Obstructive Sleep Apnea and Cardiovascular Disease: A Scientific Statement From the American Heart Association

Genome-wide epigenetic profiling and transcriptome analysis in pediatric Obstructive Sleep Apnea: A focus on Black female children

Obstructive Sleep Apnea (OSA) is a common sleep-related breathing disorder characterized by airway obstruction during sleep. Diagnosing pediatric OSA is challenging, particularly in underrepresented populations, leading to disparities in treatment and long-term negative health outcomes. Our study aimed to identify alternative diagnostic tools by investigating genome-wide epigenetic changes and associated transcriptomic alterations in Black female, pediatric patients with OSA. Whole-genome bisulfite sequencing and RNA sequencing were performed on saliva samples from healthy controls and children with OSA. Analysis of differential methylation and gene expression patterns revealed dysregulated inflammation and metabolism pathways in children with OSA. Chromosomes 19 and 22 exhibited elevated methylation signatures in this patient population. Integration of methylation and gene expression data identified specific molecular markers, including NAP1L4, CCR1, and LIF. The study emphasizes the need to consider both genetic and environmental factors in pediatric OSA, and the identified markers may offer avenues for further research.

Preventive medicine in obstructive sleep apnea-a systematic review and a call to action

STUDY OBJECTIVES

The purpose of this systematic review is to evaluate the modifiable risk factors associated with obstructive sleep apnea (OSA) and analyze extant publications solely focused on prevention of the disease.

METHODS

Studies focused on prevention strategies for OSA and modifiable risk factors were eligible for inclusion. A detailed individual search strategy for each of the following bibliographic databases was developed: Cochrane, EMBASE, MEDLINE, PubMed, and LILACS. The references cited in these articles were also crosschecked and a partial gray literature search was undertaken using Google Scholar. The methodology of selected studies was evaluated using the 14-item Quality Assessment Tool for Diagnostic Accuracy Studies.

RESULTS

Search resulted in 720 publications examining risk factors and prevention of OSA, as well as lifestyle modifications. Of these, a thorough assessment of the abstracts and content of each of these manuscripts led to the rejection of all but four papers, the latter being included in this systematic review. In contrast, a search regarding "Therapeutics" showed that 23 674 articles on OSA were published, clearly illustrating the imbalance between the efforts in prevention and those focused on therapeutics.

CONCLUSIONS

Notwithstanding the importance and benefits of technological advances in medicine, consideration of the needs of people with OSA and its consequences prompts advocacy for the prevention of the disease. Thus, despite the economic interests that focus only on diagnosis and treatment, strategies preferentially aimed at overall avoidance of OSA emerge as a major priority. Thus, public and healthcare provider education, multidimensional prevention, and early diagnosis of OSA should be encouraged worldwide.

Association between hypothyroidism and obstructive sleep apnea: a bidirectional Mendelian randomization study combined with the geo database

Background

The causal relationship between hypothyroidism and obstructive sleep apnea (OSA) remains controversial. Therefore, our research used a bidirectional Mendelian randomization (MR) method in an attempt to determine the causal relationship between hypothyroidism and OSA.

Methods

From the publicly accessible genome-wide association analysis (GWAS) summary database, we obtained single nucleotide polymorphism (SNPs) data pertaining to hypothyroidism and OSA. Inverse variance weighting (IVW) was the principal method of analysis utilized, with validation also conducted via weighted median, MR-Egger, simple model, and weighted model approaches. To further evaluate the robustness of the results, heterogeneity testing, pleiotropy testing, and the "leave-one-out" sensitivity analysis were performed. Differentially expressed genes (DEGs) from the OSA dataset (GSE135917) and hypothyroidism dataset (GSE176153) derived from the Gene Expression Omnibus (GEO) database were screened using the "limma" package. The "clusterProfiler" and "GO plot" packages were used for further enrichment analysis in order to validate the findings of the MR study. The Cytoscape software was utilized to build a protein-protein interaction (PPI) network of DEGs and to screen for hub genes.

Results

The MR analysis showed that genetically predicted hypothyroidism was associated with an increased risk of OSA [IVW odds ratio (OR) = 1.734; 95% confidence interval (CI) = 1.073-2.801; p = 0.025]. The trend of the outcomes of the other approaches is consistent with the trend of the IVW outcome. However, the reverse MR analysis suggested no evidence for the causal effect of OSA on hypothyroidism (IVW OR = 1.002, 95% CI: 0.996-1.009, p = 0.454). The robustness of the results was confirmed by the sensitivity analysis. Bioinformatics analysis revealed that there were DEGs that hypothyroidism and OSA have in common.

Conclusion

Our findings suggested that hypothyroidism may increase the risk of OSA, while the effect of OSA on hypothyroidism was not found in this MR study. Thus, patients with hypothyroidism should be enhanced with screening for OSA for early diagnosis and appropriate treatment.

Association between Obstructive Sleep Apnea and Age-related Macular Degeneration Development and Progression

OBJECTIVE

To evaluate the risk of age-related macular degeneration (AMD) development and progression in individuals with diagnosed obstructive sleep apnea (OSA).

DESIGN

Retrospective cohort study.

SUBJECTS

Before propensity score matching (PSM), 60 652 and 1 173 723 individuals with OSA or not, respectively, were included in the study. After PSM and applying inclusion/exclusion criteria, 58 700 individuals in each cohort were subsequently analyzed.

METHODS

Data were collected using TriNetX, a deidentified electronic health records research network. Individuals with an International Classification of Diseases, 10th Revision, code for OSA confirmed with polysomnography and an additional code for continuous positive airway pressure use were compared with individuals without diagnosed OSA (control cohort) for the development of main outcome measures at 5 years. Secondary analyses were included to assess nonadvanced AMD progression in individuals with and without diagnosed OSA at 5 years.

MAIN OUTCOME MEASURES

The main outcome measures were the incidence of AMD, macular hemorrhage, legal blindness, and requiring anti-VEGF intervention at 5 years. Individuals with nonadvanced AMD with and without an OSA diagnosis were separately analyzed for progression to late AMD and the development of macular hemorrhage, legal blindness, and requiring anti-VEGF therapy at 5 years.

RESULTS

At 5 years, individuals with diagnosed OSA had a significantly elevated risk of nonexudative AMD (hazard ratio [HR], 2.64; 95% confidence interval [CI], 2.37-2.96; P < 0.001), exudative AMD (HR, 2.48; 95% CI, 1.99-3.11; P = 0.002), and requiring anti-VEGF therapy (HR, 2.85; 95% CI, 2.26-3.59; P < 0.001) compared with the control cohort. In the secondary analysis, individuals with nonadvanced AMD with diagnosed OSA were associated with an elevated risk of geographic atrophy (HR, 7.00; 95% CI, 4.47-11.0; P = 0.03), exudative AMD (HR, 2.87; 95% CI, 2.37-3.48; P = 0.03), and requiring anti-VEGF injections (HR, 4.72; 95% CI, 3.59-6.22; P = 0.02) compared with those with nonadvanced AMD without diagnosed OSA.

