最新声明:打鼾非小事!这些心血管疾病都该查睡眠呼吸障碍

2022-08-10 中国医学论坛报今日循环 中国循环杂志

声明中指出,睡眠呼吸障碍可增加心血管病风险,严重影响生活质量,产生恶劣情绪。

近日,美国心脏协会(AHA)发表科学声明,将睡眠呼吸障碍作为房颤、室性心动过速和缓慢性心律失常的危险因素,尤其指出,睡眠呼吸障碍可能是预防房颤发生、发展和复发的新靶点。

睡眠呼吸障碍包括阻塞性睡眠呼吸暂停(OSA)、中枢性睡眠呼吸暂停(CSA)和潮式呼吸(又称陈施呼吸)。

声明中指出,睡眠呼吸障碍可增加心血管病风险,严重影响生活质量,产生恶劣情绪。

具体机制

睡眠呼吸障碍导致反复低氧、胸内压改变、自主神经紊乱、高碳酸血症和睡眠结构紊乱;如果不采取治疗,便会进一步导致进行性心房结构和电重构,继而发生心律失常。

01有房颤,应筛查睡眠呼吸暂停

基于社区的大规模队列研究表明,房颤患者睡眠呼吸障碍患病率高达21%~74%,中重度睡眠呼吸障碍患者发生房颤的概率几乎是正常人的5倍。

另有多项研究发现,对于睡眠呼吸障碍患者,夜间低氧是发生房颤的重要风险因素。

声明强调,医生和大众必须了解,睡眠呼吸障碍能触发心律失常,尤其是房颤。

对于有打鼾、难治性高血压以及房颤患者,尤其是持续性房颤患者,检测到睡眠呼吸障碍的可能性很高。

中国医学科学院阜外医院乔树宾教授等研究发现,阻塞性睡眠呼吸暂停在非梗阻性肥厚型心肌病患者中常见,而且心血管代谢异常及心脏重构程度随疾病的严重程度增加而增加。应该对该类患者筛查阻塞性睡眠呼吸暂停。

指南也建议,针对房颤患者应筛查阻塞性睡眠呼吸暂停,以优化房颤治疗策略,也推荐了检查睡眠呼吸障碍的方法。

研究表明,在接受消融的房颤患者中,有24%~50%的患者存在睡眠呼吸障碍,且与房颤复发增加有关。

而使用呼吸机(持续气道正压通气)治疗睡眠呼吸暂停,可减少房颤复发和进展至永久性房颤。Meta分析也表明,持续气道正压通气对房颤患者有益,尤其是针对年轻、肥胖和男性患者更有效。

上述研究结果虽然一致表明治疗睡眠呼吸障碍能改善房颤患者预后,但尚未在大规模随机对照临床试验中得到证实。

02心脏猝死风险增加

流行病学研究发现,睡眠呼吸障碍患者非持续性室性心动过速的发生率升高1倍,复杂心室早搏的发生率升高50%。

一项观察1万人平均随访5.3年的研究发现,夜间缺氧是心脏猝死的独立危险因素。

欧洲心脏病学会(ESC)指南建议,睡眠呼吸暂停和缺氧可能是睡眠呼吸障碍患者发生心脏猝死的危险因素,并建议将OSA纳入心脏猝死的风险分层(Ⅱb级)。

03睡眠中缓慢性心律失常应排除睡眠呼吸障碍

在睡眠相关和睡眠呼吸障碍患者中,缓慢性心律失常包括:窦性心动过缓、窦性停搏,以及II度房室传导阻滞。

睡眠呼吸障碍患者中,深夜窦性心动过缓的患病率为7.2%~40%,Ⅱ度或Ⅲ度房室传导阻滞为1.3%~13.3%,窦性停搏为3.3%~33%。

ESC指南建议

在缓慢性心律失常的鉴别诊断时,应考虑睡眠呼吸障碍。

AHA声明|类建议

  • 睡眠期间发生心动过缓或传导阻滞的患者应进行睡眠呼吸障碍筛查;

  • 患有睡眠相关心动过缓或传导阻滞并有睡眠呼吸障碍的患者,应接受睡眠呼吸障碍治疗;

  • 对于因心动过缓或传导障碍接受或正在考虑永久起搏器的患者,筛查睡眠呼吸障碍是合理的。

END

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    2023-02-19 贵阳
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    2022-08-12 weiz

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