吸烟与心血管疾病概述.pptx

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,吸烟与心血管疾病,吸烟与心血管疾病概述,第1页,吸烟是中国人心血管疾病主要危险原因,高血压,160M,血脂异常,160M,糖尿病,20M,IFG 20M,肥胖,60M,超重,200M,吸烟,350M,被动吸烟,540M,中国,NEHNS IV,吸烟与心血管疾病概述,第2页,冠心病,是吸烟致死疾病前三位之一,由吸烟引发死亡前三位疾病：,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;.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,;20(Suppl 2):91.6.Willigendael.J Vasc Surg.;40:1158.7.Yang.BMJ.1999;319:143,吸烟与心血管疾病概述,第3页,内皮功效紊乱,血栓生成增加,炎症反应加强,氧化修饰,Lavi et al.,Circulation,.;115:2621-2627;.texasheartinstitute.org/HIC/Topics/Diag/diangio.cfm.Accessed June 14,.,右冠状动脉粥样硬化,吸烟促发心血管疾病发病机理,吸烟与心血管疾病概述,第4页,组织因子（,TF,）在动脉粥样硬化斑块有高表示，这可能在血栓形成中发挥主要作用,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.,;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,吸烟与心血管疾病概述,第5页,Barua et al.,Circulation.,;104:1905-1910.,5000,0,不吸烟者,吸烟者,4000,3000,1000,NO,浓度,(nmol/L),P,0001,1266,3613,吸烟使一氧化氮生物合成降低,吸烟与心血管疾病概述,第6页,Zeiher et al.,Circulation.,1995;92:1094-1100.,0,20,30,40,60,50,10,10,P,.01,P,.001,P,.01,吸烟者,P,.01,不吸烟者,P,.01,与不吸烟者相比，吸烟者依据流量调整内皮血管舒张功效显著减弱,动脉造影正常吸烟者,动脉造影不正常吸烟者,动脉造影正常不吸烟者,动脉造影不正常不吸烟者,流量调整内皮血管舒张功效,吸烟使血管内皮舒张功效受损,吸烟与心血管疾病概述,第7页,Lavi et al.,Circulation.,;115:2621-2627.,与不吸烟者相比，吸烟者更轻易发生心外膜内皮功效障碍,P,=.03,60,45,30,15,0,不吸烟者,戒烟者,吸烟者,46%,34%,35%,内皮功效障碍,吸烟致心外膜血管内皮功效障碍,吸烟与心血管疾病概述,第8页,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，吸烟者白细胞计数显著升高,Lavi et al.,Circulation.,;115:2621-2627;Stewart et al.,Circulation.,;111:1756-1762,8,6,4,2,0,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,10,9,/L,吸烟使白细胞计数升高,吸烟与心血管疾病概述,第9页,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/mL,a,36.8,34.8,32.8,30.8,28.8,26.8,24.8,22.8,1,2,3,4,5,12,11-,脱氢血栓烷素,B2,ns,ns,ns,Min/10 Platelets,a,1,2,3,4,5,12,丙二醛,天,5.6,2.5,3.2,3.6,4.0,4.4,4.8,5.2,ns,ns,ns,ns,ns,ns,ns,ns,ns,ns,天,被动吸烟人血小板聚集功效与吸烟者靠近,吸烟使血小板聚集功效增强,吸烟与心血管疾病概述,第10页,异构前列腺素,F2,水平是体内脂质过氧化反应指标,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,吸烟与心血管疾病概述,第11页,吸烟与心血管疾病流行病学,吸烟与心血管疾病概述,第12页,吸烟流行,10,年后出现吸烟相关疾病流行,吸烟与心血管疾病概述,第13页,吸烟与冠心病,(CAD),吸烟与心血管疾病概述,第14页,Waters et al.,Circulation,.1996;94:614-621.,已经有病变加重发生率,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,吸烟与心血管疾病概述,第15页,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(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,吸烟与心血管疾病概述,第16页,与非吸烟者相比，吸烟者发生急性非致死性心梗风险增加,3,倍。,a,The ratio of the odds of development of disease in exposed persons to the odds of development of disease in nonexposed persons.Teo.,Lancet,.;368:647-658.,10,9,8,7,6,5,4,3,2,1,0,年纪,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风险,吸烟与心血管疾病概述,第17页,Y usuf S et al.Lancet.;364:937-52,OR (99%CI),每日吸烟量与心肌梗死发生有量效关系,吸烟与心血管疾病概述,第18页,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,吸烟与心血管疾病概述,第19页,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.