CONCLUSIONS

In a large, heterogeneous database, an elevated risk of developing AMD and progression to later stages of the disease was observed among individuals with diagnosed OSA.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Exploring the complexity of obstructive sleep apnea: findings from machine learning on diagnosis and predictive capacity of individual factors

PURPOSE

Obstructive sleep apnoea (OSA) is a prevalent sleep disorder characterized by pharyngeal airway collapse during sleep, leading to intermittent hypoxia, intrathoracic pressure swings, and sleep fragmentation. OSA is associated with various comorbidities and risk factors, contributing to its substantial economic and social burden. Machine learning (ML) techniques offer promise in predicting OSA severity and understanding its complex pathogenesis. This study aims to compare the accuracy of different ML techniques in predicting OSA severity and identify key associated factors contributing to OSA.

METHODS

Adult patients suspected of OSA underwent clinical assessments and polysomnography. Demographic, anthropometric and clinical data were collected. Five supervised ML models (logistic regression, decision tree, random forest, extreme gradient boosting, support vector machine) were employed, optimized through grid search and cross-validation.

RESULTS

ML models exhibited varied performance across OSA severity levels. SVM demonstrated the highest accuracy for mild OSA, XGBoost for moderate OSA, and random forest for severe OSA. Logistic regression showed the highest AUC for moderate and severe OSA. Anthropometric measures, gender, and hypertension were significant predictors of OSA severity.

CONCLUSION

ML models offer valuable insights into predicting OSA severity and identifying associated factors. Our findings support the relevant potential clinical utility of ML in OSA management, although further validation and refinement are warranted.

Signal detection of drugs associated with obstructive and central sleep apnoea

We aim to discover new safety signals of drug-induced sleep apnoea (SA), a global health problem affecting approximately 1 billion people worldwide. We first conducted a series of sequence symmetry analyses (SSA) in a cohort composed from all patients who received a first SA diagnosis or treatment between 2006 and 2018 in the Echantillon Généraliste des Bénéficaires (EGB), a random sample of the French healthcare database. We used two primary outcomes to estimate the sequence ratio (SR) for all drug classes available in France: a sensitive one (diagnosis or treatment of SA) and a specific one (Positive Airway Pressure (PAP) therapy). We then performed disproportionality analyses using the "Bayesian neural network method" on all cases of sleep apnoea (MedDRA high level term) reported up to November 2023 in the World Health Organisation (WHO) pharmacovigilance database. Among the 728,167 individuals, 46,193 had an incident diagnosis or treatment for SA and 17,080 had started an incident treatment by PAP therapy. Fifty-eight drug classes had a significant SR, with 7 considered highly plausible: opium alkaloids and derivatives, benzodiazepine derivatives, other centrally acting agents, other anxiolytics, carbamic acid esters, quinine and derivatives and antivertigo preparations; with consistent signals found for the first 3 drug classes in the disproportionality analysis. In this signal detection study, we found that opioids, benzodiazepines (but not Z-drugs) and myorelaxing agents are associated with the onset or aggravation of SA. Moreover, a new safety signal for antivertigo preparations such as betahistine emerged and needs to be further explored.

2024 Guideline for the Primary Prevention of Stroke: A Guideline From the American Heart Association/American Stroke Association

AIM

The "2024 Guideline for the Primary Prevention of Stroke" replaces the 2014 "Guidelines for the Primary Prevention of Stroke." This updated guideline is intended to be a resource for clinicians to use to guide various prevention strategies for individuals with no history of stroke.

METHODS

A comprehensive search for literature published since the 2014 guideline; derived from research involving human participants published in English; and indexed in MEDLINE, PubMed, Cochrane Library, and other selected and relevant databases was conducted between May and November 2023. Other documents on related subject matter previously published by the American Heart Association were also reviewed.

STRUCTURE

Ischemic and hemorrhagic strokes lead to significant disability but, most important, are preventable. The 2024 primary prevention of stroke guideline provides recommendations based on current evidence for strategies to prevent stroke throughout the life span. These recommendations align with the American Heart Association's Life's Essential 8 for optimizing cardiovascular and brain health, in addition to preventing incident stroke. We also have added sex-specific recommendations for screening and prevention of stroke, which are new compared with the 2014 guideline. Many recommendations for similar risk factor prevention were updated, new topics were reviewed, and recommendations were created when supported by sufficient-quality published data.

Nocturia and obstructive sleep apnoea

Nocturia, the need to urinate at night, is a common symptom in patients with obstructive sleep apnoea (OSA). Continuous positive airway pressure treatment can reduce nocturia in some patients, but the underlying mechanisms are complex and not fully understood. OSA affects the autonomic nervous system, oxidative stress and endothelial damage. Furthermore, the commonly held theory attributing polyuria to a false signal of cardiac overload and response natriuresis has limitations. A comprehensive approach to the management of nocturia in OSA, considering factors such as comorbidities, medication use, alcohol consumption and lifestyle, is needed. Effective management of nocturia in OSA requires a multidisciplinary approach, and urologists should be aware of the potential effect of OSA on physiology and refer patients for further testing at a sleep centre. In addition to continuous positive airway pressure, other interventions such as oral appliances and surgical obstruction treatment could be beneficial for some patients. Overall, understanding the complex interplay between OSA and nocturia is crucial for optimizing patient outcomes.

Melatonin mediates intestinal barrier dysfunction and systemic inflammation in moderate-severe OSA patients

BACKGROUND

Intestinal barrier dysfunction and systemic inflammation are common in obstructive sleep apnoea (OSA). We aimed to investigate the role of melatonin, an anti-inflammatory mediator, in mediating the relationships between OSA, intestinal barrier dysfunction and systemic inflammation.

METHODS

Two hundred and thirty-five male participants who complained with sleep problems and underwent whole night polysomnography at our sleep centre between 2017 and 2018 were enrolled. Polysomnographic data, anthropometric measurements and biochemical indicators were collected. Serum melatonin, intestinal barrier function biomarker zonula occludens-1 (ZO-1) and inflammatory biomarkers C-reactive protein (CRP) with lipopolysaccharide (LPS) were detected. Spearman's correlation analysis assessed the correlations between sleep parameters, melatonin and biomarkers (ZO-1, LPS and CRP). Mediation analysis explored the effect of OSA on intestinal barrier dysfunction and systemic inflammation in moderate-severe OSA patients.

