重视冠心病患者吸烟干预

WHO估计到2025年将有1000万人死于吸烟引起的相关疾病.在15～59岁人群中,61%的疾病负担归因为吸烟.在过去的几十年,中国男性的吸烟率虽然有所下降,如2000-2001年成人男性吸烟率为60.2%[1],第四次国家卫生服务调查显示,2008年15岁以上人口男性吸烟率为48.0%,但吸烟仍然是我国公共卫生重大问题之一.     

Predictors of smoking cessation in patients admitted for acute coronary heart disease.

BACKGROUND: Smoking cessation is probably the most important single action after a coronary event. In order to increase the effectiveness of smoking cessation programs, it is important to have knowledge of the predictors of smoking cessation. Further, it is unknown whether smoking cessation programs have impact on these predictors. METHODS: Data were obtained from a randomized controlled trial of smoking cessation intervention in 240 smokers aged less than 76 years admitted for myocardial infarction, unstable angina, or cardiac bypass surgery. Baseline characteristics were prospectively recorded. Smoking cessation was determined by self report and biochemical verification at 12 months follow-up. RESULTS: In multivariate logistic regression analysis, a high level of nicotine addiction, low level of self-confidence in quitting and having previous coronary heart disease were significant negative predictors of smoking cessation at 12 months follow-up. Having previous coronary heart disease and a diagnosis other than acute myocardial infarction as a reason for admission were important negative predictors of abstinence in the usual care group, in contrast to the intervention group, although this did not reach a level of significance in the subgroup interaction analyses. A high level of nicotine addiction was a strong negative predictor in both groups. CONCLUSION: A high level of nicotine addiction is an important negative predictor of smoking cessation, even within an individualized smoking cessation program. Smoking cessation intervention seems to be especially effective in patients with previous coronary heart disease and in patients with unstable angina or coronary artery bypass surgery, compared to usual care.     

Cigarette smoking: Carboxyhemoglobin,plasma nicotine,cotinine and thiocyanate vs self-reported smoking data and cardiovascular disease

Measurement of the absorption of cigarette smoke constituents were compared with self-reported daily consumption from 450 smokers to determine the most reliable dose dependent indicator of smoke inhalation and risk for coronary heart disease. A plateau of plasma nicotine and cotinine concentration at levels above 20 cigarettes per day with a continued increase of carboxyhemoglobin and thiocyanate with increasing consumption of cigarettes occurred. Classification of smokers into groups smoking cigarettes yielding more or less than 1 mg nicotine showed that smokers of low yield brands had lower plasma levels of nicotine and cotinine, but comparable levels of carboxyhemoglobin and thiocyanate. Plasma nicotine bore no relationship to smoke inhalation, while the number of cigarettes consumed per day showed a weak correlation to smoke inhalation. Despite the lower nicotine yield of cigarettes, modification in smoking behaviour enabled the smoker to derive as much carbon monoxide and thiocyanate constituents from low and high yield cigarettes; thus counteracting the advantage of low nicotine yield brands. The relationship of these parameters to the risk of coronary heart disease is discussed.     

Cost effectiveness of a smoking cessation program in patients admitted for coronary heart disease.

BACKGROUND: Smoking cessation is probably the most important action to reduce mortality after a coronary event. Smoking cessation programs are not widely implemented in patients with coronary heart disease, however, possibly because they are thought not to be worth their costs. Our objectives were to estimate the cost effectiveness of a smoking cessation program, and to compare it with other treatment modalities in cardiovascular medicine. METHODS: A cost-effectiveness analysis was performed on the basis of a recently conducted randomized smoking cessation intervention trial in patients admitted for coronary heart disease. The cost per life year gained by the smoking cessation program was derived from the resources necessary to implement the program, the number needed to treat to get one additional quitter from the program, and the years of life gained if quitting smoking. The cost effectiveness was estimated in a low-risk group (i.e. patients with stable coronary heart disease) and a high-risk group (i.e. patients after myocardial infarction or unstable angina), using survival data from previously published investigations, and with life-time extrapolation of the survival curves by survival function modeling. RESULTS: In a lifetime perspective, the incremental cost per year of life gained by the smoking cessation program was euro 280 and euro 110 in the low and high-risk group, respectively (2000 prices). These costs compare favorably to other treatment modalities in patients with coronary heart disease, being approximately 1/25 the cost of both statins in the low-risk group and angiotensin-converting enzyme inhibitors in the high-risk group. In a sensitivity analysis, the costs remained low in a wide range of assumptions. CONCLUSIONS: A nurse-led smoking cessation program with several months of intervention is very cost-effective compared with other treatment modalities in patients with coronary heart disease.     

