用于睡眠呼吸中止症的CPAP或许可预防高血压


  【24drs.com】两篇研究确认了阻塞性睡眠呼吸中止症(OSA)和高血压的关联,并指出运用连续阳压呼吸道疗法(CPAP)或许可降低高血压风险。
  
  这些研究刊载于5月23/30日版的JAMA,编辑评论作者指出,这些资料大致支持OSA和高血压之间的关联。
  
  华盛顿大学的Vishesh K. Kapur医师和Edward M. Weaver医师指出,OSA的治疗可能不只可以降低高血压(平均效果为中等),如果有后续研究确认,或许还可以预防有风险患者的高血压;因此,对于已经发生或者有发生高血压风险的病患,OSA可作为潜在的治疗原因且有临床重要结果。
  
  西班牙Miguel Servet大学医院的Jose M. Marin医师等人在他们的报告中发表一篇观察世代的结果,研究对象是在1994年1月1日至2000年12月31日之间、转诊进行多层次睡眠检查的1,889名无高血压病患。
  
  在1,579名OSA病患中,依据国家治疗指引,462人不适合CPAP治疗,195人适合但是拒绝CPAP,98人适合且开始CPAP但是未确实执行,824人适合且遵循CPAP。
  
  追踪期间中位数为12.2年,705名病患(37.3%)发生高血压;Marin医师表示,与没有OSA者相比,未治疗之OSA和新发生的高血压风险增加有关,而使用CPAP治疗和新发生之高血压风险降低有关。
  
  表、OSA之高血压风险
组别 校正风险比(95%信心区间)
不适用CPAP 1.33 (1.01 - 1.75)
拒绝CPAP 1.96 (1.44 - 2.66)
未落实CPAP 1.78 (1.23 - 2.58)
CPAP治疗 0.71 (0.53 - 0.94)

  Marin医师表示,对于新发生的高血压,OSA看来是个可修饰的风险因素,这类结果的临床关联是,OSA虽然在西方人有高盛行率,绝大多数仍然无法识别和未经治疗的。
  
  另一篇报告中,西班牙Recerca Biomedica研究中心的Ferran Barbe医师等人报告了一篇随机控制试验(RCT)结果,检视了CPAP对723名有OSA但是没有日间嗜睡之成人的偶发高血压或心血管事件的影响;CPAP组有357名成人,对照组(一般照护)有366人。
  
  在追踪中位数4年之间,CPAP组有68例新发生高血压和28例心血管事件,对照组则是79例新发生高血压和31例心血管事件。
  
  CPAP组中,高血压和心血管事件发生率倾向较低,但是未达统计上的显著意义。每100人-年之新发生高血压或心血管事件的发生率,CPAP组为9.20 (95%信心区间[CI],7.36 - 11.04),对照组为11.02 (95% CI,8.96 - 13.08)(发生率密度比为0.83;95% CI,0.63 - 1.1;P = .20)。
  
  不过,研究者指出,他们的研究未能显出显著差异,若有更大型或追踪更久的研究,或许可以确认治疗和结果之间的显著关联。
  
  他们指出,事后分析认为,CPAP治疗可降低每晚使用CPAP 4小时以上者的高血压或心血管事件的发生率。
  
  Barbe医师表示,这是第一篇聚焦在CPAP治疗对预防睡眠呼吸中止患者之高血压和心血管事件的RCT,我们的结果显示,当病患夜间使用CPAP达4小时以上,则高血压和心血管事件发生率降低。
  
  Barbe医师建议,如果你要预防心血管事件或发生高血压,督促你的病患每晚使用CPAP治疗超过4小时。
  
  Kapur 医师和Weaver医师在编辑评论中写道,整体看来,这些研究增加了「OSA患者有偶发高血压风险」的证据,且提出强烈但未定论的证据认为,CPAP治疗或许可降低风险;在睡眠困难的OSA病患中,CPAP治疗处方的效果依旧不清楚。
  
  他们也指出,有关OSA、高血压和治疗还有许多问题:
  * 哪里些属于适合与有反应者(例如OSA严重度分组、入睡和未入睡病患、地缘区分)?
  * 多常使用CPAP才会有重要的治疗效果?
  * 其它OSA治疗的影响?
  
  Kapur医师和Weaver医师表示,这些问题将需要一些可行的RCT且进行次组分析、以及对照适当的观察研究,也需要一些新方法,如治疗戒断规范。
  
  尽管有这些问题,他们结论表示,相当多证据支持确认并治疗OSA对改善症状、生活质量、和心血管事件的重要性。
  
  资料来源:http://www.24drs.com/professional/list/content.asp?x_idno=6831&x_classno=0&x_chkdelpoint=Y
  

CPAP for Sleep Apnea May Prevent New Hypertension

By Megan Brooks
Medscape Medical News

May 23, 2012 — A pair of studies released this week confirm an association between obstructive sleep apnea (OSA) and hypertension, and hint that adherent continuous positive airway pressure (CPAP) therapy may reduce the risk for new-onset hypertension.

The studies appear in the May 23/30 issue of JAMA. The authors of an accompanying editorial point out that the data "generally support" a causal link between OSA and hypertension.