RESULTS

As OSA severity increased, serum melatonin decreased, whereas ZO-1, LPS and CRP increased. Spearman's correlation analysis showed that serum melatonin was significantly negatively correlated with ZO-1 (r = -0.19, p < .05) and LPS (r = -0.20, p < .05) in the moderate-OSA group; serum melatonin was significantly negatively correlated with ZO-1 (r = -0.46, p < .01), LPS (r = -0.35, p < .01) and CPR (r = -0.30, p < .05) in the severe-OSA group. Mediation analyses showed melatonin explain 36.12% and 35.38% of the effect of apnoea-hypopnea index (AHI) on ZO-1 and LPS in moderate to severe OSA patients.

CONCLUSIONS

Our study revealed that melatonin may be involved in mediating intestinal barrier dysfunction and systemic inflammation in moderate-to-severe OSA patients.

Effects of multilevel OSA surgery on patients with poor cardiopulmonary performance: A prospective pilot study

OBJECTIVE

Multilevel airway surgery for obstructive sleep apnea/hypopnea syndrome (OSA) has benefits in improving sleep quality, but its effect on polysomnography (PSG) and 6-minute walk test (6MWT) parameters, including walking distance and cardiopulmonary performance, in patients with poor pre-operative cardiopulmonary performance remains understudied, which should be further investigated.

METHODS

This prospective pilot study enrolled 27 consecutive OSA patients with poor pre-operative 6MWT results. All patients received multilevel OSA surgery, and the alterations of sleep parameters and 6MWT profiles were studied. The pre- and post-operative values of polysomnographic data and 6MWT profiles were analyzed using the Wilcoxon signed-rank tests. The relationships among changes of the indices of PSG and 6MWT were further investigated with the Spearman's correlations.

RESULTS

After surgery, the sleep parameters and certain cardiopulmonary indices improved. When analyzing the correlations among changes of the indices of PSG and 6MWT, the improvement of daytime sleepiness (with ESS) was found related to farther walking distance (ρ=-0.414, p = 0.032) and higher percentage of "distance/target distance" (ρ=-0.435, p = 0.023). Moreover, the change of maximal expiratory pressure was the only index associated with the changes of AHI (apnea/hypopnea index, /hr.; ρ=-0.407, p = 0.035) and AHI in REM (ρ=-0.502, p = 0.009) among the cardiopulmonary performance parameters.

CONCLUSION

This pilot study showed that OSA patients with poor pre-operative cardiopulmonary status undergoing multilevel sleep surgery could experience improvement in the sleep study and 6MWT to some extent. The relatively better walking distance and cardiopulmonary performance after the operation might potentially result from the improvement of daytime sleepiness and better respiration.

Estimating Cardiovascular Benefits of Tirzepatide in Sleep Apnea and Obesity: Insight from the SURMOUNT-OSA Trials

PURPOSE OF COMMENTARY

This commentary aims to offer a perspective on the effect of tirzepatide on hypoxic burden and provide indirect evidence of cardiovascular risk reduction after tirzepatide for the treatment of obstructive sleep apnea and obesity. It also discusses the role of tirzepatide-induced weight loss in the management of obstructive sleep apnea.

RECENT FINDINGS

In the SURMOUNT-OSA phase 3 trials, tirzepatide, a new GIP/GLP-1 receptor co-agonist, reduced the apnea-hypopnea index, hypoxic burden, and body weight in adults with moderate-to-severe obstructive sleep apnea and obesity. The change in apnea-hypopnea index is clinically relevant, but its impact on cardiovascular mortality remains unclear. Conversely, hypoxic burden predicts cardiovascular mortality across populations independent of AHI. We attempted to postulate the magnitude of cardiovascular benefits of tirzepatide based on the reduction in hypoxic burden. Tirzepatide treatment for obstructive sleep apnea and obesity seems to result in hypoxic burden values associated with a lower cardiovascular mortality rate and thus might attenuate the negative cardiovascular impact of hypoxic burden.

Advances in Multimodal Echocardiographic Evaluation of Ischemic Cardiomyopathy due to Obstructive Sleep Apnea Syndrome

Obstructive sleep apnea syndrome (OSAS) is characterized by recurrent complete (apneas) and partial (hypopneas) upper airway events, causing intermittent hypoxemia and sleep fragmentation. It significantly impacts the cardiovascular system, increasing the morbidity and mortality associated with various complications. Therefore, employing appropriate echocardiographic methods to assess myocardial function in OSAS patients is crucial. It can facilitate early clinical intervention, enhance the quality of life, and potentially extend patients' survival.

The modified Baveno classification for obstructive sleep apnoea: development and evaluation based on the ESADA database

BACKGROUND

The "Baveno classification" replaced the apnoea-hypopnoea index (AHI) with symptoms and comorbidities for treatment indication in obstructive sleep apnoea (OSA). This study evaluates a modified Baveno classification which adds a validated cardiovascular disease (CVD) risk score and acknowledges severe breathing disturbances.

METHOD

OSA patients from the European Sleep Apnoea Database (ESADA) were retrospectively allocated into CVD risk groups 1-3 based on the SCORE2 risk prediction model and European Society of Cardiology guidelines. AHI ≥30 events·h-1 conferred strong treatment indication. When AHI was <30 events·h-1, symptoms and CVD risk dictated allocation to the weak, intermediate or strong treatment indication group. Changes in Epworth Sleepiness Scale (ESS) score and office systolic blood pressure (SBP) at follow-up (12-24 months) under positive airway pressure (PAP) were assessed.

RESULTS

8625 patients were analysed (29% female; median (interquartile range) age 56 (49-64) years and body mass index 31.9 (28.4-36.3) kg·m-2). Treatment indication was weak in 501 (6%), intermediate in 2085 (24%) and strong in 6039 (70%). There was a continuous increase in age, SBP, C-reactive protein and glycosylated haemoglobin from weak to strong (p<0.001). PAP prescription increased from 52% to 64% to 93% (weak to strong; p<0.001). The change in ESS score was -2, -4 and -5, respectively (p<0.001). Reductions of ≥3 mmHg median SBP occurred when AHI was ≥30 events·h-1 and in symptomatic patients with CVD risk levels >1 when AHI was <30 events·h-1.

CONCLUSION

This analysis provides supporting evidence for the key role of CVD risk assessment and severe breathing disturbances in the identification of OSA patients most likely to benefit from treatment.

