腦卒中風(fēng)險(xiǎn)aThe probability of an event (developing a disease) occurring in exposed people compared with the probability of the event in nonexposed people.Adjusted for age, exercise, alcohol consumption, body mass index, history of hypertension, and histor

21、y of diabetes. Kurth et al. Stroke. 2003;34:2792-2795.不吸煙者 (n=20,339)每日吸煙量少于15支 (n=1914)每日吸煙量多于15支 (n=3265)總出血性腦卒中腦內(nèi)出血蛛網(wǎng)膜下腔出血2.063.432.392.891.744.04相對風(fēng)險(xiǎn)可信區(qū)間95吸煙增加出血性卒中風(fēng)險(xiǎn)aTwenty-year age-adjusted mortality per 10,000 person-years for men. P.014 for trend. Hart et al. Stroke. 1999;30:1999-2007.15-241

22、-1525吸煙者每日吸煙量（支）死亡率/10000人*年吸煙增加腦卒中死亡風(fēng)險(xiǎn)吸煙與外周血管疾病 (PVD)吸煙使發(fā)生PVD的時(shí)間早10年吸煙使發(fā)生PVD的風(fēng)險(xiǎn)增加10-16倍，高于冠心病的發(fā)生風(fēng)險(xiǎn)吸煙與以下血管疾病的風(fēng)險(xiǎn)增加有關(guān):無病癥的 PVD間歇性跛行PVD的進(jìn)展因PVD并發(fā)癥引起的截肢股幗動(dòng)脈旁路失敗血管手術(shù)后的死亡Freund KM, The Framingham Study: 34 years of follow-up. Ann Epidemiol 1993;3:417-424吸煙增加外周血管疾病危險(xiǎn)吸煙促進(jìn)主動(dòng)脈擴(kuò)張吸煙增加主動(dòng)脈瘤死亡風(fēng)險(xiǎn)Witteman JC,. Circul

23、ation 1993; 88:2156-2162Wilmink TB, J Vasc Surg 1999; 30:1099-1105吸煙與主動(dòng)脈瘤發(fā)生有量效關(guān)系戒煙對心血管的益處戒煙對心血管益處的病理生理機(jī)制長期吸煙者戒煙2周后，纖維蛋白原濃度和纖維蛋白原的合成速率均明顯減低ASR=absolute rate of fibrinogen synthesis. aAbstention period of 2 weeks. Hunter et al. Clin Sci (Lond). 2001;100(4):459-465.P.001P.001吸煙戒煙a93.06吸煙戒煙a血

24、漿纖維蛋白原濃度g/L纖維蛋白原絕對合成速率ASR)mg/kg戒煙使纖維蛋白原下降aAbstention period of 17 weeks.Eliasson et al. Nicotine Tob Res. 2001;3(3):249-255.戒煙a吸煙P.026白細(xì)胞計(jì)數(shù)109/L戒煙使白細(xì)胞計(jì)數(shù)明顯降低aQuit smoking for 28 days. bResumed smoking after quitting for 14 days.ADP=adenosine diphosphate. ADP is a platelet aggregation agonist.Morita e

25、t al. J Am Coll Cardiol. 2005;45:589-594.腺苷二磷酸（ADP）=5.0 mol/LA組aB組b血小板聚集 (%)020601004080時(shí)間（天）07142128NSP.01NSNSP.01戒煙使血小板聚集率下降HDL=high-density lipoprotein; LDL=low-density lipoprotein. aAbstention period of 17 weeks. Eliasson et al. Nicotine Tob Res. 2001;3(3):249-255.低密度脂蛋白 (mmol/L)P.001 高密度脂蛋白 (mm

26、ol/L)吸煙戒煙a戒煙使血脂改善P.015吸煙戒煙a HDL/LDL 比值P.001吸煙戒煙a戒煙可改善脂蛋白構(gòu)成，包括高密度脂蛋白升高，低密度脂蛋白降低增強(qiáng)指數(shù) (%)baProvides an assessment of small arteriolar compliance. bThe amplitude of the reflected wave depends on the stiffness of the small vessels and large arteries and thus provides a measure of systolic arterial stiffn