Vishesh K. Kapur, MD, MPH, and Edward M. Weaver, MD, MPH, both from the University of Washington in Seattle, add that treatment of OSA "may not only reduce blood pressure (although modestly on average), but if confirmed by future studies also may prevent hypertension in at-risk patients. Thus, OSA deserves attention in patients with or at risk of developing hypertension as a potentially treatable cause of hypertension as well as other clinically important outcomes."

A Modifiable Risk Factor

In their paper, Jose M. Marin, MD, from the Hospital Universitario Miguel Servet in Zaragoza, Spain, and colleagues report results of an observational cohort study of 1889 adults without hypertension referred for polysomnography between January 1, 1994, and December 31, 2000.

Among the 1579 patients with OSA, 462 were ineligible for CPAP therapy according to national treatment guidelines, 195 were eligible but declined CPAP, 98 were eligible and started CPAP but were nonadherent, and 824 were eligible and adhered to CPAP.

During a median follow-up of 12.2 years, 705 patients (37.3%) developed hypertension. "Compared with participants without OSA, untreated OSA was associated with an increased risk of new-onset hypertension, whereas treatment with CPAP therapy was associated with a lower risk of new-onset hypertension," Dr. Marin told Medscape Medical News.

Table. Risk for Hypertension With OSA

Group Adjusted Hazard Ratio (95% Confidence Interval)
Ineligible for CPAP 1.33 (1.01 - 1.75)
Declined CPAP 1.96 (1.44 - 2.66)
Nonadherent to CPAP 1.78 (1.23 - 2.58)
CPAP therapy 0.71 (0.53 - 0.94)

"OSA appears to be a modifiable risk factor for new-onset hypertension. Such findings are clinically relevant considering that OSA, despite a high prevalence in Western populations, remains overwhelmingly unrecognized and untreated," Dr. Marin said.

In a separate paper, Ferran Barbe, MD, from the Institut de Recerca Biomedica, Lleida, Spain, and colleagues report results of a randomized, controlled trial (RCT) testing the effects of CPAP on incident hypertension or cardiovascular events in 723 adults with OSA but without daytime sleepiness. There were 357 adults in the CPAP group and 366 in the control group (usual care).

During follow-up lasting a median of 4 years, there were 68 cases of new hypertension and 28 cardiovascular events in the CPAP group, compared with 79 cases of new hypertension and 31 cardiovascular events in the control group.

In the CPAP group, there was a trend toward a reduction in the incidence of hypertension and cardiovascular events that did not reach statistical significance. The incidence of new hypertension or cardiovascular event per 100 person-years was 9.20 (95% confidence interval [CI], 7.36 - 11.04) in the CPAP group vs 11.02 (95% CI, 8.96 - 13.08) in the control group (incidence density ratio, 0.83; 95% CI, 0.63 - 1.1; P = .20).

However, the investigators note that their study may have limited power to detect a significant difference, and that a larger study or longer follow-up might have been able to identify a significant association between treatment and outcome.

They point out that a post hoc analysis "suggested that CPAP treatment may reduce the incidence of hypertension or cardiovascular events in patients with CPAP adherence of 4 h/night or longer."

"This is the first RCT to focus on the effects of CPAP treatment in the prevention of hypertension and cardiovascular events in patients with sleep apnea," Dr. Barbe added in comments to Medscape Medical News. "Our results show that when the patients use CPAP for more than 4 hours per night there is a reduction in the incidence of hypertension and cardiovascular events."

Dr. Barbe's advice: "If you want to prevent cardiovascular events or the development of hypertension, push your patients to use CPAP treatment for more than 4 hours per night."

Questions Remain

In their editorial, Dr. Kapur and Dr. Weaver write that, "Taken together, these studies augment the evidence that the presence of OSA poses a risk for incident hypertension and provide strong but not definitive evidence that CPAP therapy may reduce the risk. In nonsleepy patients with OSA, the effect of CPAP therapy prescription remains unclear."

They also note that many questions remain regarding OSA, hypertension, and treatment, including:

  • What are the susceptible and responsive subgroups (eg, OSA severity subgroups, sleepy vs nonsleepy patients, and demographic subgroups)?
  • How much CPAP use is necessary for an important treatment effect?
  • What are the effects of other OSA treatments?

These questions, Dr. Kapur and Dr. Weaver say, "will require RCTs when feasible, subgroup analyses within these trials, and well-controlled observational studies. Novel approaches are needed, such as treatment withdrawal protocols."

Despite lingering questions, they conclude, "considerable evidence supports the role of identification and treatment of OSA to improve symptoms, quality of life, and cardiovascular end points."

Both studies were supported by grants from the Instituto Carlos III, Ministry of Health, Madrid, and the Spanish Society of Respiratory Medicine. The study by Dr. Barbe was also supported by Resmed (Bella Vista, Australia), Air Products-Carburos Metalicos (Barcelona), Respironics (Murrysville, Pennsylvania) and Breas Medical (Madrid). The study authors have disclosed no relevant disclosures. Dr. Kapur reported having owned stock within the last 3 years in Merck, Johnson & Johnson, and Bristol-Myers Squibb. Dr. Weaver had disclosed no relevant financial relationships.

JAMA. 2012;307:2161-2168, 2169-2176, 2197-2198.

    
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