Epidemiology of cardiovascular risk factors: Behavioural risk factors

Cardiovascular diseases (CVDs) have a multifactorial origin. Among the risk factors, so-called behavioural risk factors play a major role in the onset of these diseases: smoking, unhealthy diet, lack of physical activity and sedentary lifestyle, alcohol, sleep disorders, depression and illicit drug use are among the main behavioural risk factors for CVD and are considered to be modifiable and accessible to prevention. The prevalence of these cardiovascular risk factors remains high among the French population. Nearly one in three adults are smokers, 71.7% do not meet the recommendation to eat five fruits and vegetables per day, and 4 out of 5 adults consume more than 6g of salt per day. Further, 38.7% of adults do not meet the recommendations for physical activity, 40.8% have a high level of sedentary, 49.4% report sleep problems in the last 8 days, and 12.5% have had a major depressive episode in the last 12 months. Despite some positive trends, such as an increase in the level of physical activity among men and the decline in smoking prevalence, the epidemiological situation regarding these risk factors remains a cause for concern in France. While the gap between risk factors in men and women is narrowing, this is often due to a worsening of the situation among women, who are increasingly adopting unfavourable behaviours and tending to reach the higher levels of risk factors traditionally observed among men. The epidemiological situation demonstrates the urgent need to strengthen policies to prevent these risk factors.

Study on OSA screening and influencing factors in community-based elderly hypertensive patients based on single-lead wearable ECG devices

PURPOSE

Assessing whether single-lead ECG can be effectively and relatively inexpensively used in large-scale OSA screening, and identifying factors influencing moderate-to-severe OSA among elderly hypertensive patients without atypical symptoms in primary care.

METHODS

The study gathered data from 15 medical institutions in Ningxia between January and December 2022 using cloud platforms. The dataset included basic information and 72-h ECG monitoring for 2573 hypertensive patients over 65. OSA screening was conducted using the single-lead wearable ECG devices based on the ACAT algorithm. A multivariable logistic regression identified the main factors affecting OSA severity in these patients, and the AUC was used to assess the model's predictive accuracy.

RESULTS

The study found an OSA detection rate of 87.10%, with 55.42% being moderate to severe cases. Key risk factors associated with developing moderate-to-severe OSA included cardiac irregularities like supraventricular extrasystole and atrioventricular block, male gender, lifestyle factors like alcohol consumption and smoking, and health indicators such as SDNN ≤ 100 ms, abnormal LF/HF ratio, BMI, and age. The model's accuracy for predicting OSA, indicated by a ROAUC of 0.625, was moderate. Factors like gender, tea consumption, stroke history, and ventricular tachycardia were also independently linked to OSA severity.

CONCLUSION

This study combines single-lead wearable ECG devices with the ACAT algorithm for OSA screening in Ningxia, China. Initial screening identified 87.10% of participants as having OSA, with 55.42% being moderate to severe cases. This suggests a convenient, low-cost, and repeatable ECG-based method for OSA screening, potentially improving early detection and management of OSA by identifying potential risk factors.

Two-stage screening for obstructive sleep apnea in the primary practice setting

PURPOSE

To evaluate the effectiveness of a two-stage screening model for obstructive sleep apnea (OSA) in primary care that combines the STOP-BANG questionnaire (SBQ) with an automated home sleep apnea test (HSAT).

METHODS

This cross-sectional study was conducted from August 2018 to August 2022 in four Slovenian primary care practices. It included 153 randomly selected patients aged 18 to 70 years who visited the practice for any reason. Participants completed the SBQ and underwent HSAT with type III polygraphy on the same night. The HSAT recordings were scored automatically and by an experienced, accredited somnologist.

RESULTS

There was a strong correlation between manual and automated HSAT scorings for the detection of OSA (Pearson's r = 0.93). Cohen's kappa was 0.80 for OSA (respiratory event index (REI) ≥ 5) and 0.77 for OSA severity categorization. The two-stage model demonstrated sensitivity of 64%, a specificity of 97.4%, a positive predictive value (PPV) of 96.0%, a negative predictive value (NPV) of 73.8% and an accuracy of 81.1% for any OSA (REI ≥ 5). For moderate to severe OSA (REI ≥ 15), the model showed 72.7% sensitivity, 96.7% specificity, 85.7% PPV, 92.8% NPV and 91.5% accuracy.

CONCLUSIONS

The two-stage model for OSA screening combining the SBQ and automated HSAT was shown to be effective in primary care, especially for moderate and severe OSA. This method provides a practical and efficient approach for the early detection of OSA.

The association between obstructive sleep apnea and osteoporosis: A systematic review and meta-analysis

Obstructive sleep apnea (OSA) is a sleep disorder with well-known metabolic consequences. The relationship between OSA and bone health, especially osteoporosis, remains poorly understood. Given that both OSA and osteoporosis are highly prevalent chronic conditions with significant public health implications, this study aims to investigate the association of OSA with bone health and osteoporosis. A systematic search of PubMed, Embase and Cochrane Library was conducted from inception to November 22, 2022. Fifteen studies comprising 158,273 individuals were included. The presence of OSA correlated negatively with bone mineral density on meta-analysis (pooled correlation = -0.30; 95 % CI, -0.42 to -0.17; N = 8). Individuals with OSA had poorer bone mineral density scores (mean difference = -0.58, 95 % CI, -1.15 to -0.01; N = 8), and significantly higher risk of developing osteoporosis (adjusted odds ratio = 2.18; 95 % CI, 1.14 to 4.16; N = 4). Notably, both body mass index (BMI) and age were not significant effect modulators in the correlation of OSA and bone density. These findings suggest that OSA is associated with diminished bone health, and it is severity-dependent. Further studies are required to determine if treatment of OSA may have the potential to mitigate these risks.

Sleep apnea prevalence and severity after coronary revascularization versus no intervention: a systematic review & meta-analysis

PURPOSE

Obstructive sleep apnea (OSA) is a common disease in patients with coronary artery disease (CAD). Approximately 40-80% of cardiovascular disease patients have obstructive sleep apnea. The manifestation of it can vary significantly in different types of CAD patients. This systematic review and meta-analysis investigate the prevalence and severity of OSA in patients with acute coronary syndrome (ACS).

METHODS

This systematic review was conducted according to PRISMA guidelines. The first inclusion criteria were that a reliable sleep study had to be done after treating the patients' acute coronary incident. All patients in the studies included were adults suffering from an ACS who underwent either coronary artery bypass grafting surgery (CABG), a percutaneous coronary intervention (PCI) or had no invasive coronary intervention done. A search was conducted within four valid databases 27.1.2023 and all suitable articles published after 1.1.2010 were included.