吸烟的冠心病患者戒烟现状及影响因素分析

目的 了解吸烟的冠心病患者对于吸烟问题的认识及戒烟状况,揭示戒烟及戒烟未成功的原因和影响因素,为更有效地帮助冠心病患者控烟提供参考.方法 对350例吸烟的冠心病患者进行问卷调查,包括性别、年龄、吸烟史等,采用分组分析、logistic回归分析等方法分析戒烟的影响因素.结果 350例吸烟的冠心病患者平均年龄(59.6±10.2)岁,男321例(占91.7%).57.1%(200/350)的患者已戒烟,42.9%(150/350)的患者目前仍在吸烟.将患者按年龄分两组,非老年组患者(≤65岁,n=239)戒烟率50.6%,显著低于老年组患者(>65岁,n=111)的71.2%(P<0.001).非老年组有戒烟意愿及尝试过戒烟的比例分别为70.3%和48.3%,均低于老年组的81.2%和59.4%(P<0.001).76例戒烟复吸者中,复吸最主要原因为缺乏自我控制能力,占76.3%.logistic回归分析,影响戒烟未成功的因素:年龄≤65岁(OR=2.336,P=0.004)、文化程度低(OR=1.310,P=0.028)、行经皮冠状动脉介入治疗术(OR=0.261,P<0.001)、行冠状动脉旁路移植术(OR=0.107,P=0.004)、家庭总收入>4000 元/月(OR=1.828,P=0.003).结论 吸烟的冠心病患者戒烟水平和意识仍有待提高;除现有的控烟政策外,应更加关注中青年、文化程度较低、未行经皮冠状动脉介入治疗及冠状动脉旁路移植术、家人有人吸烟、体质指数及家庭总收入越高的吸烟冠心病患者的控烟活动;在针对吸烟冠心病患者控烟活动的同时对其周围环境宣传控烟活动也是迫切需要的.

Abstract：

Objective To investigate the status quo of smoking cessation and analyze factors influencing smoking cessation in cigarette smoking patients with coronary artery disease(CAD).Method A total of 350 smoking patients with CAD was surveyed by questionnaire,logistic regression analysis was performed to analyze factors influencing smoking cessation.Results Incidence of smoking cessation was 57.1%(200/350)in this cohort.Patients were divided into two groups,the elderlv(>65 years old,n=111)and the young group(≤65 years old,n=239).The smoking cessation rate in the elderlv group is significantly higher than in the young group(71.2%vs.50.6%,P<0.001).Aged patients and patients with high cultural level are easier to give up smoking.Logistic analysis showed that age≤65 years old (OR=2.336,P=0.004),low cultural level(OR=1.310,P=0.028),PCI(OR=0.261.P<0.001).coronary artery bypass graft(OR=0.107,P=0.004),total family income>4000 RMB/month (OR=1.828,P=0.003)are risk factors for failed smoking cessation.There are 76 patients smoking again in current smokers,most due to lack of self-control(76.3%).Compared to the elderly group,there is a higher proportion of smoking again due to the need of daily communication and work in the young group.Conclusions We still need to raise the awareness of smoking cessation for smoking patients with CAD.Following factors should be focused for tobacco control in CAD patients:younger age,lower cuItural level,not treated with PCI or CABG,patients with smoking family members.higher body mass index and higher total family income.     

Predictors of smoking cessation in patients with a diagnosis of coronary artery disease

PURPOSE: This study aimed to examine demographic, psychosocial, and clinical variables as predictors of smoking cessation in patients with coronary artery disease. METHODS: Smoking status and psychosocial variables were obtained at baseline. Participants were followed up at 3 months then annually up to 6 years for smoking status. Participants were recruited from the population of patients undergoing coronary angiography from 1986 through 1990. Patients were included in the study if they reported smoking at baseline and had valid data for demographic and clinical measures of interest. Depending on the psychosocial measure analyzed, sample size ranged from 525 to 303. Age, gender, education, marital status, disease severity, cardiac procedure, hostility, and four ratings of distress were evaluated as predictors of smoking cessation. RESULTS: Of the full sample, 40% (n = 210) quit smoking without relapse. Education (odds ratio [OR] 0.61; 95% confidence interval [CI] 0.44-0.84; P <.003), disease severity (OR 0.58; 95% CI 0.40-0.84; P <.004), and coronary artery bypass surgery (OR 0.60; 95% CI 0.43-0.85; P <.004) were associated with a lower likelihood of relapse. Higher levels of hostility (OR 2.36; 95% CI 1.46-3.84; P <.001), concern about health (OR 1.90; 95% CI 1.33-2.74; P <.001), tension (OR 1.60; 95% CI 1.12-2.30; P <.012), and depressive feelings (OR 1.60; 95% CI 1.12-2.27; P <.010) were associated with a higher risk of continuing to smoke. CONCLUSIONS: These findings describe demographic, clinical, and psychological mechanisms that might underlie successful smoking cessation and also may guide the identification of patients in need of special intervention.     

