Клинический профиль пациентов с синдромом обструктивного апноэ сна в кардиологическом стационаре
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Elfimova E.M., Mikhailova O.O., Khachatryan N.T., et al. Clinical profile of patients with obstructive sleep apnea syndrome in a cardiology hospital. Therapeutic Archive. 2020; 92 (4): 9–16. DOI: 10.26442/00403660.2020.04.000553
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Цель. Изучить эпидемиологический и клинический профиль пациентов, направленных врачом-кардиологом в специализированную лабораторию сна для верификации диагноза СОАС.
Материалы и методы. Объект исследования – 527 пациентов в возрасте 56,9±12,5 года, находившихся на стационарном лечении в НИИ клинической кардиологии им. А.Л. Мясникова в 2016–2018 гг., с факторами риска СОАС. На первом этапе проводился сбор жалоб, анамнеза, антропометрических данных. В качестве скринингового обследования проводилось анкетирование с использованием опросных шкал. Верификация диагноза СОАС и определение степени тяжести проводились посредством кардиореспираторного или респираторного мониторирования. Впоследствии сформировано 4 группы в зависимости от наличия и степени тяжести СОАС.
Результаты. Распространенность СОАС среди пациентов кардиологического стационара, направленных на верифицирующее исследование, составила 88,6%. При сравнительном анализе групп выявлено прогрессирующее увеличение значений антропометрических показателей при увеличении степени тяжести СОАС. Не определено различий между группами по гендерному признаку и уровню дневной сонливости по Каролинской шкале сонливости. Средний балл по шкале сонливости Эпворт оказался статистически значимо ниже только в группе больных без СОАС при сравнении с группой с тяжелой степенью СОАС и сопоставим с баллами в группах легкой и средней степени СОАС. В многофакторной модели логистической регрессии выявлены такие независимые предикторы СОАС, как возраст старше 45 лет, указания на громкий прерывистый храп, учащенное ночное мочеиспускание, избыточная масса тела или ожирение. По результатам оценки частоты встречаемости различных сердечно-сосудистых заболеваний у пациентов, направленных в лабораторию сна, значимых отличий не выявлено. В то же время определена значимая разница частоты наличия ожирения у больных с тяжелой степенью СОАС в сравнении с остальными группами, а также частоты встречаемости сахарного диабета 2-го типа или нарушения толерантности к глюкозе – при сравнении с группами без СОАС и с СОАС легкой степени. В однофакторных моделях логистических регрессий выявлено, что вероятность наличия тяжелой степени СОАС увеличивается с возрастанием как коморбидности, так и возраста больного.
Заключение. Подтверждена высокая распространенность СОАС у пациентов кардиологического стационара, направленных на дообследование в специализированную лабораторию сна. Учитывая данные, что ранняя диагностика и лечение СОАС могут оказать влияние как на течение обеих нозологий, так и на качество жизни и прогноз данных пациентов, целесообразно проведение рутинного скрининга и верификации диагноза СОАС у пациентов с сердечно-сосудистыми заболеваниями.
Ключевые слова: синдром обструктивного апноэ сна, дневная сонливость, сердечно-сосудистые заболевания, фибрилляция предсердий, сахарный диабет.
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Relevance. Obstructive sleep apnea syndrome (OSAS) is an important medical and social problem due to its high prevalence and impact on quality of life. The relationship between OSAS and cardiovascular pathology has been proven by many studies, which confirms the necessity for early diagnosis of OSAS and its treatment for the prevention of fatal and non-fatal events.
Aim: to study epidemiological and clinical profile of the patients referred by a cardiologist to a specialized sleep laboratory to verify the diagnosis of OSAS.
Materials and methods. Object of study – 527 patients aged 56.9±12.5 years who were hospitalized to the Myasnikov Clinical Cardiology Research Institute from 2016–2018 and had OSAS risk factors. Initially, complaints, medical history, anthropometric data were collected. As a screening survey, questionnaires were conducted using questionnaire scales. Verification of the diagnosis of OSAS and determination of the severity was carried out by cardiorespiratory or respiratory monitoring. Subsequently, 4 groups were formed depending on the presence and severity of OSAS.
Results. The prevalence of OSAS among patients in a cardiology hospital referred to a verification study was 88.6%. A comparative analysis of the groups revealed a progressive increase in the values of anthropometric indicators with increasing severity of OSAS. No differences were found between the groups by gender and daytime sleepiness on the Karolinska Sleepiness Scale. The average score on the Epworth sleepiness scale was statistically significantly lower only in the group of patients without OSAS when compared with the group with a severe degree of OSAS, and is comparable with the scores in the groups of mild and moderate degrees of OSAS. In a multivariate model of logistic regression, independent predictors of OSAS were identified as: age over 45 years, indications of loud intermittent snoring, frequent nightly urination, overweight or obesity. According to the results of assessing the incidence of various cardiovascular diseases in patients referred to the sleep laboratory, no significant differences were detected. At the same time, a significant difference was found in the frequency of obesity in patients with severe OSAS compared with other groups, as well as the frequency of type 2 diabetes mellitus or impaired glucose tolerance – when compared with groups without OSAS, and with mild OSAS. In one-factor logistic regression models, it was found that the likelihood of having a severe degree of OSAS increases with increasing both comorbidity and age.