RESULTS

Eight studies fulfilled the full inclusion criteria. In five of them, a sleep study had been performed after PCI, in two after no coronary intervention, and in one study after CABG. Mean AHI in no-OSA group after PCI was 9.5 /h (95% CI 5.3-13.7) and in the no intervention group 6.4 /h (95% CI 3.5-9.4). In OSA patients, mean AHI after PCI was 34.9 /h (95% CI 25.9-43.8) vs. 24.1 /h without intervention (95% CI 15.6-32.6).

CONCLUSIONS

Sleep apnea is very common among ACS patients and should be screened for and addressed after the acute coronary intervention. Moreover, we found that OSA is more severe in patients in whom PCI for ACS was indicated as opposed to patients who underwent no coronary intervention.

Back to Roots: Dysbiosis, Obesity, Metabolic Syndrome, Type 2 Diabetes Mellitus, and Obstructive Sleep Apnea-Is There an Objective Connection? A Narrative Review

In recent decades, it has become clear that the gut is more than just a digestive organ; it also functions as an immune organ with regulatory capabilities and acts as a "second brain" that influences brain function due to the presence and regulatory roles of the gut microbiota (GM). The GM is a crucial component of its host and significantly impacts human health. Dysbiosis, or microbial imbalance, has been closely linked to various diseases, including gastrointestinal, neurological, psychiatric, and metabolic disorders. The aim of this narrative review is to highlight the roles of the GM in maintaining metabolic health. Sleep is a vital biological necessity, with living organisms having evolved an internal sleep-wake rhythm that aligns with a roughly 24 h light/dark cycle, and this is known as the circadian rhythm. This cycle is essential for tissue repair, restoration, and overall optimal body functioning. Sleep irregularities have become more prevalent in modern society, with fast-paced lifestyles often disrupting normal sleep patterns. Urban living factors, such as fast food consumption, shift work, exposure to artificial light and nighttime noise, medications, and social activities, can adversely affect circadian rhythms, with dysbiosis being one of the many factors incriminated in the etiology of sleep disorders.

Up-to-date advance in the relationship between obstructive sleep apnea and heart failure: a narrative review

PURPOSE

Obstructive sleep apnea (OSA) is recognized as an independent and significant risk factor for various cardiovascular and cerebrovascular conditions, including heart failure (HF). In this review, we explore the impact of OSA on HF, examine shared contributing factors and underlying pathophysiological mechanisms, and assess the treatment options for OSA and their potential therapeutic value in HF patients.

METHODS

Pubmed/MEDLINE were searched through September 2024 to explore the relationship between OSA and HF. The relevant papers included OSA and HF, risk factors of OSA and HF, and the prognosis and treatment of HF patients with OSA.

RESULTS

The results showed that OSA increased the risk of HF. OSA can exacerbate or contribute to the onset of HF in several ways. The application of continuous positive airway pressure (CPAP) and other treatments may benefit HF patients with OSA. Drug therapy has shown promise for treating OSA, extensive multi-center studies remain essential, particularly in patients with both OSA and HF.

CONCLUSION

OSA can exacerbate or contribute to the onset and recurrence of HF in several ways. Further studies should be carried out to explore effective treatments in patients with HF and OSA.

Evaluation of arterial stiffness and quality of life in the treatment of moderate to severe obstructive sleep apnea with Continuous Positive Airway Pressure or Mandibular Advancement Appliance: a cross-sectional study

BACKGROUND

Obstructive sleep apnea (OSA) is highly associated with a significant reduction in the Quality of Life (QoL) and is associated with deleterious effects on the cardiovascular system. Arterial stiffness is characterized by morphofunctional changes in the arteries and its assessment can be obtained non-invasively mainly through the measurement of pulse wave velocity (PWV). Arterial stiffness has been proposed as a predictor of cardiovascular diseases.

OBJECTIVE

To compare arterial stiffness as well as QoL in patients diagnosed with moderate to severe OSA treated with Continuous Positive Airway Pressure (CPAP) or Mandibular Advancement Appliance (MAA) therapies.

METHODS

This is a cross-sectional study involving 105 participants diagnosed with moderate to severe OSA categorized into three independent groups: A Non-treated Control Group and CPAP and MAA treated Groups. QoL was assessed by the Quebec Sleep Questionnaire (QSQ) and arterial stiffness was assessed noninvasively by Mobil-O-Graph.

RESULTS

The groups were homogeneous, except for the polysomnographic parameters Apnea and Hypopnea Index (AHI) (p = 0.036) and Minimum O2 saturation (p = 0.011) (evaluated to diagnose the OSA condition before treatment) and Body Mass Index (BMI) (p < 0.001). The MAA group presented higher scores in all QoL domains (p < 0.05), except Social Interactions in relation to the Control group. For the CPAP group, only Nocturnal Symptoms presented significantly higher scores compared to the control group (p = 0.39). For Arterial Stiffness, no statistical differences were observed among comparisons.

CONCLUSIONS

Our results show better QoL scores in patients with OSA treated by CPAP and mainly by MAA. Differently, arterial stiffness parameters did not differ between the groups treated with CPAP and MAA and the control group.

Gut Microbiota and Derived Metabolites Mediate Obstructive Sleep Apnea Induced Atherosclerosis

Background

Obstructive sleep apnea (OSA) is characterized by intermittent hypoxia/hypercapnia (IHC), affects predominantly obese individuals, and increases atherosclerosis risk. Since we and others have implicated gut microbiota and metabolites in atherogenesis, we dissected their contributions to OSA-induced atherosclerosis.

Results

Atherosclerotic lesions were compared between conventionally-reared specific pathogen free (SPF) and germ-free (GF) ApoE -/- mice following a high fat high cholesterol diet (HFHC), with and without IHC conditions. The fecal microbiota and metabolome were profiled using 16S rRNA gene amplicon sequencing and untargeted tandem mass spectrometry (LC-MS/MS) respectively. Phenotypic data showed that HFHC significantly increased atherosclerosis as compared to regular chow (RC) in both aorta and pulmonary artery (PA) of SPF mice. IHC exacerbated lesions in addition to HFHC. Differential abundance analysis of gut microbiota identified an enrichment of Akkermansiaceae and a depletion of Muribaculaceae (formerly S24-7) family members in the HFHC-IHC group. LC-MS/MS showed a dysregulation of bile acid profiles with taurocholic acid, taurodeoxycholic acid, and 12-ketodeoxycholic acid enriched in the HFHC-IHC group, long-chain N-acyl amides, and phosphatidylcholines. Interestingly, GF ApoE -/- mice markedly reduced atherosclerotic formation relative to SPF ApoE -/- mice in the aorta under HFHC/IHC conditions. In contrast, microbial colonization did not show a significant impact on the atherosclerotic progression in PA.