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,相对风险,可信区间,95,吸烟增加心源性猝死风险,吸烟与心血管疾病概述,第20页,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 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,相对风险,可信区间,95,0.0,1.0,2.0,3.0,4.0,不吸烟者,戒烟者,吸烟者,吸烟使冠脉介入治疗后发生,Q,波心梗风险增高,吸烟与心血管疾病概述,第21页,被动吸烟与冠心病,吸烟与心血管疾病概述,第22页,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.,a,Light active refers to men smoking 1-9 cigarettes a day.,b,Heavy passive refers to upper three quarters of cotinine concentration combined(0.8 to 14.0 ng/mL).,c,Light passive refers to lowest quarter of cotinine concentration among nonsmokers(0-0.07 ng/mL).,Whincup et al.,BMJ.,;329:200-205.,被动吸烟发生心脏疾病风险比不吸烟者增加,30,随访时间（年）,0,5,10,15,20,0,0.05,0.10,0.15,0.20,轻度主动吸烟,a,重度被动吸烟,b,轻度被动吸烟,c,严重冠心病发生百分比,被动吸烟增加冠心病发生风险,吸烟与心血管疾病概述,第23页,a,The 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,.;368:647-658.,被动吸烟暴露连续时间（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风险量级增加,比值比,可信区间,95,被动吸烟增加急性心梗发生风险,吸烟与心血管疾病概述,第24页,吸烟与脑卒中,吸烟与心血管疾病概述,第25页,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,.;37:1583-1633;.ucihs.uci.edu/stroke/whatisastroke.shtml.Accessed October 19,.,吸烟增加急性缺血性卒中风险,吸烟与心血管疾病概述,第26页,不论是主动还是被动吸烟都会加紧颈动脉粥样硬化,a,Adjusted for demographic characteristics,cardiovascular risk factors,and lifestyle variables(risk factor model and Keys score,education,leisure activity,body mass index,and alcohol use).,b,To 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,吸烟与心血管疾病概述,第27页,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,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.,1-14,15-24,不吸烟者,25,吸烟者每日吸烟量（支）,相对风险,可信区间,95,青年、中年女性，发生脑卒中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,吸烟与心血管疾病概述,第28页,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,exercise,alcohol consumption,body mass index,history of hypertension,and history of diabetes.Kurth et alStroke,.;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),总出血性脑卒中,脑内出血,蛛网膜下腔出血,2.06,3.43,2.39,2.89,1.74,4.04,相对风险,可信区间,95,吸烟增加出血性卒中风险,吸烟与心血管疾病概述,第29页,a,Twenty-year age-adjusted mortality per 10,000 person-years for men.,P,.014 for trend.Hart et al.,Stroke.,1999;30:1999-.,15-24,1-15,25,吸烟者每日吸烟量（支）,死亡率,/10000,人*年,吸烟增加脑卒中死亡风险,吸烟与心血管疾病概述,第30页,吸烟与外周血管疾病,(PVD),吸烟与心血管疾病概述,第31页,吸烟使发生,PVD,时间早,10,年,吸烟使发生,PVD,风险增加,10-16,倍，高于冠心病发生风险,吸烟与以下血管疾病风险增加相关,:,无症状,PVD,间歇性跛行,PVD,进展,因,PVD,并发症引发截肢,股帼动脉旁路失败,血管手术后死亡,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,吸烟与心血管疾病概述,第32页,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;88:2156-2162,Wilmink TB,J Vasc Surg 1999;30:1099-1105,吸烟与主动脉瘤发生,有量效关系,吸烟与心血管疾病概述,第33页,戒烟对心血管益处,吸烟与心血管疾病概述,第34页,戒烟对心血管益处病理生理机制,吸烟与心血管疾病概述,第35页,长久吸烟者戒烟,2,周后，纤维蛋白原浓度和纤维蛋白原合成速率均显著减低,ASR=absolute rate of fibrinogen synthesis.,a,Abstention period of 2 weeks.,Hunter et al.,Clin Sci(Lond),.;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,吸烟与心血管疾病概述,第36页,a,Abstention period of 17 weeks.,Eliasson et al.,Nicotine Tob Res,.;3(3):249-255.,戒烟,a,吸烟,P,.026,白细胞计数,10,9,/L,戒烟使白细胞计数显著降低,吸烟与心血管疾病概述,第37页,a,Quit smoking for 28 days.,b,Resumed smoking after quitting for 14 days.,ADP=adenosine diphosphate.ADP is a platelet aggregation agonist.,Morita et al.,J Am Coll Cardiol,.;45:589-594.,腺苷二磷酸（,ADP,）,=5.0 mol/L,A,组,a,B,组,b,血小板聚集,(%),0,20,60,100,40,80,时间（天）,0,714,21,28,NS,P,.01,NS,NS,P,.01,戒烟使血小板聚集率下降,吸烟与心血管疾病概述,第38页,HDL=high-density lipoprotein;,LDL=low-density lipoprotein.,a,Abstention period of 17 weeks.Eliasson et al.,Nicotine Tob Res.,;3(3):249-255.,低密度脂蛋白,(mmol/L),P,.001,高密度脂蛋白,(mmol/L),吸烟,戒烟,a,戒烟使血脂改进,P,.015,吸烟,戒烟,a,HDL/LDL,比值,P,.001,吸烟,戒烟,a,戒烟可改进脂蛋白组成，包含高密度脂蛋白升高，低密度脂蛋白降低,吸烟与心血管疾病概述,第39页,增强指数,(%),b,a,Provides an assessment of small arteriolar compliance.,b,The 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.,c,Abstention