饮酒和心血管健康-课件

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,饮酒和心血管健康,刘品明,M.D., Ph.D.,中山大学附属第二医院心内科,考虑红葡萄酒因素后,法国反常现象,Markus,Flesch, et al. Alcohol and the risk of myocardial infarction. Basic Res,Cardiol, 2001,96:128-135,法国人在,CHD,危险因素与其他西方国家相仿的背景下，,CHD,死亡率显著低于这些国家,吸烟者,不吸烟者,既往吸烟者,Markus F, et al. Alcohol and the risk of myocardial infarction. Basic Res,Cardiol, 2001,96:128-135,饮酒与全因死亡的相对风险,适量饮酒与总死亡率的关系,全因死亡风险,RR,每日饮酒量,Boffetta,P,Garfinkel,L. Alcohol drinking and mortality among men enrolled in an American Cancer Society prospective study. Epidemiology, 1990;1:342-348.,OKeefe, J. H. et al. J Am Coll Cardiol,2007,50:1009-1014,饮酒量与全因死亡率：,J,型或,U,型曲线,饮酒量与心肌梗死、卒中的风险,OKeefe, J. H. et al. J Am Coll Cardiol,2007,50:1009-1014,适量饮酒有益于心血管健康,啤酒,350ml,（酒精含量,4.5,左右）,葡萄酒,120ml,（酒精含量,12,左右）,烈性酒,30ml,（酒精含量,50,左右）,饮酒量的单位,单位：,drink/unit,地域差别,美国、加拿大等北美地区相当于,12g,酒精,西欧、澳大利亚相当于,10g,酒精,美国：,1,单位饮酒量大约相当于,1,单位饮酒量,适量饮酒的概念,美国：平均每日饮酒量女性不超过,1,单位，男性不超过,2,单位,澳大利亚：平均每日饮酒量男性不超过,4,单位（单日内不超过,6,单位）；女性不超过,2,单位（单日内不超过,4,单位），并建议每周有,1,2,日不饮酒,Light to moderate drinking,（少至中量饮酒）,适量饮酒，界定不同,饮酒与血压,适量饮酒并不增加健康人群患高血压的风险 （,NHANES 1990-2000,）,过量饮酒时，随饮酒量增加血压升高,每日酒精量超过,30g,可使高血压的患病率升高，每日饮酒,6,8,单位大约使收缩压升高,9.1mmHg,，舒张压升高,5.6mmHg,高血压人群，适量饮酒使心肌梗死发生率降低,Beulens JW, et al.,Alcohol consumption and risk for coronary heart disease among men with hypertension. Ann Intern Med 2007,146:10-19,饮酒与高血压人群心肌梗死风险,饮酒与血脂谱,HDL-C,水平与饮酒量呈剂量依赖性。每日饮酒,1,单位或,2,3,单位，,HDL-C,分别升高,5%,和,10%,。,过量饮酒却使,TG,升高，并呈剂量依赖性。,饮酒与,LDL,水平呈“,U”,型曲线关系。,适量饮酒饮酒对总胆固醇无显著影响,小分子,LDL,颗粒处于最低水平,饮酒与中、小分子,VLDL,呈负相关。,适量饮酒与大、中分子,HDL,颗粒正相关,饮酒影响着脂蛋白亚组分,Mukamal KJ, et al.,Alcohol consumption and lipoprotein subclasses in older adults. J,Clin,Endocrinol,Metab, 2007,92:2559-2566.,饮酒与血糖,适量饮酒减少健康人群糖尿病的发生率,适量饮酒使糖尿病患者的冠心病风险下降,过量饮酒或暴饮使糖尿病的发生率升高，且与糖尿病并发症相关,Copyright 2007 American College of Cardiology Foundation. Restrictions may apply.,OKeefe, J. H. et al. J Am Coll,Cardiol,2007, 50:1009-1014,饮酒与新发,2,型糖尿病风险,Tanasescu,M, et al. Alcohol consumption and risk of coronary heart disease among individuals with type 2 diabetes.,Curr,Diab,Rep.,2001;1(2):187-91.,饮酒与,2,型糖尿病患者的冠心病风险,Tanasescu,M,Hu,FB, Willett WC, et al. Alcohol consumption and risk of coronary heart disease among men with type 2 diabetes mellitus. J Am,Coll,Cardio1, 2001, 38:1836-1842.,适量饮酒降低冠心病的风险,饮酒与冠心病,少至适量饮酒可以降低冠心病发病率,30%,35%,，降低冠心病死亡率,30%,，降低全因死亡率,18%,INTER-HEART,研究揭示，不论地域、种族或性别，规律的适量饮酒均可降低心肌梗死的风险。