Conclusions

In summary, this research demonstrated that (1) IHC acts cooperatively with HFHC to induce atherosclerosis; (2) gut microbiota modulate atherogenesis, induced by HFHC/IHC, in the aorta not in PA; (3) different analytical methods suggest that a specific imbalance between Akkermansiaceae and Muribaculaceae bacterial families mediate OSA-induced atherosclerosis; and (4) derived bile acids, such as deoxycholic acid and lithocholic acid, regulate atherosclerosis in OSA. The knowledge obtained provides novel insights into the potential therapeutic approaches to prevent and treat OSA-induced atherosclerosis.

Relationship Between the Risk of Obstructive Sleep Apnea and Cardiovascular Health in Middle-Aged Korean Men and Women: A Nationwide Study

Background/Objectives: Cardiovascular health (CVH) can be conceptualized as encompassing seven health behaviors and metabolic factors that contribute to cardiovascular disease. We explored the relationship between the risk of obstructive sleep apnea (OSA) and CVH among middle-aged Korean adults. Methods: Data from 5909 participants, aged between 40 and 64 years, in the Korea National Health and Nutrition Examination Survey (2019-2021) were analyzed. The risk of OSA was assessed using STOP-Bang questionnaire. CVH metrics, including smoking status, diet, physical activity, body mass index (BMI), blood pressure, total cholesterol level, and fasting glucose concentration, were evaluated using American Heart Association criteria. Multivariate logistic regression analysis was employed to investigate the association between OSA risk and CVH. Results: Among study participants, 78.6% of men and 16.3% of women displayed moderate-to-high risk of OSA, while 45.4% of men and 17.2% of women exhibited poor CVH. The ORs (95% CIs) for poor CVH were 2.69 (2.08-3.49) for men at moderate risk of OSA and 6.54 (4.81-8.90) for those at high risk, compared to men at low risk. For women, the ORs were 3.21 (2.47-4.19) for those with moderate risk and 12.88 (6.29-26.38) for those with high risk of OSA, compared to women at low risk. CVH metrics associated with moderate-to-high OSA risk included high BMI, high blood pressure, elevated fasting glucose, and smoking. Conclusions: The risk of OSA was associated with poor CVH, while various CVH components were linked to moderate-to-high OSA risk. Managing both OSA and components of CVH is essential to minimize poor CVH.

2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery.

METHODS

A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.

2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery.

METHODS

A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.

Metabolically 'extremely unhealthy' obese and non-obese patients with diabetes and the risk of cardiovascular events: a French nationwide cohort study

BACKGROUND

Non-obese patients with diabetes mellitus (DM) are becoming more prevalent, but their cardiovascular risk (CV) especially when accompanied with cardio-renal-metabolic co-morbidities (hypertension, chronic kidney disease, hyperlipidemia) is not well characterised. The aim of the study was to assess the CV risk among patients with DM in relation to obesity and cardio-renal-metabolic co-morbidities.

MATERIALS AND METHODS

This was a cohort study of all patients with DM without a history of major adverse cardiovascular event who were hospitalized for any reason in France in 2013 with at least 5 years of follow-up. They were categorized by the presence of obesity vs no obesity, as well as three cardio-renal-metabolic co-morbidities: hypertension, chronic kidney disease, hyperlipidemia. 'Extremely unhealthy' patients with DM were defined as those having all 3 co-morbidities.

RESULTS

There were 196,112 patients (mean age 65.7 (SD 13.7) years; 54.3% males) included into the analysis. During a mean follow-up of 4.69 ± 1.79 years, when adjusted for multiple covariates, the non-obese and 'extremely unhealthy' obese patients had the highest risk of CV death [aHR 1.40 (95% CI, 1.22-1.61) and 1.48 (95% CI, 1.25-1.75), respectively]. The 'extremely unhealthy' obese had the highest risk of MACE-HF [aHR 1.84 (95% CI, 1.72-1.97)] and new-onset AF [aHR 1.64 (95% CI, 1.47-1.83)].

CONCLUSION

Both non-obese and obese patients with DM with associated cardio-renal-metabolic co-morbidities are an 'extremely unhealthy' phenotype with the highest risk of CV death and CV events.

OSA diagnosis goes wearable: are the latest devices ready to shine?

STUDY OBJECTIVES

From 2019-2023, the United States Food and Drug Administration has cleared 9 novel obstructive sleep apnea-detecting wearables for home sleep apnea testing, with many now commercially available for sleep clinicians to integrate into their clinical practices. To help clinicians comprehend these devices and their functionalities, we meticulously reviewed their operating mechanisms, sensors, algorithms, data output, and related performance evaluation literature.

METHODS

We collected information from PubMed, United States Food and Drug Administration clearance documents, ClinicalTrials.gov, and web sources, with direct industry input whenever feasible.

RESULTS

In this "device-centered" review, we broadly categorized these wearables into 2 main groups: those that primarily harness photoplethysmography data and those that do not. The former include the peripheral arterial tonometry-based devices. The latter was further broken down into 2 key subgroups: acoustic-based and respiratory effort-based devices. We provided a performance evaluation literature review and objectively compared device-derived metrics and specifications pertinent to sleep clinicians. Detailed demographics of study populations, exclusion criteria, and pivotal statistical analyses of the key validation studies are summarized.

CONCLUSIONS

In the foreseeable future, these novel obstructive sleep apnea-detecting wearables may emerge as primary diagnostic tools for patients at risk for moderate-to-severe obstructive sleep apnea without significant comorbidities. While more devices are anticipated to join this category, there remains a critical need for cross-device comparison studies as well as independent performance evaluation and outcome research in diverse populations. Now is the moment for sleep clinicians to immerse themselves in understanding these emerging tools to ensure our patient-centered care is improved through the appropriate implementation and utilization of these novel sleep technologies.

CITATION

Chiang AA, Jerkins E, Holfinger S, et al. OSA diagnosis goes wearable: are the latest devices ready to shine? J Clin Sleep Med. 2024;20(11):1823-1838.

Cardiovascular Events Risk in Office-Masked Nocturnal Hypertension Defined by Home Blood Pressure Monitoring

Background

Nocturnal home blood pressure monitoring (HBPM) may identify people at higher cardiovascular disease (CVD) risk than expected.

Objectives

The aim of this study was to examine the association between office-masked nocturnal hypertension, defined by HBPM, and CVD risk in a clinical practice-based population.

Methods

Prospective observational study including Japanese high cardiovascular-risk participants. Three office blood pressures (OBPs) were taken on two different occasions. Nocturnal home blood pressure (HBP) was measured three times per night for 2 weeks. The association between office-masked nocturnal hypertension and time to first CVD events (fatal and nonfatal stroke or coronary heart disease) was examined using Cox regression.

