Lege Artis Medicinae

[The role of dyslipidaemia in the patomechanism of obstructive sleep apnoea ]

MÉSZÁROS Martina, BIKOV András

MARCH 10, 2020

Lege Artis Medicinae - 2020;30(03)

DOI: https://doi.org/10.33616/lam.30.014

[Obstructive sleep apnoea (OSA) is the most recent sleep-breathing disorder, which is characterised by repetitive collapses of the upper airways. Chronic intermittent hy­poxia, sleep fragmentation and systemic inflammation play pre-eminent role in the pathogenesis of OSA and its comorbidities, such as dyslipidaemia. The triple impaired lipid metabolism results in OSA by dysregulated lipid synthesis of the liver, insuffi­cient lipoprotein clearance and increased lypolysis. Several previous studies examined the association between dyslipidaemia and OSA with various outcomes. The aim of this review is to present the pathomechanism of dyslipidemia in the OSA. ]

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[In 2019 the European Atherosclerosis So­ciety (EAS) and European Society of Car­dio­logy (ESC) renewed their dyslipidae­mia guidelines. The new version is more progressive than the previous ones. Thus, in the low-risk, not severely hy­per­choles­te­ro­lae­mic population cholesterol-lowering medication is also suggested. Except this low-risk group, atherogenic target values, e.g. for LDL-cholesterol, were reduced by an entire category, in some cases to the lowest one. If these goals cannot be achieved with statin-monotherapy, combined treatment is recommended generally by the cholesterol inhibitor ezetimib, and in some very high-risk cases also by innovative cholesterol lowering so-called PCSK9 inhibitor. ]

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[BACKGROUND - When treating very el­der­ly and frail hypertensive patients, there have to be taken in account the general health condition and frailty of patients, the present cardiovascular diseases (CVD) and values of the systolic blood pressure (SBP). Goals - In a clinical study performed in 29 countries, we aimed to analyse differences in practical antihypertensive therapy of family doctors among patients older than 80 years; further we sought to answer how much was influenced their therapeutic choice by frailty of the old age. The other goal of our study was to compare Hungarian versus international outcomes. Methodology - As part of an online survey, family practitioners had to decide about necessity of starting antihypertensive treatment among very elderly patients according to different patterns of frailty, SBP and CVD. The ratio of specific cases with positive treatment decision of family practitioners was compared in all 29 countries. We used a logistic mixed model analysis to multivariately model the role of frailty. Results - 2543 family practitioners participated in the cross-national study; 52% were female; 51% practised in urban environment. In 61% of practices, there was the ratio higher than 10% of very elderly patients. Hungary participated with 247 family practitioners in the study; 52.3% were female; 63.1% practised in urban environment. In 48.8% of practices the ratio of very elderly patients was higher than 10%. In 24 out of the 29 countries (83%), frailty was associated with GPs’ negative decision about starting treatment even after adjustment for SBP, CVD, and GP characteristics (odds ratio [OR 0.53]), 95% CI: 0.48-0.59; ORs per country 0.11-1.78). The lowest treatment ratio was in the Netherlands (34.2%; 95% CI: 32.0-36.5%) and the highest one in Ukraine (88.3%; 95% CI: 85.3-90.9%). In Hungary’s treatment ratio ranged 50-59%. This country ranked on the 27th place since Hungarian family practitioners chose rather to start antihypertensive treatment despite the frailty of the patient (OR=1.16; 95% CI: 0.85-1.59). Hungarian family practitioners started pharmacotherapy of elderly patients more frequently if they were males (OR= 1.45; 95% CI: 0.81-2.61), were working in their practice for less than 5 years (OR=2.41; 94% CI: 0.51-11.38), and if they had many patients aged over 80 years in their practice (OR=2.18; 95% CI: 0.70-6.80), however these differences were sta­­tistically not significant. Among Hun­ga­rian family practitioners starting therapy was significantly influen­ced by cardiovascular disease (OR=3.71; 95% CI: 2.64-5.23) and a SBP over 160 mmHg (OR=190.39; 95% CI: 106.83-339.28). Conclusions - In our study, there was significant difference between countries in starting antihypertensive treatment for very elderly patients. However, Hungary was among the countries where family practitioners preferred to treat their frail patients. The patients’ frailty did not have any impact on starting the therapy; rather cardiovascular disease and a SBP over 160 mmHg decided. It is an important message of the study that there is continuous need to educate family practitioners and trainees about the treatment of frail, elderly hypertensive patients.]

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