文献摘要

阻塞性睡眠呼吸中止病患的上呼吸道手術及心血管生物指標的改善與風險之關聯性
Association of upper airway surgery and improved cardiovascular biomarkers and risk in OSA

Volume 4, Issue 4

關鍵字 :
阻塞性睡眠呼吸中止,睡眠呼吸中止手術,手術結果, Obstructive sleep apnea, surgical treatment of obstructive sleep apnea, outcomes

作者 :
Yingjun Qian, MD, PhD; Jianyin Zou, MD, PhD; Huajun Xu, MD, PhD; Huaming Zhu, MD; Lili Meng, MD; Suru Liu, MD, PhD; Hongliang Yi, MD, PhD; Jian Guan, MD, PhD ; Shankai Yin, MD, PhD; Stefan Gräbel, MD, PhD; Heidi Olze, MD, PhD

譯者 :
嘉義長庚醫院 耳鼻喉科 徐正明 醫師

摘要:


Objectives: To evaluate the association between upper airway surgery and changes of cardiological metabolic biomarkers and the overall cardiovascular risk in obstructive sleep apnea (OSA), and to define factors associatedwith better cardiovascular outcomes.


Methods: A total of 161 patients with newly diagnosed OSA who underwent classical or modified uvulopalatopharyngoplasty with or without genioglossus advancement and hyoid suspension were included. The pre- and postoperative (at least 6 months later) assessments, including polysomnography, measurement of glucose and lipids, blood pressure, and overall cardiovascular risk (as estimated by Framingham Risk Scores), were compared. We accounted for multiple comparisons with the use of the Benjamini-Hochberg correction.


Results: The mean follow-up time was 2.5  1.9 years. The apnea hypopnea index decreased significantly in the entire cohort (mean changes with 95% confidence intervals were [-25.3 (-29.5, -21.0) events/hour, P < 0.001.] We also noted decreases in the ageadjusted Framingham Risk Scores [-2.5% (-4.0%, -1.0%), P < 0.001] as well as single cardiometabolic biomarkers, including glucose [-0.50 (-0.70, -0.30) mmol/L, P < 0.001], total cholesterol [-0.46 (-0.65, -0.28) mmol/L, P < 0.001], triglycerides [-0.56, (-0.99,-0.14) mmol/L, P = 0.014], low-density lipoprotein cholesterol [-0.27, (-0.43, -0.11) mmol/L, P = 0.002], apolipoprotein B [-0.10 (-0.14, -0.07) g/L, P < 0.001], systolic blood pressure [-3.58 (-6.02, -1.14) mmHg, P = 0.007], and diastolic blood pressure [-3.25

(-5.47, -1.02) mmHg, P = 0.008] after surgery. Patients with preoperative metabolic abnormalities exhibited better postoperative risk profiles changes (P < 0.001). In addition, associations were found between Δapolipoprotein B, Δsystolic blood pressure, and improvements in nocturnal oxygen level after surgery.


Conclusion: OSA-related upper airway surgery was associated with improvements in cardiological metabolic biomarker levels and the overall cardiovascular risk, especially in patients with both OSA and metabolic disorders. The changes in biomarker levels may be associatedwith improved oxygen saturation after surgery.

專家評論:


阻塞性睡眠呼吸中止患者的上呼吸道手術及心血管生物指標的改善與風險之關聯性


嘉義長庚醫院 耳鼻喉科 徐正明醫師


阻塞性睡眠呼吸暫停 (obstructive sleep apnea, OSA) 的特徵是在睡眠期間,反覆出現部分或完全氣道阻塞,導致間歇性氧飽和度下降和睡眠中斷。此疾病影響約 2% - 4% 的成人,並且與死亡率的升高相關,尤其是與心血管疾病 (cradiovascular disease, CVD) 相關的疾病。因夜間缺氧和與睡眠中斷所造成的睡眠質量降低,在 OSA 患者伴隨的代謝併發症(包括高血壓,高血糖和血脂異常)的形成有著重要的病生理作用。因此有效的 OSA 治療可降低心臟代謝風險。本篇目的在於評估上呼吸道手術與心臟病代謝生物標誌物的變化,和睡眠呼吸暫停的相關性,以及找出心血管標誌好轉的相關因素。


本篇研究回溯上海交通大學人民第六醫院耳鼻喉科的 161 例新診斷為 OSA 的患者,自 2002 3 月至 2014 2 月,共有 147 名患者(82 位男性,65 位女性),接受傳統或改良的懸壅顎咽部整形術 (uvulopalatopharyngoplasty) 或有加上頦舌肌前移 (genioglossus advancement) 和舌骨懸吊術 (hyoid suspension)。術前及術後至少經過 6 個月評估,包括多項式睡眠檢查 (polysomnography, PSG)、血糖和血脂測定、血壓、心血管危險度評估總分 (Framingham Risk Scores, FRS),最後使用 Benjamini Hochberg correction 進行多次比較;平均追蹤時間為 2.5 ± 1.9 年。在全部患者中,呼吸暫停/低通氣指數 (apnea / hypopnea index, AHI) 顯著下降 25.3 事件數/小時 (95% CI -29.5, -21.0, p < 0.001)。我們還注意到年齡調整後的 Framingham 風險評分降低了 2.5% (95% CI -4.0%, -1.0%, p < 0.001)。以及心臟代謝生物標誌改善,包括葡萄糖減少 0.50 mmol / L (95% CI -0.70, -0.30, p < 0.001)、總膽固醇減少 0.46 mmol / L (95% CI -0.65, -0.68, p < 0.001)、三酸甘油酯減少 0.56 mmol / L (95% CI -0.99, -0.14, p = 0.014)、低密度脂蛋白膽固醇降低 0.27 mmol / L (95% CI -0.43, -0.11, p = 0.002)、缺脂脂蛋白 B 降低 0.10 g / L (95% CI -0.14, -0.07, p < 0.001)、收縮壓降低 3.58 mmHg(95% CI -6.02, -1.14, p = 0.007)、和舒張壓降低 3.25 mmHg (95% CI -5.47, -1.02, p = 0.008)。術前代謝異常的患者,術後風險指數顯著改善 (p < 0.001),此外也發現缺脂脂蛋白 B 及收縮壓變化,與術後夜間血氧的改善存在關聯性。本研究的結論是:針對 OSA 患者的上呼吸道手術與心血管代謝生物標誌物水平,與整體心血管風險的改善具相關性;特別是在同時有 OSA 和代謝異常的患者中尤為顯著。手術後心臟生物標誌物水平的變化,可能與血氧飽和度的提高有關。


以前有關 OSA 治療的健康相關影響的研究,主要集中在非手術治療上,尤其是持續性正壓呼吸器 (continuous positive airway pressure, CPAP)。最近研究顯示,CPAP 略為但顯著地改善了許多代謝參數,包括脂質、胰島素不耐性 (insulin resistance)、高血壓等。儘管 CPAP 仍然是 OSA 的標準療法,但許多患者使用該裝置的時間不足,因此無法降低心血管疾病的風險。上呼吸道手術減少了夜間使用 CPAP 的需要,並且可以比 CPAP 更大程度地改善整體健康,但這個結論仍需要進一步研究。目前睡眠手術也隨著時代進步有很大的進展;尤其包括達文西的使用,把軟組織手術帶向另一個境界。利用各式的睡眠手術,若可以改善以往認為僅能透過吃藥控制的內科代謝疾病,那將為內科治療上帶來很重要的觀念改變,患者也更願意接受睡眠手術,然在此之前我們需要更多的研究來證明此一結果。


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