Results

The cohort included 2,545 participants who were followed for a median of 7.8 years (18,116 person-years), during which 152 CVD events occurred. The proportions of participants with nocturnal normotension (OBP <140/90 mm Hg and nocturnal HBP <120/70 mm Hg), white-coat nocturnal hypertension (OBP ≥140/90 mm Hg and nocturnal HBP <120/70 mm Hg), office-masked nocturnal hypertension (OBP <140/90 mm Hg and nocturnal HBP ≥120/70 mm Hg), and sustained nocturnal hypertension (OBP ≥140/90 mm Hg and nocturnal HBP ≥120/70 mm Hg) were 25.3%, 14.4%, 23.2%, and 37.1%, respectively. Relative to nocturnal normotension, those with both office-masked nocturnal hypertension (adjusted HR: 1.72; 95% CI: 1.01-2.92) and sustained nocturnal hypertension (adjusted HR: 1.75; 95% CI: 1.03-2.96) had similarly increased CVD risk, even after adjustment for daytime HBP values.

Conclusions

Screening for office-masked nocturnal hypertension with HBPM identifies a potentially important group of patients with increased risk for incident CVD events for whom additional preventative measures may be appropriate.

Resistant Hypertension in Older Adults

Resistant hypertension is a complex disorder that requires a comprehensive evaluation of several patient characteristics. Attention should be paid to medication and lifestyle adherence, and investigation into potential secondary causes of resistant hypertension should occur as clinically indicated. Moreover, a shared, multidisciplinary decision-making approach with the patient, specialized care providers, and family members may enhance blood pressure control.

Influence of sleep on physiological systems in atherosclerosis

Sleep is a fundamental requirement of life and is integral to health. Deviation from optimal sleep associates with numerous diseases including those of the cardiovascular system. Studies, spanning animal models to humans, show that insufficient, disrupted or inconsistent sleep contribute to poor cardiovascular health by disrupting body systems. Fundamental experiments have begun to uncover the molecular and cellular links between sleep and heart health while large-scale human studies have associated sleep with cardiovascular outcomes in diverse populations. Here, we review preclinical and clinical findings that demonstrate how sleep influences the autonomic nervous, metabolic and immune systems to affect atherosclerotic cardiovascular disease.

Impact of Continuous Positive Airway Pressure Termination on Permanent Work Disability in Obstructive Sleep Apnea: A French Nationwide ALASKA Database Analysis

Rationale: Three-year continuous positive airway pressure (CPAP) therapy termination rates are up to 50%, and therapy termination is associated with higher all-cause mortality and incident cardiovascular event risk. Objectives: This study investigated the impact of CPAP therapy termination in the first year on long sick leave leading to permanent work disability in patients with obstructive sleep apnea based on data from the Nationwide Claims Data Lake for Sleep Apnoea (ALASKA). Methods: French national health insurance reimbursement system data were analyzed for all adults with OSA aged ≤62 years who started CPAP therapy in France in 2015 and 2016. CPAP therapy termination was defined as the cessation of CPAP reimbursements triggered by the respiratory physician or sleep specialist in charge of follow-up. Individuals who terminated therapy were compared with those who continued to use CPAP. The primary outcome was sick leave ultimately leading to permanent work disability. A multivariable Fine and Gray model, adjusted for age, sex, cardiovascular and metabolic comorbidities, depression, and CPAP prescriber clinical specialty was used to assess the risk of long-term sick leave leading to permanent work disability over 3 years' follow-up. Results: The analysis included 174,270 individuals (median age, 52.0 yr [interquartile range, 44.0-57.0 yr]; 67.5% male). The 1-year CPAP therapy termination rate was 22.3%. The proportion of individuals with long-term sick leave leading to permanent work disability was significantly higher in the CPAP termination versus continuation group (0.60% vs. 0.52%; P = 0.042). In an adjusted multivariable Cox model, CPAP termination was associated with an increased risk of permanent work disability (hazard ratio, 1.21; 95% confidence interval [CI], 1.04-1.41; P = 0.01), primarily in the subgroup aged >55 years (hazard ratio, 1.41; 95% CI, 1.06-1.87; P = 0.02). Conclusions: These real-world data from a comprehensive, unbiased database highlight the potential occupational impact of CPAP therapy termination.

Prognostic effect of obstructive sleep apnea in acute coronary syndrome patients with heart failure

BACKGROUND AND OBJECTIVE

Acute coronary syndrome (ACS), heart failure (HF) and obstructive sleep apnea (OSA) often overlap and interact, the impact of OSA on ACS patients with HF remains unclear. The study sought to comprehensively evaluate the effects of the interaction between OSA and HF on long-term cardiovascular outcomes in ACS patients.

METHODS

Between June 2015 and January 2020, patients hospitalized for ACS were prospectively enrolled and underwent portable sleep monitoring after clinically stabilization. OSA was defined as an apnea hypopnea index ≥15 events/h. HF was defined using medical records. The primary endpoint was major adverse cardiovascular and cerebrovascular event (MACCE), including death, myocardial infarction, stroke, ischemia-driven revascularization, and hospitalization for unstable angina.

RESULTS

Among all 1927 included patients, 214 (11.1 %) had HF, and 1014 (52.6 %) had OSA. For 2.9 years (1.5, 3.6 years) follow-up, OSA was independently associated with the risk of MACCE in HF patients (adjusted hazard ratio [HR], 2.11; 95%CI, 1.16-3.84; P = 0.014), but not in those without HF (adjusted HR, 1.15; 95%CI, 0.92-1.45; P = 0.228). Further analysis showed OSA exerted more prognostic effect in HF patients with preserved eject fraction (adjusted HR, 2.45; 95 % CI, 1.11-5.41; P = 0.027) than those with reduced eject fraction (adjusted HR, 1.62; 95 % CI, 0.63-4.20; P = 0.319).

CONCLUSIONS

In the settings of ACS, OSA was independently associated with poor prognosis in patients with concomitant HF especially those with persevered ejection fraction. Screening and treatment for OSA are highly recommended in ACS patients with HF.

CLINICAL TRIAL REGISTRATION

URL: www.clinicaltrails.gov; Unique Identifier: NCT03362385.

Clinical Efficacy of a Position-Responding Mandibular Advancement Device in Patients With Obstructive Sleep Apnea

OBJECTIVES

Although mandibular advancement device (MAD) treatment is effective for obstructive sleep apnea (OSA), some concerns remain regarding its potential therapeutic impact and side effects. Thus, we developed a novel MAD that auto-titrates depending on its position in patients with OSA. We conducted a clinical trial to determine the efficacy of an auto-titrating mandibular advancement device (AMAD) for treating OSA.

