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금연이후 매우 낮아진 혈압, 흡연과 혈압과의 관계는?


40대 중반 여자

2019.4월 초진, 당시 telmisartan 40 mg, amlodipine 5 mg 유지중 (혈압약 투약한지 3개월째)

진료시 혈압 132/74

같은 성분 유지하면서

5월 132/80

7월 132/78

9월 자동 혈압 98/60, 진료실 혈압 90/58

"3개월 전부터 금연했다. 한달전부터 혈압이 낮아지기 시작했다. 2주전부터 수축기 혈압이 90 내외였다."

"체중 변화는 없다."

감량하여 telmisartan만 유지하고 추적하기로 하였다.

SMOKING AND HYPERTENSION — Tobacco use is the most common cause of avoidable cardiovascular mortality worldwide [1]. There are now 1.3 billion cigarette smokers, 82 percent in developing countries, and if current practices continue, there will be an estimated one billion tobacco-related deaths during the 21st century. The immediate noxious effects of smoking are related to sympathetic nervous overactivity, which increases myocardial oxygen consumption through a rise in blood pressure, heart rate, and myocardial contractility [2].

Chronically, cigarette smoking induces arterial stiffness which may persist for a decade after smoking cessation [3]. The incidence of hypertension is increased among those who smoke 15 or more cigarettes per day [4], and the coexistence of hypertension and smoking decreases left ventricular function in asymptomatic people [5]. 만성적으로 흡연은 동맥의 경직도를 증가시키고, 금연 후에도 그 효과는 10여년 지속된다. 15개피 이상 하루에 흡연하면 혈압의 발생이 증가한다고 보고된다.

With each cigarette, the blood pressure rises transiently and the pressor effect may be missed if the blood pressure is measured 30 minutes after the last smoke. The transient rise in blood pressure may be most prominent with the first cigarette of the day even in habitual smokers. In one study of normotensive smokers, there was an average elevation in systolic pressure of 20 mmHg after the first cigarette (figure 1) [6]. Furthermore, ambulatory blood pressure monitoring suggests an interactive effect between smoking and coffee drinking in patients with mild primary hypertension (formerly called "essential" hypertension), resulting in a mean elevation in daytime systolic pressure of approximately 6 mmHg [7]. 흡연후 혈압이 올라가므로 혈압 측정 전 30분 이내에 흡연하지 않아야 한다.

However, habitual smokers generally have lower blood pressures than nonsmokers as observed in most [8,9], but not all [10], studies. The mild reduction in blood pressure in smokers is related to decreased body weight [11]. Support for this observation is the higher body weight and increased blood pressure among former smokers versus that observed among never-smokers [12]. A vasodilator effect of cotinine, the major metabolite of nicotine, also may contribute to the lower blood pressure [13].

그러나, 만성 흡연자에서 낮은 혈압을 보이는 경우가 있기도 한데, 이는 두 군간에 몸무게 차이의 변수가 있어서 인 것으로 생각된다. 니코틴의 대사산물인 cotinine이 혈관 확장으로 인해 혈압을 낮출수가 있다.

Despite these observations, smoking should be avoided in any hypertensive patient because it can markedly increase the risk of secondary cardiovascular complications and enhance the progression of renal insufficiency [14,15]. An example of the latter effect was observed in one prospective study (with a mean follow-up of 35 months) that examined the factors associated with alterations in renal function among 53 hypertensive patients in whom the serum creatinine concentration rose from 1.5 to 1.9 mg/dL (133 to 168 µmol/L) despite a significant reduction in the target mean blood pressure (127 to 97 mmHg) [14]. Smoking was the most significant independent factor underlying progressive renal disease (serum creatinine 1.5 and 2.1 mg/dL [133 and 186 µmol/L] at the beginning and end of the study for smokers, respectively, versus 1.25 and 1.32 mg/dL [110 and 117 µmol/L] for nonsmokers, respectively). The mechanism underlying this adverse effect is unclear but may be related to the transient increase in systemic blood pressure with smoking being transmitted to the glomerulus, resulting in glomerular hypertension.

Cessation of smoking can rapidly lower the risk of coronary heart disease by 35 to 40 percent; this benefit is independent of the duration of smoking. It is unclear whether cessation of smoking has a similar benefit in helping preserve renal function.

만성 흡연과 혈압 발생과의 관계는 보고에 따라 다르다.

흡연에 의해 혈압 발생이 증가한다는 중국 연구, 2012

https://www.nature.com/articles/jhh2011111

금연에 의해 혈관 경직성이 오래 지속되기 때문에 혈압이 떨어진다고 할 수 없겠으나, 상기 환자는 금연 후 약 40의 수축기 혈압 감소 현상을 보여 혈압약을 조절하였다. 추후 중지할 수 있을지 관찰이 필요하다.

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동대문구 답십리 우리안애, 우리안愛 내과, 건강검진 클리닉 내과 전문의 전병연


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