Conclusions. High prevalence of OSAS in patients of a cardiological hospital, referred to a sleep laboratory for verification study, was confirmed. Considering the data that early diagnosis and treatment of OSAS can affect the course of both nosologies, the quality of life and prognosis of these patients, it is advisable to routinely screen and verify the diagnosis of OSAS in patients with cardiovascular diseases.
Keywords: obstructive sleep apnea syndrome, daytime sleepiness, cardiovascular disease, atrial fibrillation, diabetes mellitus.
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1. Phillipson E. Sleep apnea – a major public health problem. N Engl J Med. 1993;328:1271-3. doi: 10.1056/NEJM199304293281712
2. Young T, Palta M, Dempsey J, et al. Burden of sleep apnea: rationale, design, and major findings of the Wisconsin Sleep Cohort study. Wisconsin Medical J. 2009;108(5):246-9.
3. Peppard P, Young T, Barnet J, et al. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol. 2013;177(9):1006. doi: 10.1093/aje/kws342
4. Jennum P, Soul A. Epidemiology of snoring and obstructive sleep apnoea in the Dannish population age 30–60. J Sleep Res. 1992;1(4):240-4.
doi: 10.1111/j.1365-2869.1992.tb00045.x
5. Lindberg E, Gislason T. Epidemiology of sleep-related obstructive breathing. Sleep Med Rev. 2000;4(5):411-433. doi: 10.1053/smrv. 2000.0118
6. Aksenova AV, Elfimova EM, Galitsin PV, et al. Role of the Pulse Oximetry in the cardiologist's practice. Systemic Hypertension. 2014;11(4):26-30 (In Russ.) doi: 10.26442/2075-082X_11.4.26-30
7. Parati G, Lombardi C, Hedner J, et al. Recommendations for the management of patients with obstructive sleep apnoea and hypertension. Eur Respir J. 2013;41(3):523-38. doi: 10.1183/09031936.00226711
8. Teran-Santos J, Jimenez- Gomez A, Cordero-Guevara J. The association between sleep apnea and the risk of traffic accidents. Cooperative Group Burgos Santander. N Engl J Med. 1999;340(11):847-51. doi: 10.1056/NEJM199903183401104
9. Kryger M, Roth T, Dement W. Elsevier. Principles and practices of sleep medicine, sleep and cardiovascular disease: present and future. 6th edition. Philadelphia. 2017.
10. Drager L, McEvoy R, Barbe F, et al. Sleep Apnea and Cardiovascular Disease Lessons From Recent Trials and Need for Team Science. Circulation. 2017;136(19):1840-50. doi: 10.1161/CIRCULATIONAHA. 117.029400
11. Young T, Evans L, Finn L, Palta M. Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women. Sleep. 1997;20(9):705-6. doi: 10.1093/sleep/20.9.705
12. Kryger M, Roth T, Dement W. Elsevier. Principles and practices of sleep medicine. Philadelphia. 2005.
13. Lin C, Davidson T, Ancoli-Israel S. Gender differences in obstructive sleep apnea and treatment implications. Sleep Med Rev. 2008;12(6):481-96. doi: 10.1016/j.smrv.2007.11.003
14. Tung P, Levitzky Y, Wang R, et al. Obstructive and Central Sleep Apnea and the Risk of Incident Atrial Fibrillation in a Community Cohort of Men and Women. J Am Heart Assoc. 2017;6(7):e004500. doi: 10.1161/JAHA.116.004500
15. Sands S, Owens R. Congestive Heart Failure and Central Sleep Apnea. Critical Care Clinics. 2015;31(3):473-95. doi: 10.1016/j.ccc. 2015.03.005
16. Blissitt P. Sleep-disordered breathing after stroke nursing implications. Stroke. 2017;48(3):e81-e84. doi: 10.1161/STROKEAHA.116.013087
17. Bartels M. Fatigue in Cardiopulmonary Disease. Phys Med Rehabil Clin N Am. 2009;20(2):389-404. doi: 10.1016/j.pmr.2008.12.002
18. Newman A, Spiekerman C, Enright P, et al. Daytime sleepiness predicts mortality and cardiovascular disease in older adults. The Cardiovascular Health Study Research Group. J Am Geriatrics Soc. 2000;48(2):115-23. doi: 10.1111/j.1532-5415.2000.tb03901.x
19. Bruno R, Palagini L, Gemignani A, et al. Poor sleep quality and resistant hypertension. Sleep Med. 2013;14(11):1157-63. doi: 10.1016/j.sleep.2013.04.020
20. Spiegelhalder K, Scholtes C, Riemann D. The association between insomnia and cardiovascular diseases. Nature and science of sleep. 2010;4(2):71-8. doi:10.2147/nss.s7471