,饮酒与,CHD,病死率,饮酒与,全因死亡率,饮酒与,CHD,发病率,饮酒与冠心病,Koppes LLJ, et al.,Meta-analysis of the relationship between alcohol consumption and coronary heart disease and mortality in type 2 diabetic patients.,Diabetologia, 2006, 49:648-652.,Copyright 2007 American College of Cardiology Foundation. Restrictions may apply.,OKeefe JH, et al. Alcohol and cardiovascular health: the razor-sharp double-edged sword. J Am,Coll,Cardiol,2007,50:1009-1014.,适量饮酒减轻冠状动脉钙化,饮酒与心力衰竭的风险,Framingham,心脏研究,Walsh CR, et al. Ann Intern Med, 2002;136:181-191,饮酒与射血分数,饮酒与脑卒中,适量饮酒与脑卒中发生呈显著负相关，主要减少缺血性卒中的发生,适量饮酒并不增加高血压患者缺血性卒中发生率,即使是适量饮酒也可能使出血性卒中发病率升高,前瞻性队列研究,纳入,21 870,饮酒男医师,平均随访,12.2,年,Berger K, et al. Light-to-Moderate Alcohol Consumption and the Risk of Stroke among U.S. Male Physicians. N Eng J Med, 1999,341:1557-1564,饮酒与脑卒中,饮酒量与缺血性脑卒中发病率,饮酒与缺血性卒中,OKeefe JH, et al. Alcohol and cardiovascular health: the razor-sharp double-edged sword. J Am,Coll,Cardiol, 2007, 50:1009-1014.,适量饮酒的效应机制,提高血浆,HDL-C,水平,抗凝及抗血小板聚集,增强胰岛素敏感性,抗炎,抗氧化,提高血浆,HDL-C,水平,加快胆固醇逆向转运速度,抑制,LDL-C,的氧化，促进病变部位脂质和胆固醇溢出，减少黏附分子表达,减少基质金属蛋白酶和组织因子的释放，抑制巨噬细胞的凋亡，抑制炎症细胞迁徙进入血管内皮；,改善脂代谢过程系列中的各种酶和蛋白的活性,饮酒量与,HDL-C,HDL-C,与载脂蛋白,A,输送速度,饮酒量与载脂蛋白,A,输送速度,适量饮酒升高,HDL,载体（载脂蛋白,A,和载脂蛋白,A,）的浓度，并增快其输送速率,De Oliveira e Silva ER, et al.,Alcohol consumption raises HDL cholesterol levels by increasing the transport rate of,apolipoproteins,A-I and A-II. Circulation, 2000, 102:2347-2352.,适量饮酒提高胆固醇逆向转运速率,纤维蛋白原、,vonWillebrand,因子、凝,血因子,水平、血浆粘稠度下降,纤溶酶原激活物抑制剂,-1,（,PAI-1,）及组织型纤溶酶原激活物（,t-PA,）水平升高,抑制血小板的聚集。,适量饮酒：,抗凝及抗血小板聚集,Markus F, et al. Alcohol and the risk of myocardial infarction. Basic Res,Cardiol, 2001 96: 128-135,饮酒可以抑制脂肪组织释放脂肪酸，减少骨骼肌,Krebs,循环中 底物的竞争从而改善葡萄糖代谢,使非糖尿病患者空腹及餐后胰岛素水平降低,降低糖尿病患者餐后血糖的升高幅度。,安慰剂组,OKeefe JH, et al. Alcohol and cardiovascular health: the razor-sharp double-edged sword. J Am,Coll,Cardiol, 2007, 50:1009-1014.,增强胰岛素敏感性,增强胰岛素敏感性,Model 1: adjusted for demographic (clinic, sex, ethnicity, age) and,lifestyle (smoking, diet, physical activity) variables,Model 2: also adjusted for BMI and waist circumference,*,*,Bell et al. Diabetes Care 2000. 