1、吸烟与心血管疾病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吸烟是中国人心血管疾病的重要危险因素中国NEHNS IV冠心病冠心病是吸烟致死疾病的前三位之一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.Mi
2、ligi.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;319:143Lavi 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吸烟促发心血管疾病的发病
3、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/minP=.0032172830100200300400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使血栓生成增加Barua et al.Circulation.2001;104:1905-1910.50000不吸烟者吸烟者4000300020001000NO浓度浓度(nmol/L)P.
4、000112663613吸烟使一氧化氮生物合成减少吸烟使一氧化氮生物合成减少Zeiher et al.Circulation.1995;92:1094-1100.020304060501010P.01P.001P.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
5、功能障碍P=.03604530150不吸烟者戒烟者吸烟者46%34%35%内皮功能障碍吸烟致心外膜血管内皮功能障碍吸烟致心外膜血管内皮功能障碍Lavi et al.Circulation.2007;115:2621-2627;Stewart et al.Circulation.2005;111:1756-176286420P.0001P=.03P.0001P.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吸烟使白细胞计数升高ns=not significant.a Unless marked as“ns,”differences for ea
6、ch 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/mLa36.834.832.830.828.826.824.822.8123451211-脱氢血栓烷素B2 nsnsnsMin/10 Plateletsa1234512丙二醛天5.62.53.23.64.04.44.85.2nsnsnsnsnsnsnsnsnsns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吸烟使血小板聚集功能增强
7、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):1198-1203.64056048040032024016080吸烟者不吸烟者1000900800700600500400300吸烟者不吸烟者自由异构前列腺素F2pmol/L酯化
8、异构前列腺素F2pmol/L吸烟增加氧化修饰吸烟增加氧化修饰吸烟与心血管疾病的流行病学吸烟与心血管疾病的流行病学吸烟流行吸烟流行10年后出现吸烟相关疾病的流行年后出现吸烟相关疾病的流行吸烟与冠心病吸烟与冠心病(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=.002P=.00757373620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加重动脉粥样硬化aThe probability of an event(developing a disease)occurring in exposed
9、 people compared with the probability of the event in nonexposed people.Adjusted for age.Willett et al.N Engl J Med.1987;317(1):1303-1309.1.01.62.62.01-14/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增加心绞痛风险aThe ratio of the odds of development of disease in exposed persons to the odds of developmen
10、t of disease in nonexposed persons.Teo.Lancet.2006;368:647-658.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吸烟增加急性非致死性心梗的风险Y usuf S et al.Lancet.2004;364:937-52OR (99%CI)每日吸烟量与心肌梗死发生有量效关系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 wit
11、h 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
12、 the event in nonexposed people.Adjusted for age.Wannamethee et al.Circulation.1995;91:1749-1756.1.02.30.01.02.03.04.0不吸烟者吸烟者相对风险可信区间95吸烟增加心源性猝死的风险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
13、.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)1.01.282.08相对风险可信区间950.01.02.03.04.0不吸烟者戒烟者吸烟者吸烟使冠脉介入治疗后发生吸烟使冠脉介入治疗后发生Q波心梗的风险波心梗的风险增高增高被动吸烟与冠心病被动吸烟与冠心病Adjusted for age,systolic blood pressure,diastolic blood pressur
14、e,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 co
15、mbined(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.随访时间（年）随访时间（年）0510152000.050.100.150.20轻度主动吸烟轻度主动吸烟a重度被动吸烟重度被动吸烟b轻度被动吸烟轻度被动吸烟c严重冠心病发生比例被动吸烟增加冠心病发生风险被动吸烟增加冠心病发生风险aThe ratio of the odds of dev
16、elopment 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1-78-1415-21224210.75被动吸烟使发生非致死性心梗的风险量级增加比
17、值比可信区间95被动吸烟增加急性心梗发生风险被动吸烟增加急性心梗发生风险吸烟与脑卒中吸烟与脑卒中脑核磁共振像 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吸烟增加急性缺血性卒中风险aAdjusted for demographic characteristics,cardiovascular risk factors,and lifestyle variables(
18、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b43.038.831.632.825.9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促进颈动脉粥样硬化进展aThe probability of an event(dev
19、eloping 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):937-941.1-1415-24不吸烟者2
20、5吸烟者每日吸烟量（支）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,histo
21、ry 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)总出血性脑卒中脑内出血蛛网膜下腔出血相对风险可信区间95吸烟增加出血性卒中风险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.
