老年阻塞性睡眠呼吸暂停综合征患者房颤发生机制和治疗的研究进展

阻塞性睡眠呼吸暂停(OSA)是老年常见的睡眠呼吸异常综合征。近年研究发现,OSA患者心房颤动(AF)的发生率明显增加,OSA可能通过代谢异常、组织重构、炎症反应和自主神经失衡等机制诱发心房结构改变和电重构,促进AF发生和发展。OSA患者AF的非药物治疗包括持续气道正压(CPAP)通气治疗、神经刺激、口腔装置和悬雍垂腭咽成形术等,药物治疗包括抗心律失常药物、抗炎药物等;OSA的早期发现和积极治疗可降低AF的发生率。     

Body mass index, obstructive sleep apnea, and outcomes of catheter ablation of atrial fibrillation

Background: Obesity and obstructive sleep apnea (OSA) are associated with atrial fibrillation (AF). The effects of a large body mass index (BMI) and OSA on the results of radiofrequency catheter ablation (RFA) of AF are unclear.
Objective: To evaluate the effect of BMI and OSA on the efficacy of RFA for AF.
Methods: RFA was performed in 324 consecutive patients (mean age = 57 ± 11 years) with paroxysmal (234) or chronic (90) AF. OSA was diagnosed by polysomnography in 32 of 324 patients (10%) prior to ablation. Among the 324 patients, 18% had a normal BMI (<25 kg/m²), 39% were overweight (BMI ≥ 25 kg/m² and <30 kg/m²), and 43% were obese (≥30 kg/m²). RFA was performed to eliminate complex fractionated atrial electrograms (CFAE) in the pulmonary vein antrum and left atrium.
Results: At 7 ± 4 months after a single ablation procedure, 63% of patients without OSA and 41% with OSA were free from recurrent AF without antiarrhythmic drug therapy (P = 0.02). Multivariate analysis including variables of age, gender, type and duration of AF, OSA, BMI, left atrial size, ejection fraction, and hypertension demonstrated that OSA was the strongest predictor of recurrent AF (OR = 3.04, 95% CI: 1.11–8.32, P = 0.03). There was no association between BMI and freedom from recurrent AF. A serious complication occurred in 3 of 324 patients, with no relationship to BMI.
Conclusions: OSA is a predictor of recurrent AF after RFA independent of its association with BMI and left atrial size. Obesity does not appear to affect outcomes after radiofrequency catheter ablation of AF.     

Mechanisms, prevention, and treatment of atrial fibrillation after cardiac surgery

Post-operative atrial fibrillation (POAF) is a frequent complication occurring in 30% to 50% of patients after cardiac surgery. It is associated with an increased risk of mortality and morbidity, predisposes patients to a higher risk of stroke, requires additional treatment, and increases the costs of the post-operative care. The aim of this review is to present the current state of knowledge about the risk factors, mechanisms, prevention, and treatment of this complication. In addition to the well known risk factors for the development of POAF such as age, left atrial enlargement, and valvular surgery, new metabolic risk factors related to visceral obesity have been identified. With regard to the prevention of POAF, beta-blocker drugs are effective and safe and can be used in most patients, whereas amiodarone can be added in high-risk patients. Biatrial pacing was shown to be effective; however, its complexity might limit its application. Although there are only few data regarding the usefulness of magnesium, statins, N-3 polyunsaturated fatty acids, and corticosteroids, their addition to beta-blocker drugs might be of benefit for further reducing POAF. Treatment includes the use of an AV nodal blocking agent to achieve the rate control. If AF does not spontaneously convert to sinus rhythm within 24 h, anticoagulation should be initiated and a rhythm control strategy should be attempted. More investigations are warranted to explore mechanisms by which POAF occurs. This new knowledge would undoubtedly translate into a more efficient prevention and treatment of this common post-operative complication that is associated with a major health and economic burden.     

Implications of obstructive sleep apnea for atrial fibrillation and sudden cardiac death

Obstructive sleep apnea (OSA) is a sleep-related breathing disorder with important cardiovascular consequences, including arrhythmogenesis. The unique pathophysiology of OSA results in multiple intermediate mechanisms that may promote atrial fibrillation, ventricular arrhythmias, and sudden cardiac death. These mechanisms may act acutely to trigger nocturnal dysrhythmias, or chronically by affecting the electrical and myocardial substrates. Burgeoning epidemiological data have identified an increased risk for atrial fibrillation and sudden cardiac death related to OSA. Currently, few data exist to support the efficacy of OSA therapy, namely continuous positive airway pressure, as an adjunct for arrhythmia prevention or management.     

Obstructive sleep apnea, obesity, and the risk of incident atrial fibrillation.

