吸烟与心血管疾病概述

吸烟与心血管疾病,吸烟是中国人心血管疾病的重要危险因素,高血压160M血脂异常160M糖尿病20MIFG20M肥胖60M超重200M吸烟350M被动吸烟540M,中国NEHNSIV,冠心病是吸烟致死疾病的前三位之一,由吸烟引起死亡的前三位疾病：国外资料为：COPD冠心病肺Ca国内资料为：COPD肺Ca冠心病,1.SurgeoenGeneralsReport.HealthConsequencesofSmoking;2004.2.JNatlCancerInst.1993;85(24):1994.3.Crane.CancerEpidemiolBiomarkersPrev.1996;5(8):639.4.Miligi.AmJIndMed.1999;36(1):60.5.Roman.CerebrovascDis,2005;20(Suppl2):91.6.Willigendael.JVascSurg.2004;40:1158.7.Yang.BMJ.1999;319:143,内皮功能紊乱血栓生成增加炎症反应加强氧化修饰,Lavietal.Circulation.2007;115:2621-2627;./HIC/Topics/Diag/diangio.cfm.AccessedJune14,2007.,右冠状动脉粥样硬化,吸烟促发心血管疾病的发病机理,组织因子（TF）在动脉粥样硬化斑块有高表达，这可能在血栓形成中发挥重要作用TF水平以Xa因子(FXa)进行评价吸烟者与非吸烟者比，循环中TF活性远高于后者,Sambolaetal.Circulation.2003;107:973-977.,FactorXa(FXa)pmol/L/min,P=.003,217,283,0,100,200,300,400,吸烟者吸烟前（2支烟）,吸烟者吸烟后(2支烟),吸烟使血栓生成增加,Baruaetal.Circulation.2001;104:1905-1910.,吸烟使一氧化氮生物合成减少,Zeiheretal.Circulation.1995;92:1094-1100.,P.01,P.001,P.01,吸烟者,P.01,不吸烟者,P.01,与不吸烟者相比，吸烟者根据流量调节的内皮血管舒张功能明显减弱,动脉造影正常的吸烟者,动脉造影不正常的吸烟者,动脉造影正常的不吸烟者,动脉造影不正常的不吸烟者,流量调节的内皮血管舒张功能,吸烟使血管内皮舒张功能受损,Lavietal.Circulation.2007;115:2621-2627.,与不吸烟者相比，吸烟者更容易发生心外膜内皮功能障碍,46%,34%,35%,内皮功能障碍,吸烟致心外膜血管内皮功能障碍,白细胞计数升高与更高心血管事件风险相关与不吸烟者相比，吸烟者的白细胞计数明显升高,Lavietal.Circulation.2007;115:2621-2627;Stewartetal.Circulation.2005;111:1756-1762,P.0001,P=.03,P.0001,P.0001,吸烟者,戒烟者,白细胞,中性粒细胞,淋巴细胞,单核细胞,不吸烟者,细胞计数,109/L,吸烟使白细胞计数升高,ns=notsignificant.aUnlessmarkedas“ns,”differencesforeachvaluebetweengroupswerestatisticallysignificantatalevelofP.05.Schmidetal.ThrombRes.1996;81:451-460.,不吸烟者,吸烟者,pg/mLa,11-脱氢血栓烷素B2,ns,ns,ns,Min/10Plateletsa,丙二醛,天,ns,ns,ns,ns,ns,ns,ns,ns,ns,ns,天,被动吸烟的人血小板聚集功能与吸烟者接近,吸烟使血小板聚集功能增强,异构前列腺素F2水平是体内脂质过氧化反应的指标Thedotsrepresentingsubjectswhosmokedareeachconnectedtoadotrepresentinganonsmokermatchedtothesubjectforageandsex.AdaptedfromMorrowetal.NEnglJMed.1995;332(18):1198-1203.,640,560,480,400,320,240,160,80,吸烟者,不吸烟者,1000,900,800,700,600,500,400,300,吸烟者,不吸烟者,自由异构前列腺素F2,pmol/L,酯化异构前列腺素F2,pmol/L,吸烟增加氧化修饰,吸烟与心血管疾病的流行病学,吸烟流行10年后出现吸烟相关疾病的流行,吸烟与冠心病(CAD),Watersetal.Circulation.1996;94:614-621.,已有病变加重的发生率,吸烟者,非吸烟者,新病变发生率,吸烟者,P=.002,P=.007,57,37,36,20,非吸烟者,患者百分率,患者百分率,吸烟加重动脉粥样硬化,aTheprobabilityofanevent(developingadisease)occurringinexposedpeoplecomparedwiththeprobabilityoftheeventinnonexposedpeople.Adjustedforage.Willettetal.NEnglJMed.1987;317(1):1303-1309.,1.0,1.6,2.6,2.0,1-14/日,非吸烟者,15-24/日,25/日,吸烟者每日吸烟量,相对风险可信区间,95,吸烟增加心绞痛风险,与非吸烟者相比，吸烟者发生急性非致死性心梗的风险增加3倍。