22、15-241-1525吸烟者每日吸烟量（支）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增加脑卒中死亡风险吸烟与外周血管疾病吸烟与外周血管疾病(PVD)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增加外周血管疾病危险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吸烟与主动脉瘤发生
23、有量效关系戒烟对心血管的益处戒烟对心血管的益处戒烟对心血管益处的病理生理戒烟对心血管益处的病理生理机制机制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吸烟戒烟a16.124.12.493.06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戒烟使纤维蛋白原下降aAbstention period of 17 weeks.Eliasso
24、n et al.Nicotine Tob Res.2001;3(3):249-255.戒烟a吸烟P.026白细胞计白细胞计数数109/L戒烟使白细胞计数明显降低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.腺苷二磷酸（腺苷二磷酸（ADP）=5.0 mol/LA
25、组aB组b血小板聚集血小板聚集(%)020601004080时间（天）时间（天）07142128NSP.01NSNSP.01戒烟使血小板聚集率下降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)P.001 高密度脂蛋白高密度脂蛋白(mmol/L)吸烟戒烟a戒烟使血脂改善戒烟使血脂改善P.015吸烟戒烟a HDL/LDL
26、比值比值P.001吸烟戒烟a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(%)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 stiffness.cAbstention period of 6 months.O
27、ren et al.Angiology.2006;57(5):564-568.P.05振荡顺应性振荡顺应性(mL/mm Hg 100)aP.01吸烟戒烟c63.150.6吸烟戒烟c戒烟使动脉顺应性改善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P.05平均动脉压平均动脉压(mm Hg)吸烟戒烟a戒烟a戒烟使血液动力学改善戒烟使血液动力学改善戒烟对心血管益处的流行病学戒烟对心血管益处的流行病学1.CDC.Surgeon General R
28、eport 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 nonexpose
29、d persons.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戒烟者(戒烟年数)3-515-20421比值比可信区间95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戒烟使急性心梗风险降低生存率(%)100806040200023456789101112时间（年）Hasdai.N Engl J Med.1997;3
30、36(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戒烟使冠状动脉介入治疗后死亡率下降Adapted from van Domburg et al.J Am Coll Cardiol.2000;36(3):878-883.生存概率(%)05101520年P.0001(戒烟者 vs 吸烟者)不吸烟者持续吸烟者100806040200戒烟者戒烟使冠状动脉旁路移植术后死亡率减低戒烟使冠状动脉旁路移植术后死亡率减低Peters et al.J Am Coll Cardiol.1995;26(5):1287-1292.P=.040生存时间（年）0204060801000231
31、戒烟者吸烟生存率戒烟使心律失常死亡风险减少戒烟使心律失常死亡风险减少 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2719051015202530吸烟者戒烟者a戒烟使心脏骤停风险减低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(%)3020100P=.0492716543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
32、改善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.不吸烟者戒烟者吸烟者(20支/日)吸烟者(20 支/日）P.0001(趋势趋势)相对风险可信区间95与持
33、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10.10.40.71.01.31.61.9全因死亡降胆固醇3降压2CVD死亡戒烟、降压、降胆固醇戒烟、降压、降胆固醇对无对无CVD史者死亡的影响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40.10.40.71.01.31.61.9降胆固醇31.Critchley,2003.2.BPLTTC
34、,2003.3.Vrercer,2003.4.CTT,2005全因死亡戒烟、降压、降胆固醇戒烟、降压、降胆固醇对有对有CVD史者死亡的影响史者死亡的影响 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
35、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
36、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）戒烟给心血管系统带来的益处（总结）