27、ess.cAbstention period of 6 months. Oren et al. Angiology. 2006;57(5):564-568.P.05振蕩順應(yīng)性 (mL/mm Hg 100)aP.01吸煙戒煙c63.150.6吸煙戒煙c戒煙使動(dòng)脈順應(yīng)性改善 a Abstention period of 6 months. Oren et al. Angiology. 2006;57(5):564-568.心率 (Beats/min)P.05吸煙P.05平均動(dòng)脈壓 (mm Hg)吸煙戒煙a戒煙a戒煙使血液動(dòng)力學(xué)改善戒煙對心血管益處的流行病學(xué)1. CDC. Surgeon Gener

28、al Report 2004 2. American Cancer Society. Guide to Quitting Smoking2006 肺功能改善減少咳嗽鼻竇充血呼吸急促等 3個(gè)月肺Ca發(fā)生率是繼續(xù)吸煙者的30-50% CAD危險(xiǎn)減少50%CAD危險(xiǎn)與正常不吸煙者相似卒中危險(xiǎn)恢復(fù)到正常不吸煙者水平1年5 年10 年15 年戒煙戒煙使冠心病風(fēng)險(xiǎn)減少aThe ratio of the odds of development of disease in exposed persons to the odds of development of disease in nonexposed p

29、ersons. Adjusted for sex, region, diet, alcohol, physical activity, consumption of fruits, vegetables, and alcohol.Adapted from Teo. Lancet. 2006;368:647-658.P1-35-1010-1520戒煙者 (戒煙年數(shù))3-515-20421比值比可信區(qū)間95戒煙數(shù)年后，發(fā)生急性心梗的風(fēng)險(xiǎn)明顯降低戒煙使急性心梗風(fēng)險(xiǎn)降低與吸煙者相比，冠狀動(dòng)脈介入治療后戒煙者整體死亡風(fēng)險(xiǎn)明顯下降生存率 (%)100806040200023456789101112時(shí)間年H

30、asdai. N Engl J Med. 1997;336(11):755-761.戒煙者持續(xù)吸煙者戒煙使冠狀動(dòng)脈介入治療后死亡率下降對戒煙的生存收益進(jìn)行評估，戒煙5年，生存率提高3，戒煙5年可提高10，戒煙15年那么可提高15。Adapted from van Domburg et al. J Am Coll Cardiol. 2000;36(3):878-883.生存概率 (%)05101520年P(guān).0001 (戒煙者 vs 吸煙者)不吸煙者持續(xù)吸煙者100806040200戒煙者戒煙使冠狀動(dòng)脈旁路移植術(shù)后死亡率減低對于心梗后左心室功能異常的患者，戒煙可使心律失常造成死亡風(fēng)險(xiǎn)降低Peter

31、s et al. J Am Coll Cardiol. 1995;26(5):1287-1292.P=.040生存時(shí)間年0204060801000231戒煙者吸煙生存率戒煙使心律失常死亡風(fēng)險(xiǎn)減少戒煙者與持續(xù)吸煙者相比，反復(fù)發(fā)生心臟驟停風(fēng)險(xiǎn)明顯降低 aAbstention period of 3 years. Hallstrom et al. N Engl J Med. 1986;314:271-275.3年內(nèi)發(fā)生率 (%)P=.038心臟驟停反復(fù)發(fā)作2719051015202530吸煙者戒煙者a戒煙使心臟驟停風(fēng)險(xiǎn)減低Jonason et al. Acta Med Scand. 1987;221

32、:253-260.年累積靜息痛 (%)3020100P=.0492716543戒煙吸煙對于間歇性跛行IC患者，戒煙可減緩?fù)庵苎懿〉倪M(jìn)一步加重。戒煙使外周血管疾病病癥改善aThe probability of an event (developing a disease) occurring in exposed people compared with the probability of the event in nonexposed people. Adjusted for age and treatment assignment.Robbins et al. Ann Intern Me

