Department of Surgery.
Department of Surgery; School of Medicine, University of California San Francisco.
Am J Med. 2022 Jan;135(1):60-66. doi: 10.1016/j.amjmed.2021.07.041. Epub 2021 Sep 9.
Resistant hypertension is common in patients with primary aldosteronism and in those with obstructive sleep apnea. Primary aldosteronism treatment improves sleep apnea. Despite Endocrine Society guidelines' inclusion of sleep apnea and hypertension co-diagnosis as a primary aldosteronism screening indication, the state of screening implementation is unknown.
All hypertensive adult patients with obstructive sleep apnea (n = 4751) at one institution between 2012 and 2020 were compared with a control cohort without sleep apnea (n = 117,815). We compared the association of primary aldosteronism diagnoses, risk factors, and screening between both groups. Patients were considered to have screening if they had a primary aldosteronism diagnosis or serum aldosterone or plasma renin activity evaluation.
Obstructive sleep apnea patients were predominantly men and had higher body mass index. On multivariable analysis, hypertensive sleep apnea patients had higher odds of drug-resistant hypertension (odds ratio [OR] 2.70; P < .001) and hypokalemia (OR 1.26; P < .001) independent of body mass index, sex, and number of antihypertensive medications. Overall, sleep apnea patients were more likely to be screened for primary aldosteronism (OR 1.45; P < .001); however, few patients underwent screening whether they had sleep apnea or not (pre-guideline publication 7.8% vs 4.6%; post-guidelines 3.6% vs 4.6%; P < .01). Screening among eligible sleep apnea patients remained low prior to and after guideline publication (4.4% vs 3.4%).
Obstructive sleep apnea is associated with primary aldosteronism risk factors without formal diagnosis, suggesting screening underutilization and underdiagnosis. Strategies are needed to increase screening adherence, as patients may benefit from treatment of concomitant primary aldosteronism to reduce sleep apnea severity and its associated cardiopulmonary morbidity.
原发性醛固酮增多症和阻塞性睡眠呼吸暂停患者中常见耐药性高血压。原发性醛固酮增多症的治疗可改善睡眠呼吸暂停。尽管内分泌学会指南将睡眠呼吸暂停和高血压合并诊断作为原发性醛固酮增多症筛查的一个指征，但目前尚不清楚筛查的实施情况。
比较了 2012 年至 2020 年间某机构 4751 例阻塞性睡眠呼吸暂停的高血压成年患者（观察组）和无睡眠呼吸暂停的 117815 例患者（对照组）。比较了两组间原发性醛固酮增多症的诊断、危险因素和筛查的相关性。如果患者有原发性醛固酮增多症的诊断或血清醛固酮或血浆肾素活性评估，则认为其进行了筛查。
阻塞性睡眠呼吸暂停患者主要为男性，且体重指数较高。多变量分析显示，与对照组相比，高血压合并睡眠呼吸暂停患者发生耐药性高血压的可能性更高（比值比[OR]2.70；P <.001），发生低钾血症的可能性也更高（OR 1.26；P <.001），这与体重指数、性别和降压药物的数量无关。总的来说，睡眠呼吸暂停患者更有可能接受原发性醛固酮增多症的筛查（OR 1.45；P <.001）；然而，无论是否患有睡眠呼吸暂停，进行筛查的患者都很少（指南发布前为 7.8%比 4.6%；指南发布后为 3.6%比 4.6%；P <.01）。在指南发布前后，合格的睡眠呼吸暂停患者的筛查率仍然较低（4.4%比 3.4%）。
阻塞性睡眠呼吸暂停与原发性醛固酮增多症的危险因素相关，但未得到明确诊断，这表明筛查的利用率和检出率都较低。需要采取策略来增加筛查的依从性，因为患者可能会从治疗并存的原发性醛固酮增多症中获益，从而降低睡眠呼吸暂停的严重程度及其相关的心肺发病率。
