吸烟与 36 种心血管疾病亚型的风险：一项大型前瞻性澳大利亚研究中的致死和非致死结局。
Tobacco smoking and risk of 36 cardiovascular disease subtypes: fatal and non-fatal outcomes in a large prospective Australian study.
机构信息
National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Mills Road, Acton, ACT, 2601, Australia.
The Sax Institute, Sydney, Australia.
出版信息
BMC Med. 2019 Jul 3;17(1):128. doi: 10.1186/s12916-019-1351-4.
BACKGROUND
Tobacco smoking is a leading cause of cardiovascular disease (CVD) morbidity and mortality. Evidence on the relation of smoking to different subtypes of CVD, across fatal and non-fatal outcomes, is limited.
METHODS
A prospective study of 188,167 CVD- and cancer-free individuals aged ≥ 45 years from the Australian general population joining the 45 and Up Study from 2006 to 2009, with linked questionnaire, hospitalisation and death data up to the end of 2015. Hazard ratios (HRs) for hospitalisation with or mortality from CVD among current and past versus never smokers were estimated, including according to intensity and recency of smoking, using Cox regression, adjusting for age, sex, urban/rural residence, alcohol consumption, income and education. Population-attributable fractions were estimated.
RESULTS
During a mean 7.2 years follow-up (1.35 million person-years), 27,511 (crude rate 20.4/1000 person-years) incident fatal and non-fatal major CVD events occurred, including 4548 (3.2) acute myocardial infarction (AMI), 3991 (2.8) cerebrovascular disease, 3874 (2.7) heart failure and 2311 (1.6) peripheral arterial disease (PAD) events. At baseline, 8% of participants were current and 34% were past smokers. Of the 36 most common specific CVD subtypes, event rates for 29 were increased significantly in current smokers. Adjusted HRs in current versus never smokers were as follows: 1.63 (95%CI 1.56-1.71) for any major CVD, 2.45 (2.22-2.70) for AMI, 2.16 (1.93-2.42) for cerebrovascular disease, 2.23 (1.96-2.53) for heart failure, 5.06 (4.47-5.74) for PAD, 1.50 (1.24-1.80) for paroxysmal tachycardia, 1.31 (1.20-1.44) for atrial fibrillation/flutter, 1.41 (1.17-1.70) for pulmonary embolism, 2.79 (2.04-3.80) for AMI mortality, 2.26 (1.65-3.10) for cerebrovascular disease mortality and 2.75 (2.37-3.19) for total CVD mortality. CVD risks were elevated at almost all levels of current smoking intensity examined and increased with smoking intensity, with HRs for total CVD mortality in current versus never smokers of 1.92 (1.11-3.32) and 4.90 (3.79-6.34) for 4-6 and ≥ 25 cigarettes/day, respectively. Risks diminished with quitting, with excess risks largely avoided by quitting before age 45. Over one third of CVD deaths and one quarter of acute coronary syndrome hospitalisations in Australia aged < 65 can be attributed to smoking.
CONCLUSIONS
Current smoking increases the risk of virtually all CVD subtypes, at least doubling the risk of many, including AMI, cerebrovascular disease and heart failure. Paroxysmal tachycardia is a newly identified smoking-related risk. Where comparisons are possible, smoking-associated relative risks for fatal and non-fatal outcomes are similar. Quitting reduces the risk substantially. In an established smoking epidemic, with declining and low current smoking prevalence, smoking accounts for a substantial proportion of premature CVD events.
背景
吸烟是心血管疾病（CVD）发病率和死亡率的主要原因。关于吸烟与不同类型 CVD 的关系，包括致命和非致命结局的证据有限。
方法
本研究前瞻性纳入了澳大利亚一般人群中 188167 名年龄≥45 岁、无 CVD 和癌症的个体，这些个体参加了 45 岁及以上研究，时间为 2006 年至 2009 年，随访至 2015 年底，通过问卷调查、住院和死亡数据进行随访。使用 Cox 回归模型估计了当前和过去吸烟者与从不吸烟者相比，住院或死于 CVD 的风险比（HR），包括根据吸烟强度和吸烟时间进行估计，同时还调整了年龄、性别、城乡居住、饮酒量、收入和教育程度等因素。估计了人群归因分数。
结果
在平均 7.2 年（135 万个人年）的随访期间，共发生 27511 例（粗率为 20.4/1000 人年）致命和非致命性主要 CVD 事件，包括 4548 例（3.2）急性心肌梗死（AMI）、3991 例（2.8）脑血管疾病、3874 例（2.7）心力衰竭和 2311 例（1.6）外周动脉疾病（PAD）事件。基线时，8%的参与者为当前吸烟者，34%的参与者为过去吸烟者。在 36 种最常见的特定 CVD 亚型中，29 种的事件发生率在当前吸烟者中显著增加。当前吸烟者与从不吸烟者相比，调整后的 HR 如下：任何主要 CVD 的 HR 为 1.63（95%CI 1.56-1.71），AMI 的 HR 为 2.45（2.22-2.70），脑血管疾病的 HR 为 2.16（1.93-2.42），心力衰竭的 HR 为 2.23（1.96-2.53），PAD 的 HR 为 5.06（4.47-5.74），阵发性心动过速的 HR 为 1.50（1.24-1.80），心房颤动/扑动的 HR 为 1.31（1.20-1.44），肺栓塞的 HR 为 1.41（1.17-1.70），AMI 死亡率的 HR 为 2.79（2.04-3.80），脑血管疾病死亡率的 HR 为 2.26（1.65-3.10），总 CVD 死亡率的 HR 为 2.75（2.37-3.19）。在目前的吸烟强度水平下，几乎所有 CVD 风险都有所升高，并随着吸烟强度的增加而增加，当前吸烟者与从不吸烟者相比，总 CVD 死亡率的 HR 分别为 1.92（1.11-3.32）和 4.90（3.79-6.34），每日吸烟 4-6 支和≥25 支的风险。戒烟后风险会降低，大多数情况下，戒烟年龄低于 45 岁可避免这些风险。澳大利亚 65 岁以下人群中，1/3 以上的 CVD 死亡和四分之一的急性冠状动脉综合征住院可归因于吸烟。
结论
当前吸烟增加了几乎所有 CVD 亚型的风险，使许多 CVD 的风险增加了一倍以上，包括 AMI、脑血管疾病和心力衰竭。阵发性心动过速是新发现的与吸烟有关的风险。在可比较的情况下，致命和非致命结局的与吸烟相关的相对风险相似。戒烟可显著降低风险。在一个已建立的吸烟流行中，随着吸烟率的下降和吸烟率的降低，吸烟导致了相当一部分的 CVD 事件。
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