阻塞性睡眠呼吸暂停相关性高血压患者血压节律影响因素分析

Analysis of influencing factors on circadian blood pressure of hypertensive patients with obstructive sleep apnea-hypopnea syndrome

目的 探讨肥胖、低氧与交感神经活性增加等多种因素对阻塞性睡眠呼吸暂停相关性高血压患者昼夜血压节律变化的影响。 方法 对诉有睡眠时打鼾、白天嗜睡、其他原因不能解释的唇舌发绀、难治性高血压或伴有不明原因的高血红蛋白血症的436例高血压住院患者，行多导睡眠监测（PSG），根据睡眠呼吸暂停低通气指数（AHI），将入选者分为高血压合并轻度阻塞性睡眠呼吸暂停低通气综合征（OSAHS）组131例（5≤AHI〈15）、高血压合并中度OSAHS组95例（15≤AHI〈30）、高血压合并重度OSAHS组95例（AHI≥30），以及单纯高血压对照组115例（AHI〈5）。对比四组患者的动态血压（ABPM）、PSG、尿离子、24 h尿香草扁桃酸（VMA）各参数，采用因子分析方法提取影响血压节律变化的公因子，多元线性回归分析影响血压节律变化的因素。 结果 四组患者年龄、颈围和腹围差异均有统计学意义（均P〈0.001）。重度组24 h平均收缩压（24 h SBP）［（137.0±16.8）mm Hg比（131.3±11.9）mm Hg、（131.3±13.2）mm Hg （1 mm Hg=0.133 kPa）］、日间平均收缩压［（140.8±16.8）mm Hg比（135.7±11.9）mm Hg、（135.3±13.5）mm Hg］和夜间平均收缩压［（130.9±17.0）mm Hg比（124.5±14.0）mm Hg、（124.3±13.2）mm Hg］均高于对照组、轻度组（均P〈0.01），4组间夜间收缩压下降百分率（ΔSBP%）、夜间舒张压下降百分率（ΔDBP%）差异无统计学意义（均P〉0.05）。因子分析纳人可能影响血压节律变化的因素，共提取5个公因子：OSAHS、体质量、生活行为习惯、尿离子、年龄病程因子；多元线性回归显示OSAHS因子与ΔSBP% （β=-0.128, P〈0.01）和ΔDBP% （β=-0.126, P〈0.01）相关，ΔSBP%的影响因素依次为年龄病程〉OSAHS〉体质量因子（分别β=-0.148，P=0.002；β=-0.128，P=0.007；β=0.099，P=0.035），ΔDBP%的影响因素依次为OSAHS〉年龄病程〉体质量因子（分别β=-0.126，P=0.008；β=-0.105，P=0.026；β=0.097，P=0.042）。 结论 在阻塞性睡眠呼吸暂停相关性高血压患者中，OSAHS、年龄病程和体质量因素可能是导致该人群血压节律异常变化的主要因素。

Objective To investigate the effect of obesity, arousal, hypoxia and sympathetic activation on the circadian blood pressure of hypertensive patients with obstructive sleep apnea-hypopnea syndrome. Methods Polysomnography （PSG） was performed in 436 hypertensive patients complaining of snoring, daytime sleepiness, lips cyanosis, hyperhemoglobinemia of unknown etiology, or with refractory hypertension. Hypertensive subjects were divided into four groups according to apnea-hypopnea index （AHI）： hypertensive with mild obstructive sleep apnea-hypopnea syndrome （OSAHS） （n = 131 ）, hypertensive with moderate OSAHS （n = 95 ）, hypertensive with severe OSAHS （n = 95 ） and hypertensive without OSAHS as control group （n = 115 ）. The ambulatory blood pressure monitoring （ABPM）, PSG, urine electrolyte, and urine vanillyhnandelic acid （VMA） were compared among groups. Factor analysis was employed to identify common factors related to the alterations of circadian blood pressure. Multiple linear regression analysis was used to analyze the influencing factors of the observed variables. Results There were significant ditterences among groups in age, neck circumference and waist circumference（P 〈 0. 001 ）. In severe group, 24 hour average systolic blood pressure （24 hSBP） [ （ 137.0 ±16.8） mm Hg vs. （ 131.3 ± 11.9） mm Hg, （ 131.3 ± 13.2 ）mm Hg （ 1 mm Hg = 0. 133 kPa） ], daytime systolic blood pressure （ day- SBP） [（140.8±16.8） mm Hg vs. （135.7±11.9） mm Hg, （135.3±13.5） mm Hg]and night systolic blood pressure （night-SBP） [ （ 130.9 ± 17.0） mm Hg vs. （ 124. 5 ±14. 0 ） mm Hg, （ 124. 3 ± 13.2 ）mm Hg ] were signific.antly higher than those of contrul or mild OSAS groups （ P 〈 0.01 ）. Factor analysis showed that body mass （BM） , life style, urine electrolyte, age and course of disease （ACD） were the common factors influencing circadian blood pressure. OSAHS was cmTelated with declining percentage of SBP （β = -0. 128,P 〈 0.01 ） and declining percentage of DBP （β = - 0. 126, P 〈 0.01 ） . The contribution according to priority was ACD 〉 OSAHS 〉 BM for declining percentage of SBP（β = -0. 148, P = 0. 002 ;β = - 0. 128, P = 0. 007 ;β = 0. 099, P = 0. 035 ）, OSAHS 〉 ACD 〉 BM for declining percentage of DBP （β = -0.126,P=0.008;β= -0. 105,P=0.026;β=0.097,P=0.042）.Conclusion OSAHS, ACD and BM are the independent risk factors contributing to the alterations of circadian blood pressure in hypertensive patients with obstructive sleep apnea-hypopnea syndrome.