period of 6 months.,Oren et al.,Angiology,.;57(5):564-568.,P,.05,振荡顺应性,(mL/mm Hg 100),a,P,.01,吸烟,戒烟,c,63.1,50.6,吸烟,戒烟,c,戒烟使动脉顺应性改进,吸烟与心血管疾病概述,第40页,a,Abstention period of 6 months.,Oren et al.,Angiology.,;57(5):564-568.,心率,(Beats/min),P,.05,吸烟,P,.05,平均动脉压,(mm Hg),吸烟,戒烟,a,戒烟,a,戒烟使血液动力学改进,吸烟与心血管疾病概述,第41页,戒烟对心血管益处流行病学,吸烟与心血管疾病概述,第42页,1.CDC.Surgeon General Report 2.American Cancer Society.Guide to Quitting Smoking,肺功效改进降低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,30-50%,CAD,危险降低,50%,CAD,危险与正常不吸烟者相同,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,戒烟使冠心病风险降低,吸烟与心血管疾病概述,第43页,a,The 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,.;368:647-658.,P,1-3,5-10,10-15,20,戒烟者,(,戒烟年数,),3-5,15-20,4,2,1,比值比,可信区间,95,戒烟多年后，发生急性心梗风险显著降低,戒烟使急性心梗风险降低,吸烟与心血管疾病概述,第44页,与吸烟者相比，冠状动脉介入治疗后戒烟者整体死亡风险显著下降,生存率,(%),100,80,60,40,20,0,0,2,3,4,5,6,7,8,9,10,11,12,时间（年）,Hasdai.,N Engl J Med.,1997;336(11):755-761.,戒烟者,连续吸烟者,戒烟使冠状动脉介入治疗后死亡率下降,吸烟与心血管疾病概述,第45页,对戒烟生存收益进行评定，戒烟,5,年，生存率提升,3,，戒烟,5,年可提升,10,，戒烟,15,年则可提升,15,。,Adapted from van Domburg et al.,J Am Coll Cardiol,.;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,连续吸烟者,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,吸烟与心血管疾病概述,第46页,对于心梗后左心室功效异常患者，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）,0,20,40,60,80,100,0,2,3,1,戒烟者,吸烟,生存率,戒烟使心律失常死亡风险降低,吸烟与心血管疾病概述,第47页,戒烟者与连续吸烟者相比，重复发生心脏骤停风险显著降低,a,Abstention period of 3 years.,Hallstrom et al.,N Engl J Med,.1986;314:271-275.,3,年内发生率,(%),P,=.038,心脏骤停重复发作,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,吸烟与心血管疾病概述,第48页,Jonason et al.,Acta Med Scand.,1987;221:253-260.,年,累积静息痛,(%),30,20,10,0,P,=.049,2,7,1,6,5,4,3,戒烟,吸烟,对于间歇性跛行（,IC,）患者，戒烟可减缓外周血管病深入加重。,戒烟使外周血管疾病症状改进,吸烟与心血管疾病概述,第49页,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 and treatment assignment.Robbins et al.,Ann Intern Med.,1994;120(6):458-462不吸烟者,戒烟者,吸烟者,(20,支,/,日,),吸烟者,(20,支,/,日）,P,.0001(,趋势,),相对风险,可信区间,95,与连续吸烟患者比较，戒烟者非致死性脑卒中发生风险降低,戒烟使卒中风险降低,吸烟与心血管疾病概述,第50页,全因死亡降低约,15-20%,CVD,死亡降低约,25-35,%,1,。,Kawachi,1993.2.Lievre,.3.Vrcer,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,史者死亡影响,吸烟与心血管疾病概述,第51页,全因死亡降低约,12-35,%,戒烟所致风险降低最大,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,.2.BPLTTC,.3.Vrercer,.4.CTT,全因死亡,戒烟、降压、降胆固醇对有,CVD,史者死亡影响,吸烟与心血管疾病概述,第52页,戒烟,$2,000 6,000,降血压药品,$9,000 26,000,降血脂药品,$50,000 196,000,平均每挽救一个生命年（人年）成本,:,Benowitz,Prog Cardiovasc Dis,;46:91,戒烟是降低心血管风险最经济干预方式,吸烟与心血管疾病概述,第53页,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,/,低密度脂蛋白百分比改进,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,动脉顺应性改进,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,吸烟造成血小板聚集降低,长久益处,降低以下风险,卒中,重复冠脉搭桥术,心梗后重复发生冠脉事件,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,降低,冠脉搭桥术后死亡率,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,.;25:2101-2108;,Morita et al.,J Am Coll Cardiol,.;45:589-594;Oren et al.,Angiology,.;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,.;137:494-500;Hasdai et al.,N Engl J Med,.1997;336:755-761;van Domburg et al.,J Am Coll Cardiol,.;36:878-883;Bakhru et al.,PLoS Med,.;2:e160;,Eliasson et al.,Nicotine Tob Res,.;3:249-255;Hunter et al.,Clin Sci,.;100:459-465;Wannamethee et al.,JAMA,.1995;274:155-160.,戒烟给心血管系统带来益处（总结）,吸烟与心血管疾病概述,第54页,吸烟与心血管疾病概述,第55页,Thank You!,吸烟与心血管疾病概述,第56页,