,aTheratiooftheoddsofdevelopmentofdiseaseinexposedpersonstotheoddsofdevelopmentofdiseaseinnonexposedpersons.Teo.Lancet.2006;368:647-658.,年龄70y,支/日20,非吸烟者,戒烟者,1-19支/日,风险比可信区间,95,吸烟增加急性非致死性心梗的风险,YusufSetal.Lancet.2004;364:937-52,OR(99%CI),每日吸烟量与心肌梗死发生有量效关系,aTheprobabilityofanevent(developingadisease)occurringinexposedpeoplecomparedwiththeprobabilityoftheeventinnonexposedpeople.Adjustedforage.Willettetal.NEnglJMed.1987;317(21):1303-1309.,致死冠心病的相对风险,1-14/日,非吸烟者,15-24/日,25/日,吸烟者每日吸烟量,相对风险可信区间,95,吸烟增加冠心病死亡风险,aTheprobabilityofanevent(developingadisease)occurringinexposedpeoplecomparedwiththeprobabilityoftheeventinnonexposedpeople.Adjustedforage.Wannametheeetal.Circulation.1995;91:1749-1756.,1.0,2.3,0.0,1.0,2.0,3.0,4.0,不吸烟者,吸烟者,吸烟增加心源性猝死的风险,aTheprobabilityofanevent(developingadisease)occurringinexposedpeoplecomparedwiththeprobabilityoftheeventinnonexposedpeople.Adjustedforthebaselinevariablessignificantlyassociatedwitheachendpoint.Hasdaietal.NEnglJMed.1997;336:755-761.,Q波心梗(MI),1.0,1.28,2.08,0.0,1.0,2.0,3.0,4.0,不吸烟者,戒烟者,吸烟者,吸烟使冠脉介入治疗后发生Q波心梗的风险增高,被动吸烟与冠心病,Adjustedforage,systolicbloodpressure,diastolicbloodpressure,totalcholesterol,HDLcholesterol,FEV,height,preexistingCAD,bodymassindex,triglycerides,whitecellcount,diabetes,physicalactivity,alcoholintake,andsocialclass.aLightactivereferstomensmoking1-9cigarettesaday.bHeavypassivereferstoupperthreequartersofcotinineconcentrationcombined(0.8to14.0ng/mL).cLightpassivereferstolowestquarterofcotinineconcentrationamongnonsmokers(0-0.07ng/mL).Whincupetal.BMJ.2004;329:200-205.,被动吸烟增加冠心病发生风险,aTheratiooftheoddsofdevelopmentofdiseaseinexposedpersonstotheoddsofdevelopmentofdiseaseinnonexposedpersons.Adjustedforage,sex,region,physicalactivity,andconsumptionoffruits,vegetables,andalcohol.AdaptedfromTeoetal.Lancet.2006;368:647-658