冠心病介入术后患者吸烟状况调查

目的：了解冠心病介入术后患者吸烟状况。方法：采用上海公共卫生研究所设计的戒烟调查表,对109例一年前因冠心病行介入治疗,且介入治疗前为吸烟者进行问卷调查。结果：109例介入治疗术后的患者中有81例尝试戒烟,其中成功戒烟者39人,占戒烟者48．2％（39／81）,占总例数的35．78％（39／109）;复吸者42例,占戒烟者51．8％（42／81）;仍在吸烟者70例（包括戒烟复吸者）,占总例数的64．22％（70／109）。42例复吸者复吸原因：认为戒烟很痛苦36例（85．7％）,疾病已好5例（11．9％）,医师没强调,自己没认识吸烟危害1例（2．4％）;复吸时间：介入术后3个月内40例（69．23％）,6个月内20例（28．57％）,9个月内10例（14．29％）。结论：冠心病介入术后患者仍吸烟者仍占很大比例,若戒烟有困难,建议药物辅助戒烟。     

冠心病合并心力衰竭患者冠状动脉支架术后短期临床疗效评价

冠状动脉粥样硬化性心脏病（冠心病）患者由于冠状动脉严重狭窄或闭塞,导致心肌重构,心脏扩大,心功能不同程度下降。但由于缺血坏死区内有不同程度的存活心肌（冬眠心肌、顿抑心肌和伤残心肌）。如能及时实施经皮冠状动脉介入治疗术（PCI）,开通病变血管,可不同程度的挽救这些存活心肌,使心功能得以保存或改善。     

青年吸烟冠心病患者冠状动脉病变特点和控烟干预

目的 分析青年吸烟冠心病患者冠状动脉病变特点,并探讨人为干预对控烟的影响.方法 入选确诊为冠心病的青年患者160例(14～35岁),将吸烟患者118例和非吸烟患者42例均分为心理辅导组和对照组.通过冠状动脉造影分析患者的冠状动脉病变特点,并调查出院后3个月患者的吸烟情况.结果 与非吸烟患者比较,吸烟患者单支病变的比例较低(50.84%比66.67%,P＜0.01),急性冠状动脉综合征(75.42%比50.00%,P＜0.05)、双支病变(24.58%比19.05%,P＜0.05)、三支病变(11.86%比4.47%,P＜0.05)、冠状动脉瘤样扩张(12.71%比9.52%,P＜0.01)的比例和Gensini积分(61.94±40.35比45.08±28.97,P＜0.05)较高.在3个月的随访期中,吸烟患者心理辅导组的戒烟率高于对照组(61.76%比30.00%,P＜0.05);非吸烟患者心理辅导组的新发吸烟率低于对照组(0比5.00%,P＜0.05).结论 青年吸烟冠心病患者的冠状动脉病变程度重于非吸烟患者.人为干预有助于控烟.     

冠心病患者血清胆红素与血脂水平的关系

目的　探讨血清胆红素及血脂水平与冠心病的关系。方法　回顾性分析经冠状动脉造影确诊的冠心病患者6 7例及非冠心病患者 6 7例的血清胆红素及血脂水平。结果　冠心病患者血清总胆红素、直接胆红素、间接胆红素、高密度脂蛋白胆固醇水平均低于非冠心病患者 ,总胆固醇、三酰甘油、低密度脂蛋白胆固醇水平高于非冠心病患者。相关分析表明 ,血清胆红素尤其是间接胆红素与低密度脂蛋白胆固醇呈负相关 ,与高密度脂蛋白胆固醇呈正相关。结论　低水平胆红素及高水平低密度脂蛋白胆固醇对冠心病的发生产生不利影响     

Current smoking, smoking cessation, and the risk of sudden cardiac death in patients with coronary artery disease