23: 1630-36,.,CRP,与饮酒量呈“,U”,形曲线关系，每日饮酒,2,4,单位时,CRP,最低,饮酒减少肿瘤坏死因子,a,及白介素,1,的产生，增加抗炎因子白介素,10,的产生,葡萄酒中的镓酸通过抑制,P,选择素介导的炎症过程,OKeefe JH, et al. Alcohol and cardiovascular health: the razor-sharp double-edged sword. J Am,Coll,Cardiol, 2007, 50:1009-1014.,抗炎效应,一级预防,二级预防,抗氧化作用,葡萄酒中含有的多酚类、黄酮类等生理活性化合物有明显的抗氧化作用,饮葡萄酒组,对照组,Markus F, et al. Alcohol and the risk of myocardial infarction. Basic Res,Cardiol, 2001 96: 128-135,饮酒模式,暴饮使心血管事件及酒精相关问题明显增加，失去规律适量饮酒的心脏保护作用，甚至使心血管死亡增加,Markus F, et al. Alcohol and the risk of myocardial infarction. Basic Res,Cardiol, 2001 96: 128-135,Mukamal KJ, Conigrave KM, Mittleman MA, et a1.,Roles of drinking pattern and type of alcohol consumed in coronary heart disease in men. N,Engl,J Med, 2003, 348:109-118.,饮酒频率的影响,饮酒模式,进餐时饮酒模式，对心脏保护作用增强,进餐时饮酒降低高脂饮食引发的餐后内皮功能紊乱有关,进食饱和脂肪可以减缓酒精的吸收，减少血浆酒精浓度的波动。,Pownall,HJ. Alcohol: Lipid Metabolism and,Cardioprotection,.,Curr,Atheroscler,Rep.,2002; 4(2):107-12.,酒的种类,不同类型，诸如啤酒、红葡萄酒、白酒和烈性酒对心血管保护效应可能存在差异。,许多文献认定葡萄酒对于降低冠心病死亡率具有优势,少数报道饮用啤酒和白酒与心肌梗死负相关性更强,所有类型的酒精饮料均能降低心血管风险,饮用葡萄酒者受教育程度较高、吸烟较少、运动较多、饮食更均衡合理,Markus F, et al. Alcohol and the risk of myocardial infarction. Basic Res,Cardiol, 2001 96: 128-135,Mukamal KJ, et al. et a1.,Roles of drinking pattern and type of alcohol consumed in coronary heart disease in men. N,Engl,J Med, 2003, 348:109-118.,遗传因素影响酒精体内代谢,乙醇,乙醛,乙酸,ADH,：乙醇脱氢酶；,ALDH,：乙醛脱氢酶,ADH,和,ALDH,的基因多态性，尤其是,ADH3,编码,ADH3,的基因型：快代谢型,1,和慢代谢型,2,纯合型,2,饮酒者效益最显著，含有最高的血浆,HDL,浓度,起心血管保护作用是乙醇,饮酒与种族,黄种人较白种人更多拥有快代谢型的,ADH,和慢代谢型的,ALDH,黄种人饮酒后乙醇快速代谢为乙醛，伴随着更多自由基、活性氧簇的产生和脂质过氧化,乙醛缓慢代谢生成乙酸排出体外，致使体内乙醛堆积，东亚人群饮酒后更容易出现面红、胸痛不适、严重低血压等毒副作用,。,饮酒和日本人卒中、冠心病死亡,混杂因素,不饮酒人群冠心病危险因素较多,因病戒酒或不宜饮酒的人群归入到不饮酒人群,饮酒量、方式、种类的不断变化,调查方式及各种问卷设计的异质性；等等,有待设计严谨的前瞻性随,机对照的临床试验来验证,?,酒精相关问题,扩张型心肌病、心律失常、心力衰竭、猝死、高血压、高甘油三酯血症,引发酒精性肝病、肝硬化、胃肠道肿瘤及乳腺癌等,使精神障碍相关问题、交通事故等社会问题增多,比较肯定的相关肿瘤,相对风险（,RR,）,口腔及咽部,喉,食管,肝,乳腺,3.7,2.7,1.8,2.5,1.5,过量饮酒或暴饮,建议,不提倡不饮酒人群开始饮酒，以通过饮酒而预防心血管病,不鼓励适量饮酒人群戒酒,对于过量饮酒及暴饮的人群，力劝其限酒或戒酒,衡量冠心病危险因素、社会经济状况、个体差异和出现酒精相关问题的概率，科学指导,Thank you!,It has long been recognized that the problems with alcohol relate not to the use of a bad thing, but to the abuse of a good thing.,Abraham Lincoln,