吸烟与心血管疾病心血管网先心病高血压冠心病血管疾病心房颤动.ppt

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 20MIFG 20M肥胖 60M超重 200M吸烟 350M被动吸烟 540M,中国NEHNS IV,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.Surgeoen Generals Report.Health Consequences of Smoking;2004.2.J Natl Cancer Inst.1993;85(24):1994.3.Crane.Cancer Epidemiol Biomarkers 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,内皮功能紊乱血栓生成增加炎症反应加强氧化修饰,Lavi et al.Circulation.2007;115:2621-2627;http:/www.texasheartinstitute.org/HIC/Topics/Diag/diangio.cfm.Accessed June 14,2007.,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,Sambola et al.Circulation.2003;107:973-977.,Factor Xa(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,Barua et al.Circulation.2001;104:1905-1910.,吸烟使一氧化氮生物合成减少,Zeiher et al.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,Lavi et al.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,Lavi et al.Circulation.2007;115:2621-2627;Stewart et al.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=not significant.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.,不吸烟者,吸烟者,pg/mLa,11-脱氢血栓烷素B2,ns,ns,ns,Min/10 Plateletsa,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.,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),Waters et al.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,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.Willett et al.N Engl J Med.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。,aThe ratio of the odds of development of disease in exposed persons to the odds of development of disease in nonexposed persons.Teo.Lancet.2006;368:647-658.,年龄40 y,年龄40-49 y,年龄50-59 y,年龄60-69 y,年龄70 y,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,Y usuf S et al.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,a The probability of an event(developing a disease)occurring in exposed people compared with 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,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.Wannamethee et al.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,aThe probability of an event(developing a disease)occurring in exposed people compared with the probability of the event in nonexposed people.Adjusted for 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),1.0,1.28,2.08,0.0,1.0,2.0,3.0,4.0,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,Adjusted for age,systolic blood pressure,diastolic blood pressure,total cholesterol,HDL cholesterol,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 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.,被动吸烟增加冠心病发生风险,aThe ratio of the odds of development of disease in exposed 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,Goldstein et al.Stroke.2006;37:1583-1633;http:/www.ucihs.uci.edu/stroke/whatisastroke.shtml.Accessed October 19,2007.,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,aAdjusted for demographic characteristics,cardiovascular risk factors,and lifestyle variables(risk factor model 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,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,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.,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,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 history of diabetes.Kurth et al.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-year age-adjusted mortality per 10,000 person-years for men.P.014 for trend.Hart et al.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,Freund KM,The Framingham Study:34 years of follow-up.Ann Epidemiol 1993;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,Witteman JC,.Circulation 1993;88:2156-2162Wilmink TB,J Vasc Surg 1999;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=absolute rate of fibrinogen synthesis.aAbstention period of 2 weeks.Hunter et al.Clin Sci(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,aAbstention period of 17 weeks.Eliasson et al.Nicotine Tob Res.2001;3(3):249-255.,戒烟使白细胞计数明显降低,aQuit smoking for 28 days.bResumed smoking after quitting for 14 days.ADP=adenosine diphosphate.ADP is a platelet aggregation agonist.Morita et al.J Am Coll Cardiol.2005;45:589-594.,戒烟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),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,aProvides 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 stiffness.cAbstention period of 6 months.Oren et al.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,a Abstention period of 6 months.Oren et al.Angiology.2006;57(5):564-568.,心率(Beats/min),P.05,吸烟,戒烟a,戒烟使血液动力学改善,戒烟对心血管益处的流行病学,1.CDC.Surgeon General Report 2004 2.American Cancer Society.Guide to Quitting Smoking2006,肺功能改善减少咳嗽鼻窦充血呼吸急促等,3个月,肺Ca发生率是继续吸烟者的30-50%,CAD危险减少50%,CAD危险与正常不吸烟者相似,卒中危险恢复到正常不吸烟者水平,1年,5 年,10 年,15 年,戒烟,戒烟使冠心病风险减少,aThe ratio of the odds of development of disease in exposed persons to the odds of development of disease in nonexposed persons.Adjusted for sex,region,diet,alcohol,physical activity,consumption of fruits,vegetables,and alcohol.Adapted from Teo.Lancet.2006;368:647-658.,P.0001,吸烟者,1-3,5-10,10-15,20,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.N Engl J Med.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。,Adapted from van Domburg et al.J Am Coll Cardiol.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,Peters et al.J Am Coll Cardiol.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,aAbstention period of 3 years.Hallstrom et al.N Engl J Med.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,Jonason et al.Acta Med Scand.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,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 Med.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史者死亡的影响,戒烟$2,000 6,000降血压药物$9,000 26,000降血脂药物$50,000 196,000,平均每挽救一个生命年（人年）的成本:,Benowitz,Prog Cardiovasc Dis,2003;46:91,戒烟是降低心血管风险最经济的干预方式,短期益处 纤维蛋白原浓度下降 纤维蛋白原合成速率减低 白细胞计数下降高密度/低密度脂蛋白比例改善 卒中风险降低 高密度脂蛋白增加 低密度脂蛋白下降动脉压 心率下降动脉顺应性改善 心梗后心律失常所致猝死风险减低 血小板体积减小血小板环磷酸腺苷反应增强，促使前列腺素E1 发生腺苷酸环化 吸烟导致的血小板聚集减少,长期益处减少下列风险卒中 重复冠脉搭桥术 心梗后反复发生冠脉事件心梗后心律失常所致猝死继发心血管疾病 冠脉搭桥术后血运重建术减少 冠脉搭桥术后的死亡率经皮冠状动脉成形术后死亡率与心血管疾病进展相关的炎症标志分子水平(C反应蛋白,白细胞,纤维蛋白原),Twardella et al.Eur Heart J.2004;25:2101-2108;Morita et al.J Am 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;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.,戒烟给心血管系统带来的益处（总结）,Thank You!,