33、d. 1994;120(6):458-462.不吸煙者戒煙者吸煙者(20支/日)吸煙者(20 支/日）P .0001(趨勢)相對風(fēng)險(xiǎn)可信區(qū)間95與持續(xù)吸煙的患者比較，戒煙者非致死性腦卒中的發(fā)生風(fēng)險(xiǎn)降低戒煙使卒中風(fēng)險(xiǎn)降低全因死亡降低約15-20%CVD死亡降低約25-35%1。Kawachi, 1993. 2. Lievre, 2000. 3. Vrcer, 2003戒煙1降壓2降膽固醇l3 戒煙1.0全因死亡降膽固醇3降壓2CVD死亡戒煙、降壓、降膽固醇對無CVD史者死亡的影響全因死亡降低約12-35%戒煙所致的風(fēng)險(xiǎn)降低最大戒煙1降壓2a 降壓2b 降膽固

34、醇1.0降膽固醇31. Critchley, 2003. 2. BPLTTC, 2003. 3. Vrercer, 2003. 4. CTT, 2005全因死亡戒煙、降壓、降膽固醇對有CVD史者死亡的影響戒煙$ 2,000 6,000降血壓藥物$ 9,000 26,000降血脂藥物$ 50,000 196,000 平均每挽救一個(gè)生命年人年的本錢:Benowitz, Prog Cardiovasc Dis, 2003;46:91戒煙是降低心血管風(fēng)險(xiǎn)最經(jīng)濟(jì)的干預(yù)方式短期益處 纖維蛋白原濃度下降 纖維蛋白原合成速率減低 白細(xì)胞計(jì)數(shù)下降高密度/低密度脂蛋白比例改善

35、 卒中風(fēng)險(xiǎn)降低 高密度脂蛋白增加 低密度脂蛋白下降動(dòng)脈壓 心率下降動(dòng)脈順應(yīng)性改善 心梗后心律失常所致猝死風(fēng)險(xiǎn)減低 血小板體積減小血小板環(huán)磷酸腺苷反響增強(qiáng)，促使前列腺素E1 發(fā)生腺苷酸環(huán)化 吸煙導(dǎo)致的血小板聚集減少長期益處減少以下風(fēng)險(xiǎn)卒中 重復(fù)冠脈搭橋術(shù) 心梗后反復(fù)發(fā)生冠脈事件心梗后心律失常所致猝死繼發(fā)心血管疾病 冠脈搭橋術(shù)后血運(yùn)重建術(shù)減少 冠脈搭橋術(shù)后的死亡率經(jīng)皮冠狀動(dòng)脈成形術(shù)后死亡率與心血管疾病進(jìn)展相關(guān)的炎癥標(biāo)志分子水平(C反響蛋白, 白細(xì)胞, 纖維蛋白原)Twardella et al. Eur Heart J. 2004;25:2101-2108; Morita et al. J Am

36、Coll Cardiol. 2005;45:589-594; Oren et al. Angiology. 2006;57:564-568; Terres et al. Am J Med. 1994; 97:242-249; Nilsson et al. J Int Med. 1996; 240:189-194; Peters et al. J Am Coll Cardiol. 1995;26:1287-1292; Rea et al. Ann Intern Med. 2002;137: 494-500; Hasdai et al. N Engl J Med. 1997;336:755-761

37、; van Domburg et al. J Am Coll Cardiol. 2000; 36:878-883; Bakhru et al. PLoS Med. 2005;2:e160; Eliasson et al. Nicotine Tob Res. 2001;3:249-255; Hunter et al . Clin Sci. 2001;100:459-465; Wannamethee et al. JAMA. 1995;274:155-160. 戒煙給心血管系統(tǒng)帶來的益處總結(jié)Thank You !aQeUhYl!p*s+wA.D1H4L8ObSfVjZm%q(u=xC:G3J7Na

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