OBJECTIVES: This study sought to identify whether obesity and obstructive sleep apnea (OSA) independently predict incident atrial fibrillation/flutter (AF). BACKGROUND: Obesity is a risk factor for AF, and OSA is highly prevalent in obesity. Obstructive sleep apnea is associated with AF, but it is unknown whether OSA predicts new-onset AF independently of obesity. METHODS: We conducted a retrospective cohort study of 3,542 Olmsted County adults without past or current AF who were referred for an initial diagnostic polysomnogram from 1987 to 2003. New-onset AF was assessed and confirmed by electrocardiography during a mean follow-up of 4.7 years. RESULTS: Incident AF occurred in 133 subjects (cumulative probability 14%, 95% confidence interval [CI] 9% to 19%). Univariate predictors of AF were age, male gender, hypertension, coronary artery disease, heart failure, smoking, body mass index, OSA (hazard ratio 2.18, 95% CI 1.34 to 3.54) and multiple measures of OSA severity. In subjects <65 years old, independent predictors of incident AF were age, male gender, coronary artery disease, body mass index (per 1 kg/m2, hazard ratio 1.07, 95% CI 1.05 to 1.10), and the decrease in nocturnal oxygen saturation (per 0.5 U log change, hazard ratio 3.29, 95% CI 1.35 to 8.04). Heart failure, but neither obesity nor OSA, predicted incident AF in subjects > or =65 years of age. CONCLUSIONS: Obesity and the magnitude of nocturnal oxygen desaturation, which is an important pathophysiological consequence of OSA, are independent risk factors for incident AF in individuals <65 years of age.     

Effects of continuous positive airway pressure treatment in obstructive sleep apnea patients with atrial fibrillation: A meta-analysis

Background:Obstructive sleep apnea (OSA) is correlated with atrial fibrillation (AF). Over the past decade, there has been an increasing interest in the relationship between OSA with continuous positive airway pressure (CPAP) and progression or recurrence of AF.Methods:This investigation was an analysis of studies searched in the Cochrane Library, PubMed, EMBASE, EBSCO, OVID, and Web of Science databases from inception to July 2020 to evaluate the recurrence or progression of AF in CPAP users, CPAP nonusers, and patients without OSA.Results:Nine studies with 14,812 patients were recruited. CPAP therapy reduced the risk of AF recurrence or progression by 63% in a random-effects model (24.8% vs 40.5%, risk ratio [RR] = 0.70, 95% confidence interval [CI] = 0.57–0.85, P = .035). Compared with non-OSA patients, AF recurrence or progression was much higher in CPAP nonusers (40.6% vs 21.1%, RR = 1.70, 95% CI = 1.19–2.43, P = .000). However, AF recurrence or progression in the CPAP group was similar to that in the non-OSA group (24.0% vs 21.1%, RR = 1.13, 95% CI = 0.87–1.47, P = .001). Begg correlation test and Egger regression test revealed no publication bias in this analysis.Conclusions:OSA is a salient factor in the progression or recurrence of AF. CPAP therapy for OSA may contribute to reduction of AF in patients for whom radiofrequency ablation or direct current cardioversion is not performed.Trial Registration:The protocol for this meta-analysis was registered on PROSPERO with a registration No. CRD42019135229.     

Atrial fibrillation and sleep-disordered breathing

Atrial fibrillation (AF) is a common supraventricular arrhythmia that increases in prevalence with increasing age and in the presence of comorbidities such as heart failure (HF). AF increases the risk of a number of serious complications, including stroke and HF. As a result, the rate of hospitalization is high, making AF a costly disease. Treatment strategies for AF are broadly based around rate and rhythm control, either pharmacological or mechanical. There appear to be a number of links between sleep-disordered breathing (SDB) and AF, although further studies are needed to fully understand the physiological mechanisms that link these conditions. Patients with AF and SDB share a number of risk factors and comorbidities, including age, male sex, hypertension, congestive HF and coronary artery disease (CAD), and the prevalence of SDB in AF is higher than in the general population. Prevalence rates of obstructive sleep apnea (OSA) in patients with AF have been reported to range from 21% to just over 80%. The prevalence of central sleep apnea (CSA) in patients with AF is less well defined, but appears to be particularly high in patients who also have HF and a reduced left ventricular ejection fraction (LVEF). The frequency of apneas can be reduced by effective treatment of AF, while co-existing OSA reduces the effectiveness of treatments for AF and there is an increased risk of arrhythmia recurrence in the presence of SDB. Treating OSA with continuous positive airway pressure (CPAP) therapy has shown the potential to decrease the incidence of AF, improve the effectiveness of AF interventions, and decrease the risk of arrhythmia recurrence, although data from large randomized, controlled clinical trials are lacking. Based on available data, inclusion of SDB recognition and management strategies as part of AF management appears to have the potential to reduce the impact of this arrhythmia at both the individual and societal levels, and has been recognized as important in recent guidelines.     

