持续正压通气对顽固性高血压合并阻塞性睡眠呼吸暂停患者血浆醛固酮水平的影响

Influence of Continuous Positive Airway Pressure on Plasma Aldosterone Concentration in Patients With Resistant Hypertension Combined With Obstructive Sleep Apnea

目的探讨持续正压通气(CPAP)对顽固性高血压合并阻塞性睡眠呼吸暂停(OSA)患者血浆醛固酮(PAC)水平的影响。方法选取2012年7月—2013年10月于河南省中医院住院且符合纳入标准的顽固性高血压合并OSA患者513例为研究对象。17例不接受24 h动态血压监测(24 h ABPM)患者和16例呼吸暂停低通气指数(AHI)<15次/h患者均被剔除,剩下的480例患者采用随机数字表法分为CPAP组(n=240)和对照组(n=240)。CPAP组和对照组患者分别接受CPAP和药物治疗和单独药物治疗3个月。记录患者一般资料、治疗前后24 h ABPM指标〔日间收缩压(SBP)、日间舒张压(DBP)、夜间SBP、夜间DBP、24 h SBP、24 h DBP〕、Epworth嗜睡评分、PAC水平、肾素水平。结果最终有468例患者完成治疗,其中CPAP组232例、对照组236例。根据治疗前24 h ABPM结果,以血压<125/80 mm Hg(1 mm Hg=0.133 k Pa)为假性顽固性高血压,≥125/80 mm Hg为真性顽固性高血压。CPAP组中假性顽固性高血压患者113例,真性顽固性高血压患者119例;对照组中假性顽固性高血压患者133例,真性顽固性高血压患者103例。真性顽固性高血压患者CPAP时间与假性顽固性高血压患者比较,差异无统计学意义(P>0.05)。CPAP组利尿剂使用率低于对照组(P<0.05)。假性顽固性高血压患者中,单独药物治疗与CPAP和药物治疗患者治疗前日间DBP、夜间SBP、夜间DBP、24 h SBP,治疗后日间DBP、AHI、Epworth嗜睡评分、PAC水平比较,差异有统计学意义(P<0.05);单独药物治疗患者治疗后日间DBP、AHI与治疗前比较,差异有统计学意义(P<0.05);CPAP和药物治疗患者治疗后夜间DBP、AHI、Epworth嗜睡评分、PAC水平与治疗前比较,差异有统计学意义(P<0.05)。真性顽固性高血压患者中,单独药物治疗与CPAP和药物治疗患者治疗前夜间SBP、24 h SBP、AHI,治疗后日间SBP、日间DBP、夜间SBP、夜间DBP、24 h DBP、AHI、PAC水平比较,差异均有统计学意义(P<0.05);单独药物治疗患者治疗后AHI与治疗前比较,差异有统计学意义(P<0.05);CPAP和药物治疗患者治疗后日间SBP、日间DBP、夜间SBP、夜间DBP、24 h DBP、AHI、Epworth嗜睡评分及PAC水平与治疗前比较,差异有统计学意义(P<0.05)。以治疗前PAC为因变量,年龄、BMI、血氧饱和度<90%时间占总睡眠时间的百分比(CT90%)、治疗前24 h SBP、治疗前24 h DBP、治疗前AHI为自变量,进行多元线性回归分析,结果显示,回归方程为y=0.198×CT90%+0.058(P=0.023,R^2=0.026)。以治疗后PAC为因变量,年龄、BMI、CT90%、治疗前24 h SBP、治疗前24 h DBP、治疗前AHI为自变量,进行多元线性回归分析,结果显示,回归方程为y=0.168×24 h DBP+0.113(P=0.015,R2=0.094)。结论 PAC可能参与了OSA和顽固性高血压的发生过程,CPAP能有效改善顽固性高血压合并OSA患者的PAC水平。

Objective To investigate the influence of continuous positive airway pressure（ CPAP） on the plasma aldosterone concentration（ PAC） in patients with resistant hypertension and obstructive sleep apnea（ OSA）. Methods From July 2012 to October 2013,we enrolled 513 patients with resistant hypertension and OSA who were admitted into Henan Province Hospital of TCM and accorded with inclusion criteria. 17 patients who didn＇t received 24 h ABPM and 16 patients with AHI less than 15 times per hour were excluded,and other 480 patients were divided into CPAP group（ n = 240） and control group（ n= 240） by random number table method. CPAP group and control group respectively received CPAP plus medication and medication alone for 3 months. We recorded patients＇ general data,24 h ABPM indexes（ daytime SBP,daytime DBP,night SBP,night DBP, 24 h SBP and 24 h DBP）, Epworth sleepiness score, PAC level and renin level before and after treatment. Results A total of 468 patients finished treatment,including 232 patients in the CPAP group and 236 patients in the control group. According to 24 h ABPM before treatment,hypertension 125 /80 mm Hg（ 1 mm Hg = 0. 133 k Pa） was defined as pseudo resistant hypertension,and hypertension ≥125 /80 mm Hg was defined as true resistant hypertension. There were 113 pseudo resistant hypertension patients and 119 true resistant hypertension in CPAP group; there were 133 pseudo resistant hypertension patients and 103 true resistant hypertension in control group. True resistant hypertension patients were not significantly different from pseudo resistant hypertension patients in CPAP time（ P〈0. 05）. CPAP group was lower than control group in the usage rate of diuretic（ P〈0. 05）. For pseudo resistant hypertension patients,patients who received medication alone and patients who received CPAP plus medication were significantly different in daytime DBP,night SBP,night DBP and 24 h SBP before treatment and daytime DBP, AHI, Epworth sleepness score and PAC level after treatment（ P〈0. 05）; the daytime DBP and AHI of patients who received medication alone after treatment were significantly different from those before treatment（ P〈0. 05）; the night DBP,AHI,Epworth sleepiness score and PAC level of patients who received CPAP plus medication after treatment were significantly different from those before treatment（ P〈0. 05）. For patients with true resistant hypertension,patients who received medication alone and patients who received CPAP plus medication were significantly different in night SBP,24 h SBP and AHI before treatment and daytime SBP,daytime DBP,night SBP,night DBP,24 h DBP,AHI and PAC level after treatment（ P〈0. 05）; the AHI of patients who received medication alone after treatment was significantly different from that before treatment（ P〈0. 05）; the daytime SBP,daytime DBP,night SBP,night DBP,24 h DBP,AHI,Epworth sleepiness score and PAC level of patients who received CPAP plus medication after treatment were significantly different from those before treatment（ P〈0. 05）. With PAC before treatment as the dependent variable and age, BMI, CT90%,24 h SBP before treatment,24 h DBP before treatment,and AHI before treatment as independent variables, multiple linear regression analysis was conducted,and the result showed that the regression equation was y = 0. 198 × CT90% ＋ 0. 058（ P= 0. 023,R^2= 0. 026）. With PAC after treatment as the dependent variable, and age, BMI, CT90%,24 h SBP before treatment,24 h DBP before treatment, and AHI before treatment as independent variables, multiple linear regression was conducted,and the result showed that the regression equation was y = 0. 168 × 24 h DBP ＋ 0. 113（ P = 0. 015,R2= 0. 094）.Conclusion PAC may participate in the development of OSA and resistant hypertension,and CPAP can effectively improve the PAC level of patients with resistant hypertension combined with OSA.