专家解读:美国心脏协会呼吁心血管疾病患者该查“睡眠杀手”

2021-06-23 梅斯医学综合报道 MedSci原创

6月21日,美国心脏协会(AHA)发布了一份关于阻塞性睡眠呼吸暂停和心血管病的科学声明。

6月21日,美国心脏协会(AHA)在《循环》期刊上发布了一份关于阻塞性睡眠呼吸暂停和血管病的科学声明。

阻塞性睡眠呼吸暂停(obstructive sleep apnea, OSA)是一种因睡眠过程中上气道反复塌陷引起的、以阻塞性呼吸暂停和低通气为特征的疾病。阻塞性睡眠呼吸暂停 (OSA) 的特点是反复发生完全性和部分性上呼吸道阻塞性事件,导致间歇性低氧血症、自主神经波动和睡眠片段化。

声明指出,分别约有 34% 和 17% 的中年男性和女性符合 OSA 的诊断标准。睡眠障碍在中老年人中很常见且诊断不足,其患病率因种族/民族、性别和肥胖状况而异。

1 阻塞性睡眠呼吸暂停的心血管并发症

在患有高血压、心力衰竭、冠状动脉疾病、肺动脉高压、心房颤动和中风的患者中,OSA 的患病率高达 40% 至 80%。尽管 OSA 在心脏病患者中的患病率很高,而且心脏病患者容易受到 OSA 相关压力源和不良心血管结果的影响,但 OSA 在心血管实践中往往未被充分认识和治疗。

声明指出,尽管阻塞性睡眠呼吸暂停患病率如此之高,尽管心血管病患者合并此病不良转归风险高,但这种病在临床上认识和治疗常常不足。这种病的症状包括打鼾、呼吸困难、睡眠碎片化和白天嗜睡,其危险因素包括肥胖、脖子粗、颅面部异常、吸烟、家族史以及夜间鼻塞等。

2 阻塞性睡眠呼吸暂停的症状和诊断

声明认为,尽管就筛查阻塞性睡眠呼吸暂停会改善临床转归尚无共识,但鉴于心血管病患者中患病率较高,而且有证据表明治疗阻塞性睡眠呼吸暂停有助于改善生活质量,还是为筛查和治疗阻塞性睡眠呼吸暂停提供了依据。

声明建议:

1. 建议对难治性或控制不佳的高血压患者、肺动脉高压患者以及复律或消融后复发心房颤动的患者,筛查阻塞性睡眠呼吸暂停。

2. NYHA心功能 II 至 IV 级的心力衰竭患者,尤其怀疑存在睡眠呼吸障碍或白天明显嗜睡,给予睡眠评估是合理的。

3. 快-慢综合征、室性心动过速、病态窦房结综合征患者以及心原性猝死幸存患者,如存在睡眠呼吸暂停体征或症状,可考虑筛查阻塞性睡眠呼吸暂停。

夜间发生心绞痛、心肌梗死心律失常以及置入的心律转复除颤器引起恰当电击的患者,尤其可能合并睡眠呼吸暂停。

4. 对于所有确诊阻塞性睡眠呼吸暂停的患者均应给予有效治疗,包括改善生活方式和行为,以及减重。

中国呼吸睡眠暂停基层指南指出,这类患者要注意改变睡姿和减重。

侧卧位睡眠可以改善舌后坠,从而降低咽部塌陷的可能性。

部分阻塞性睡眠呼吸暂停患者可通过侧卧位睡眠缓解症状,尤其是对于体位性阻塞性睡眠呼吸暂停患者。

减重可以改善呼吸暂停频率,减轻上气道塌陷,从而有效减轻阻塞性睡眠呼吸暂停的严重程度。

5. 如可能,可用持续气道正压通气治疗重度阻塞性睡眠呼吸暂停。

持续气道正压通气的原理是人为施加一定程度的气道内正压,从而维持气道通畅。这种治疗方法能有效改善患者夜间缺氧、鼾声等问题。

河北省人民医院高洁等进行的研究曾表明,无创持续气道正压通气治疗不仅可以减轻睡眠呼吸暂停的严重程度,还可以改善患者左心室功能。

6. 对于轻-中度阻塞性睡眠呼吸暂停,可应用口腔矫治器,使得睡眠期间下颌前移,带动压迫呼吸道的软组织前移,从而扩宽呼吸道,使呼吸变通畅。

7. 进行常规随访,包括整晚夜间睡眠测试,以评估治疗效果。

声明撰写专家指出,今后还需对家庭诊断工具加以改进,此外还应开展研究对阻塞性睡眠呼吸暂停患者进行更明确的心血管风险分层。

不论如何,目前需要提高对阻塞性睡眠呼吸暂停的筛查和治疗的认识,尤其是那些存在心血管病风险因素的患者。

参考资料:

[1]Yeghiazarians Y, Jneid H, Tietjens JR,et al. Obstructive Sleep Apnea and Cardiovascular Disease: A Scientific Statement From the American Heart Association. Circulation. 2021 Jun 21, https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000988

[2]高洁,王荣国,王立立,等. 无创持续气道正压通气对阻塞性睡眠呼吸暂停综合征患者心脏亚临床功能障碍的探究. 中国循环杂志, 2019, 34: 72-76.DOI:10.3969/j.issn.1000-3614.2019.01.011

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    2021-06-23 神盾医疗局局长Jack

    很重要的解读

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