Postoperative maintenance of Crohn's disease remission with 6-mercaptopurine, mesalamine, or placebo: a 2-year trial

BACKGROUND & AIMS: No therapy has been shown to reliably prevent the evolution of postoperative recurrence of Crohn's disease. The aim of the current trial was to compare 6-mercaptopurine (6-MP) and mesalamine with placebo for the prevention of clinical, endoscopic, and radiographic recurrence of Crohn's disease after resection and ileocolic anastomosis. METHODS: Five centers randomized 131 patients to receive 6-MP (50 mg), mesalamine (3 g), or placebo daily in a double-blind, double-dummy trial. Patients had clinical assessments at 7 weeks and then every 3 months; colonoscopy at 6, 12, and 24 months; and small bowel series at 12 and 24 months. End points were clinical, endoscopic, and radiographic recurrence rates at 24 months. RESULTS: Clinical recurrence rates (intent to treat) by life-table analysis at 24 months were 50% (95% confidence interval [CI], 34%-68%), 58% (95% CI, 41%-75%), and 77% (95% CI, 61%-91%) in patients receiving 6-MP, mesalamine, and placebo, respectively. Endoscopic recurrence rates were 43% (95% CI, 28%-63%), 63% (95% CI, 47%-79%), and 64% (95% CI, 46%-81%), and radiographic recurrence rates were 33% (95% CI, 19%-54%), 46% (95% CI, 29%-66%), and 49% (95% CI, 30%-72%), respectively. 6-MP was more effective than placebo ( P < 0.05) at preventing clinical and endoscopic recurrence over 2 years. Patient withdrawals resulted in 69% of the study population evaluable for the clinical recurrence end point. CONCLUSIONS: 6-MP, 50 mg daily, was more effective than placebo at preventing postoperative recurrence of Crohn's disease and should be considered as a maintenance therapy after ileocolic resection.     

阻塞性睡眠呼吸暂停综合征与左房增大关系的探讨

目的:研究阻塞性睡眠呼吸暂停综合征(OSAS)及其严重程度是否为左房增大的影响因素。方法:对经多导睡眠呼吸监测确诊的单纯性打鼾患者20例,轻至中度OSAS患者32例,重度OSAS患者44例,行超声心动图检查,根据左房内径结果分为左房正常组和左房增大组,先进行组间单因素分析筛选有统计学意义的危险因素,再通过逐步Logistic回归分析得出左房增大的独立危险因素。结果:单因素分析提示年龄、性别、体质指数、呼吸暂停低通气指数、最小血氧饱和度、打鼾时间、高血压、饮酒、代谢综合征为左房增大的危险因素。逐步Logistic回归分析表明,重度OSAS患者致左房增大危险度为单纯性打鼾患者的6.659倍,老年、超重/肥胖、高血压及饮酒患者致左房增大的相对危险度分别为3.910、3.907、4.731和5.040。结论:重度OSAS可能为独立于年龄、体质指数、高血压及饮酒的左房增大的预测因子。     

气道阻塞性睡眠障碍与心房颤动的机制与治疗进展

摘要 心房颤动（AF）是临床最常见的心律失常,同时增加了心血管疾病的发病率和死亡率。 气道阻塞性睡眠呼吸暂停（OSA）是一种常见的呼吸系统疾病,它是 AF 发生的独立危险因素。 目前认为 OSA 患者 AF 发生的病理生理机制如下：缺氧,胸腔内压改变,交感神迷走神经失衡,心房重塑,氧化应激,炎症及神经体液因子的激活。研究表明 OSA 能降低 AF 患者药物转律、电转律及导管消融的成功率。持续气道正压通气（CPAP）能有效预防通气障碍、减少交感神经激活和房颤复发的频率。本文揭示了 OSA 与 AF 之间的关系,主要介绍了OSA 在 AF 发生中的生理机制及现有的治疗方案。     

Obstructive sleep apnea and multiple facets of a neuroinflammatory response: a narrative review

BackgroundObstructive sleep apnea (OSA) is a chronic, highly prevalent, multi-system and sleep disorder, which may contribute to cognitive impairment and a variety of structural and neurophysiologic changes. The focus on OSA is warranted given its recognized links with major psychiatric and neurologic disorders, including Alzheimer’s disease. Some preliminary studies suggest a dual effect of the inflammatory response in OSA. Neuroinflammation may present with initial, potentially adaptive and homeostatic, and later, a more distinctly maladaptive, precipitating and perpetuating role.ObjectiveWe here propose and argue in favour of the inflammatory process in the brain as a likely binding mechanism behind at least some effects that OSA may have on the brain and its function. Several OSA-triggered molecular and cellular events, that could lead to a neurodegenerative cascade, are similarly discussed.MethodsThis perspective reviews the body of literature that investigates potential links between the inflammatory processes in the brain and the OSA. A special emphasis is placed on a potential role for neuroplastin, a novel transmembrane synaptic protein involved in the neuroplasticity and known to be differentially regulated in the OSA.ConclusionsThe intricate interplay between neuroinflammation and other mechanistic correlates of OSA add to the evidence that neuroinflammation may be a key target for future therapeutic strategies in a number of comorbid disorders. The future studies will need to answer whether it is sleep fragmentation (SF) or intermittent hypoxia (IH) which may drive any such neuroinflammation.     

阻塞性睡眠呼吸暂停综合征与内分泌疾病

睡眠呼吸暂停综合征(OSAS)患者睡眠呼吸暂停以及反复低氧所致的应激状态可以引起一系列内分泌和代谢异常,并可产生肥胖、糖尿病等内分泌相关并发症;同时某些内分泌疾病如肥胖、糖尿病、肢端肥大症、多囊卵巢综合征等患者中OSAS的发病率较正常人群为高。文章就OSAS与内分泌疾病的相关性做一综述。