BACKGROUND: Cigarette smoking is a known risk factor for sudden cardiac death (SCD). However, the effect of continued cigarette smoking and smoking cessation on SCD risk in patients with established coronary artery disease (CAD) is subject to controversy. We, therefore, evaluated the effect of cigarette smoking on SCD risk in a large cohort of patients with established CAD. METHODS: The study population was composed of 3122 patients with a previous myocardial infarction or stable angina who participated in the Bezafibrate Infarction Prevention Trial. Patients were prospectively followed up for a mean of 8.2 years. The primary end point was the incidence of SCD according to smoking status. RESULTS: Among the 370 patients who were current smokers, 30 (8.1%) experienced SCD; 83 (4.6%) of the 1821 patients who had quit smoking and 43 (4.6%) of the 931 patients who had never smoked experienced SCD (P =.01). In multivariate analyses, current smoking was associated with a significant increase in the risk of SCD (hazard ratio, 2.47; 95% confidence interval, 1.46-4.19). Patients who had stopped smoking had no significant increase in the risk of SCD compared with patients who had never smoked (hazard ratio, 1.06; 95% confidence interval, 0.70-1.62). CONCLUSIONS: Current cigarette smoking is a powerful independent predictor of SCD risk in patients with CAD. Patients who quit smoking experienced a significant reduction in SCD risk. Thus, efforts to reduce mortality from SCD in patients with CAD should include vigorous smoking cessation strategies.     

Prevention of coronary heart disease: smoking

Smoking is the leading preventable cause of illness and premature death in Germany, claiming over 110,000 lives a year because it directly increases the risk of dying from heart disease, stroke, emphysema and a variety of cancers. The overwhelming majority of smokers begin tobacco use before they reach adulthood. Among those young people who smoke, the average age is now 13-14. In Germany, about 39% of male and 31% of female adults (age 18-60 years) continue to smoke, despite information about the unequivocally negative health consequences of smoking. The exact mechanisms of smoking-related vascular disease are not yet known. Smoking causes acute hemodynamic alterations such as increase in heart rate, systematic and coronary vascular resistance, myocardial contractility, and myocardial oxygen demand. These short-term effects could lower the ischemic threshold in smokers with coronary artery disease and contribute to the increased risk for acute cardiovascular events. Endothelial damage is thought to be an initiating event in atherosclerosis and early studies have demonstrated that long-term smoking has direct toxic effects with structural changes of human endothelial cells. Recent research has shown the importance of the functional role of the endothelium in regulating vascular tone, platelet-endothelial interactions, leukocyte adhesion and smooth muscle cell proliferation via synthesis and release of a variety of substances such as nitric oxide. There is strong evidence that smoking leads to endothelial dysfunction mainly by increased inactivation of nitric oxide by oxygen-derived free radicals. Smoking also increases oxidative modification of LDL and is associated with lower HDL plasma levels. Smoking induces a systemic inflammatory response with increased leukocyte count and elevation of the C-reactive protein level. Importantly, the prothrombotic effects of smoking have been repeatedly demonstrated to cause alterations in platelet function, imbalance of antithrombotic vs prothrombotic factors, and decrease of fibrinolytic activity. Given the enormous health hazard of tobacco use, complete abstinence from smoking should be achieved. Smoking cessation counselling should be given to healthy subjects and even more vigorously to patients with manifested disease. Every effort should be undertaken to prevent children and adolescents from starting to smoke. Brief tobacco dependence treatment is effective, and every smoker should be offered at least brief treatment at every office visit. More intensive treatment is more effective in producing long-term abstinence from tobacco. Nicotine replacement therapy (nicotine patches or gum), clinician-delivered social support, and skills training are the three most effective components of smoking cessation treatment. A framework for tobacco control measures is necessary to reduce tobacco consumption and exposure to tobacco smoke. Recommendations on specific tobacco control interventions are: 1. increase in tobacco taxes; 2. comprehensive tobacco advertising bans; 3. legislation prohibiting smoking in work and public places; 4. prohibiting the sales of tobacco products to persons under 18; 5. comprehensive disclosure of the physical, chemical and design characteristics of all tobacco products; 6. training of health professionals to promote smoking prevention and cessation interventions; and 7. development of a national network of smoking cessation treatment services.     

吸烟冠心病病人的冠脉造影分析

目的　初步探讨吸烟冠心病病人的冠脉造影血管形态特点。方法　选择 2 0 0 1年 7月至 2 0 0 3年 7月间我院冠脉造影确诊冠心病的病人 2 0 8例 (男 179例 ,女 2 9例 ,年龄 38～ 75岁 ) ,吸烟年限 5～ 4 8年 ,平均 (36 4 5± 7 18)年 ;对照组选取同期病人 2 0 8例从不吸烟的患者 ,按照性别、年龄以及是否有高血压、糖尿病等冠心病危险因素严格配对。结果　吸烟组 13 9%有冠脉瘤样扩张 ;而对照组仅有 1 9% (P<0 0 0 1)。另外 ,在行冠脉成形术 (PTCA)的患者中吸烟组有4 0例 (19 2 % )有PTCA相关血管PTCA后的慢血流现象。而对照组仅有 7例 (3 83% ) (P <0 0 0 1)。结论　吸烟患者冠脉病变特点为冠脉瘤样扩张或冠脉扩张症多发。吸烟患者PTCA术中相关血管慢血流现象的发生率较高。