21. Batool-Anwar S, Malhotra A, Forman J, et al. Restless legs syndrome and hypertension in middle-aged women. Hypertension. 2011;58(5):791-6. doi: 10.1161/HYPERTENSIONAHA.111.174037
22. Floras J. Sleep Apnea in Heart Failure: implications of sympathetic nervous system activation for disease progression and treatment. Current Heart Fail Reports. 2005;2(4):212-7. doi: 10.1007/bf02696652
23. Kauta S, Keenan B, Goldberg L, Schwab R. Diagnosis and treatment of sleep disordered breathing in hospitalized cardiac patients: a reduction in 30-day hospital readmission rates. J Clin Sleep Med. 2014;10(10):1051-9. doi: 10.5664/jcsm.4096
24. Duran J, Esnaola S, Rubio R, Iztueta A. Obstructive sleep apnea-hypopnea and related clinical features in a population-based sample of subjects aged 30 to 70 yr. Am J Respir Crit Care Med. 2001;163(3 Pt 1):685-9. doi: 10.1164/ajrccm.163.3.2005065
25. Arzt M, Young T, Finn L, et al. Sleepiness and sleep in patients with both systolic heart failure and obstructive sleep apnea. Ar Int Med. 2006;166(16):1716-22. doi: 10.1001/archinte.166.16.1716
26. Walsleben J, Kapur V, Newman AS et al. Sleep and reported daytime sleepiness in normal subjects: the Sleep Heart Health Study. Sleep. 2004;27(2):293-8. doi: 10.1093/sleep/27.2.293
27. Gopal M, Sammel M, Pien G, et al. Investigating the associations between nocturia and sleep disorders in perimenopausal women. J Urol. 2008;180(5):2063-7. doi: 10.1016/j.juro.2008.07.050
28. Moriyama Y, Miwa K, Tanaka H, et al. Nocturia in men less than 50 years of age may be associated with obstructive sleep apnea syndrome. Urology. 2008;71(6):1096-8. doi: 10.1016/j.urology.2008.02.038
29. Malhotra A, White D. Obstructive sleep apnoea. Lancet. 2002;360(9328):237-45. doi: 10.1016/S0140-6736(02)09464-3
30. Arnardottir E, Janson C, Bjornsdottir E, et al. Nocturnal sweating–a common symptom of obstructive sleep apnoea: the Icelandic sleep apnoea cohort. BMJ Open. 2013;3(5):e002795. doi: 10.1136/bmjopen-2013-002795
31. Kushida CA, Efron B, Guilleminault C. A predictive morphometric model for the obstructive sleep apnea syndrome. Ann Int Med. 1997;127(8 Pt 1):581-7. doi: 10.7326/0003-4819-127-8_part_1-199710150-00001
32. Pamidi S, Tasali E. Obstructive sleep apnea and type 2 diabetes: is there a link? Frontiers Neurol. 2012;3(126).eCollection. doi: 10.3389/fneur.2012.00126
33. Bairambekov EhSh, Pevzner AV, Litvin AYu, Elfimova EM. Diagnostic capabilities and the frequency of detection of obstructive sleep apnea syndrome in patients with various forms of atrial fibrillation. Cardiology Bulletin. 2016;11(2):34-41 (In Russ.)
34. Kurlykina NV, Pevzner AV, Litvin AYu, et al. The prevalence of obstructive sleep apnea syndrome in patients with nocturnal cardiac conduction disorders. Abstracts. 9th Congress of the Russian Society of Holter Monitoring and Non-Invasive Electrophysiology. Congress materials. 2008 (In Russ.)
35. Shahar E, Whitney C, Redline S, et al. Sleep disordered breathing and cardiovascular disease: cross sectional results of the Sleep Heart Health Study. Am J Respir Crit Care Med. 2001;163(1):19-25. doi: 10.1164/ajrccm.163.1.2001008
36. Tietjens J, Claman D, Kezirian E, et al. Obstructive Sleep Apnea in Cardiovascular Disease: a review of the literature and proposed multidisciplinary clinical management strategy. J Am Heart Assoc. 2019;8(1):e010440. doi: 10.1161/JAHA.118.010440
1 ФГБУ «Национальный медицинский исследовательский центр кардиологии» Минздрава России, Москва, Россия;
2 ФГБОУ ВО «Российский национальный исследовательский медицинский университет им. Н.И. Пирогова» Минздрава России, Москва, Россия
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E.M. Elfimova1, O.O. Mikhailova1, N.T. Khachatryan1, A.Yu. Litvin1,2, I.E. Сhazova1
1 National Medical Research Center for Cardiology, Moscow, Russia;
2 Pirogov Russian National Research Medical University, Moscow, Russia