.,被动吸烟暴露持续时间（小时/周）,无,1-7,8-14,15-21,22,4,2,1,0.75,被动吸烟使发生非致死性心梗的风险量级增加,被动吸烟增加急性心梗发生风险,吸烟与脑卒中,大量吸烟后急性作用：脑血管急性血栓形成,脑核磁共振像急性缺血性脑卒中,Goldsteinetal.Stroke.2006;37:1583-1633;./stroke/whatisastroke.shtml.AccessedOctober19,2007.,吸烟增加急性缺血性卒中风险,无论是主动还是被动吸烟都会加快颈动脉粥样硬化,aAdjustedfordemographiccharacteristics,cardiovascularriskfactors,andlifestylevariables(riskfactormodelandKeysscore,education,leisureactivity,bodymassindex,andalcoholuse).bToenvironmentaltobaccosmoke.Howardetal.JAMA.1998;279(2):119-124.,吸烟者,不吸烟者且无被动吸烟b,43.0,38.8,31.6,32.8,25.9,不吸烟者但有被动吸烟b,戒烟者且无被动吸烟b,戒烟者有被动吸烟b,颈动脉内膜中层厚度增加,m/3年,吸烟促进颈动脉粥样硬化进展,aTheprobabilityofanevent(developingadisease)occurringinexposedpeoplecomparedwiththeprobabilityoftheeventinnonexposedpeople.Adjustedforage,follow-upperiod,historyofdiabetes,hypertension,highcholesterollevels,andrelativeweight(in5categories).Colditzetal.NEnglJMed.1988;318(15):937-941.,青年、中年女性，发生脑卒中的风险可能与吸烟量相关,吸烟增加致命性和非致命性脑卒中风险,aTheprobabilityofanevent(developingadisease)occurringinexposedpeoplecomparedwiththeprobabilityoftheeventinnonexposedpeople.Adjustedforage,exercise,alcoholconsumption,bodymassindex,historyofhypertension,andhistoryofdiabetes.Kurthetal.Stroke.2003;34:2792-2795.,不吸烟者(n=20,339),每日吸烟量少于15支(n=1914),每日吸烟量多于15支(n=3265),吸烟增加出血性卒中风险,aTwenty-yearage-adjustedmortalityper10,000person-yearsformen.P.014fortrend.Hartetal.Stroke.1999;30:1999-2007.,吸烟增加脑卒中死亡风险,吸烟与外周血管疾病(PVD),吸烟使发生PVD的时间早10年吸烟使发生PVD的风险增加10-16倍，高于冠心病的发生风险吸烟与下列血管疾病的风险增加有关:无症状的PVD间歇性跛行PVD的进展因PVD并发症引起的截肢股帼动脉旁路失败血管手术后的死亡,FreundKM,TheFraminghamStudy:34yearsoffollow-up.AnnEpidemiol1993;3:417-424,吸烟增加外周血管疾病危险,吸烟促进主动脉扩张吸烟增加主动脉瘤死亡风险,WittemanJC,.Circulation1993;88:2156-2162WilminkTB,JVascSurg1999;30:1099-1105,吸烟与主动脉瘤发生有量效关系,戒烟对心血管的益处,戒烟对心血管益处的病理生理机制,长期吸烟者戒烟2周后，纤维蛋白原浓度和纤维蛋白原的合成速率均明显减低,ASR=absoluterateoffibrinogensynthesis.aAbstentionperiodof2weeks.Hunteretal.ClinSci(Lond).2001;100(4):459-465.,P.001,P.001,吸烟,戒烟a,16.1,24.1,2.49,3.06,吸烟,戒烟a,血浆纤维蛋白原浓度,g/L,纤维蛋白原绝对合成速率,（ASR),mg/kg,戒烟使纤维蛋白原下降,aAbstentionperiodof17weeks.Eliassonetal.NicotineTobRes.2001;3(3):249-255.,戒烟使白细胞计数明显降低,aQuitsmokingfor28days.bResumedsmokingafterquittingfor14days.ADP=adenosinediphosphate.ADPisaplateletaggregationagonist.Moritaetal.JAmCollCardiol.2005;45:589-594.,戒烟使血小板聚集率下降,HDL=high-densitylipoprotein;LDL=low-densitylipoprotein.aAbstentionperiodof17weeks.Eliassonetal.NicotineTobRes.2001;3(3):249-255.,低密度脂蛋白(mmol/L),戒烟使血脂改善,戒烟可改善脂蛋白构成，包括高密度脂蛋白升高，低密度脂蛋白降低,增强指数(%)b,aProvidesanassessmentofsmallarteriolarcompliance.bTheamplitudeofthereflectedwavedependsonthestiffnessofthesmallvesselsandlargearteriesandthusprovidesameasureofsystolicarterialstiffness.cAbstentionperiodof6months.Orenetal.Angiology.2006;57(5):564-568.,P.05,63.1,50.6,吸烟,戒烟c,戒烟使动脉顺应性改善,aAbstentionperiodof6months.Orenetal.Angiology.2006;57(5):564-568.,心率(Beats/min),P5-10,10-15,20,戒烟者(戒烟年数),3-5,15-20,4,2,1,戒烟数年后，发生急性心梗的风险明显降低,戒烟使急性心梗风险降低,与吸烟者相比，冠状动脉介入治疗后戒烟者整体死亡风险明显下降,生存率(%),100,80,60,40,20,0,时间（年）,Hasdai.NEnglJMed.1997;336(11):755-761.,戒烟者,持续吸烟者,戒烟使冠状动脉介入治疗后死亡率下降,对戒烟的生存收益进行评估，戒烟5年，生存率提高3，戒烟5年可提高10，戒烟15年则可提高15。,AdaptedfromvanDomburgetal.JAmCollCardiol.2000;36(3):878-883.,生存概率(%),0,5,10,15,20,年,P.0001(戒烟者vs吸烟者),不吸烟者,持续吸烟者,100,80,60,40,20,0,戒烟者,戒烟使冠状动脉旁路移植术后死亡率减低,对于心梗后左心室功能异常的患者，戒烟可使心律失常造成死亡风险降低,Petersetal.JAmCollCardiol.1995;26(5):1287-1292.,P=.040,生存时间（年）,戒烟者,吸烟,生存率,戒烟使心律失常死亡风险减少,戒烟者与持续吸烟者相比，反复发生心脏骤停风险明显降低,aAbstentionperiodof3years.Hallstrometal.NEnglJMed.1986;314:271-275.,3年内发生率(%),P=.038,心脏骤停反复发作,27,19,0,5,10,15,20,25,30,吸烟者,戒烟者,a,戒烟使心脏骤停风险减低,Jonasonetal.ActaMedScand.1987;221:253-260.,年,累积静息痛(%),30,20,10,0,P=.049,戒烟,吸烟,对于间歇性跛行（IC）患者，戒烟可减缓外周血管病的进一步加重。,戒烟使外周血管疾病症状改善,aTheprobabilityofanevent(developingadisease)occurringinexposedpeoplecomparedwiththeprobabilityoftheeventinnonexposedpeople.Adjustedforageandtreatmentassignment.Robbinsetal.AnnInternMed.1994;120(6):458-462.,与持续吸烟的患者比较，戒烟者非致死性脑卒中的发生风险降低,戒烟使卒中风险降低,全因死亡降低约15-20%,CVD死亡降低约25-35%,1。Kawachi,1993.2.Lievre,2000.3.Vrcer,2003,戒烟1,降压2,降胆固醇l3,戒烟1,0,.,1,0,.,4,0,.,7,1,.,0,1,.,3,1,.,6,1,.,9,全因死亡,降胆固醇3,降压2,CVD死亡,戒烟、降压、降胆固醇对无CVD史者死亡的影响,全因死亡降低约12-35%戒烟所致的风险降低最大,戒烟1,降压2a,降压2b,降胆固醇4,0,.,1,0,.,4,0,.,7,1,.,0,1,.,3,1,.,6,1,.,9,降胆固醇3,1.Critchley,2003.2.BPLTTC,2003.3.Vrercer,2003.4.CTT,2005,全因死亡,戒烟、降压、降胆固醇对有CVD