Sleep apnea: State of the art
Sleep apnea: State of the art
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DOI：
10.1016/j.tcm.2016.12.005
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发表时间：
2017-05-01
影响因子：
9.3
通讯作者：
Cowie, Martin R.
中科院分区：
文献类型：
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作者：
Cowie, Martin R.
许多有心血管疾病或有心血管疾病风险的患者有睡眠呼吸障碍(SDB)，这种呼吸可以是阻塞性的(伴随着上呼吸道的间歇性塌陷)，也可以是中枢性的(发作性的呼吸动力丧失)。SDB与睡眠障碍、低氧血症、血流动力学改变和交感神经激活有关。这类患者的预后比那些没有SDB的患者更差。针对SDB的基于面罩的气道正压治疗可以改善睡眠质量，并部分恢复睡眠和呼吸生理学，但最近关于SDB心血管结局的随机试验要么是中性的(阻塞性睡眠呼吸暂停)，要么表明中枢性睡眠呼吸暂停的危害可能来自猝死增加。人们正在探索治疗SDB的替代方法，包括植入性技术，但这些方法还没有在充分有效的随机对照研究中进行研究。国际指南建议对SDB进行筛查，这在临床实践中很容易完成，因为阻塞性睡眠呼吸暂停和日间嗜睡、顽固性高血压或心房颤动的患者可能会有治疗作用。还需要进一步的随机结果研究，以确定基于面罩的SDB治疗是否适用于慢性收缩性心力衰竭和阻塞性睡眠呼吸暂停患者、射血分数保留的心力衰竭患者以及失代偿性心力衰竭患者。这个案例表明，呼吸和睡眠指标改善的替代终点不再能被视为睡眠呼吸暂停和心血管疾病患者的适当治疗结果指标。
Many patient with, or at risk of, cardiovascular disease have sleep disordered breathing (SDB), which can be either obstructive (with intermittent collapse of the upper airway) or central (episodic loss of respiratory drive). SDB is associated with sleep disturbance, hypoxemia, hemodynamic changes, and sympathetic activation. Such patients have a worse prognosis than those without SDB. Mask based therapies of positive airway pressure targeted at SDB can improve measures of sleep quality and partially normalize the sleep and respiratory physiology, but recent randomized trials of cardiovascular outcomes in SDB have either been neutral (obstructive sleep apnea) or suggested the possibility of harm, likely from increased sudden death, in central sleep apnea. Alternative methods for the treatment of SDB are being explored, including implantable technologies, but these have not been studied in adequately powered randomized controlled studies. International guidelines recommend screening for SDB, which can be done easily in clinical practice, as there may be a role for the treatment of patients with obstructive sleep apnea and daytime sleepiness, or resistant hypertension, or atrial fibrillation. Further randomised outcome studies are required to determine whether mask-based treatment for SDB is appropriate for patients with chronic systolic heart failure and obstructive sleep apnea; for those with heart failure with preserved ejection fraction; and for those with decompensated heart failure. The case is made that no longer can the surrogate endpoints of improvement in respiratory and sleep metrics be taken as adequate therapeutic outcome measures in patients with sleep apnea and cardiovascular disease.