METHODS

Fourteen patients diagnosed with OSA participated in this study. Polysomnography (PSG) was performed at the beginning of the clinical trial, and after 3 months of treatment, PSG with AMAD in situ was conducted.

RESULTS

The mean scores for the Epworth Sleepiness Scale (ESS) and STOP-Bang were 8.21±4.21 and 5.00±1.00, respectively. After 3 months of AMAD treatment, the STOP-Bang scores improved to 3.75±1.06; however, the ESS scores did not show a significant change. Additionally, we observed statistically significant improvements in several respiratory parameters in the PSG data following AMAD treatment. These included reductions in the apnea-hypopnea index (AHI) (from 32.85±21.71 to 12.93±10.70), supine AHI (from 45.91±23.58 to 15.59±12.76), and lateral AHI (from 13.94±10.95 to 5.49±7.40). Improvements were also noted in the lowest O2 saturation (from 79.71±6.22 to 84.00± 5.71), total arousal number (from 191.14±112.07 to 86.57±48.80), and arousal index (from 33.76±21.00 to 15.05± 8.42). However, there were no significant changes in total sleep time, sleep efficiency, or mean oxygen saturation. Additionally, no major side effects were observed during treatment, specifically related to tooth or jaw pain.

CONCLUSION

Our clinical trial found that AMAD improved PSG parameters and reduced the incidence of common side effects. Therefore, AMAD may be an effective alternative treatment for OSA.

Obstructive sleep apnea syndrome attenuated high-density lipoprotein function

BACKGROUND

Obstructive sleep apnea (OSA) is associated with an increased risk of cardiovascular disease. High-density lipoproteins (HDLs) exert anti-atherogenic effects, even on cholesterol efflux capacity (CEC). The HDL proteome is reportedly altered in patients with coronary artery disease.

OBJECTIVE

We hypothesized that OSA attenuates HDL function through an altered HDL proteome, which could be alleviated by continuous positive airway pressure (CPAP) therapy.

METHODS

Patients aged ≥ 20 years (n = 115) with suspected OSA were enrolled in this cross-sectional study, with 34 patients diagnosed with moderate and severe OSA included in the interventional study and treated with CPAP therapy for 12 weeks. To further investigate the HDL proteome in OSA, we conducted a discovery study by analyzing HDL proteomes in 10 patients.

RESULTS

In this study, CEC was significantly lower in the sleep apnea syndrome (SAS) group (apnea-hypopnea index [AHI] ≥ 5) than in the non-SAS group (AHI < 5; 0.96 ± 0.14 vs. 1.06 ± 0.15, p = 0.01). Multiple regression analysis revealed that minimal pulse oxygen saturation (MinSpO2) was positively correlated with CEC. In the interventional study, 12-week CPAP therapy did not affect CEC. We identified orosomucoid 1 (ORM1), an acute-phase inflammatory molecule, as a candidate protein for OSA-induced HDL dysfunction. Further validation study revealed that serum ORM1 levels were inversely associated with CEC, independent of HDL-cholesterol and high-sensitivity C-reactive protein.

CONCLUSIONS

HDL function was impaired in patients with OSA and a reduced CEC. However, CPAP therapy did not affect CEC. An altered HDL proteome, particularly with increased ORM1 levels, may be associated with impaired HDL function.

TRIAL REGISTRATION

This clinical study was registered with the University Hospital Medical Information Network Clinical Trials Registry (UMIN000025335 and UMIN000025341).

Chronic intermittent hypoxia triggers cardiac fibrosis: Role of epididymal white adipose tissue senescent remodeling?

AIM

Obstructive sleep apnea (OSA) is a growing health problem affecting nearly 1 billion people worldwide. The landmark feature of OSA is chronic intermittent hypoxia (CIH), accounting for multiple organ damage, including heart disease. CIH profoundly alters both visceral white adipose tissue (WAT) and heart structure and function, but little is known regarding inter-organ interaction in the context of CIH. We recently showed that visceral WAT senescence drives myocardial alterations in aged mice without CIH. Here, we aimed at investigating whether CIH induces a premature visceral WAT senescent phenotype, triggering subsequent cardiac remodeling.

METHODS

In a first experiment, 10-week-old C57bl6J male mice (n = 10/group) were exposed to 14 days of CIH (8 h daily, 5%-21% cyclic inspired oxygen fraction, 60 s per cycle). In a second series, mice were submitted to either epididymal WAT surgical lipectomy or sham surgery before CIH exposure. Finally, we used p53 deficient mice or Wild-type (WT) littermates, also exposed to the same CIH protocol. Epididymal WAT was assessed for fibrosis, DNA damages, oxidative stress, markers of senescence (p16, p21, and p53), and inflammation by RT-qPCR and histology, and myocardium was assessed for fibrosis and cardiomyocyte hypertrophy.

RESULTS

CIH-induced epididymal WAT remodeling characterized by increased fibrosis, oxidative stress, DNA damage response, inflammation, and increased expression of senescent markers. CIH-induced epididymal WAT remodeling was associated with subtle and early myocardial interstitial fibrosis. Both epididymal WAT surgical lipectomy and p53 deletion prevented CIH-induced myocardial fibrosis.

CONCLUSION

Short-term exposure to CIH induces epididymal WAT senescent remodeling and cardiac interstitial fibrosis, the latter being prevented by lipectomy. This finding strongly suggests visceral WAT senescence as a new target to mitigate OSA-related cardiac disorders.

Obstructive sleep apnoea is independently associated with non-alcoholic fatty pancreatic disease

PURPOSE

This study investigated the prevalence of non-alcoholic fatty pancreatic disease (NAFPD) in patients with obstructive sleep apnoea (OSA) and analysed the correlation between them.

MATERIALS AND METHODS

Patients who underwent polysomnography and modified abdominal ultrasound examinations were continuously enrolled and divided into OSA and control groups. The OSA group was further divided into NAFPD and non-NAFPD groups. Differences in various indicators were compared. Binary logistic regression analyses were conducted to identify factors influencing NAFPD.

RESULTS

A total of 210 participants were included in the study, including 178 in the OSA group and 32 in the control group. The prevalence of NAFPD, weight, body mass index (BMI), and other indicators were significantly higher in the OSA group than that in the control group (p < 0.05). The above indices, prevalence of hypertension and metabolic associated steatotic liver disease (MASLD), and severity of sleep apnoea were higher in the NAFPD group than that in the non-NAFPD group (p < 0.05). Binary logistic regression analysis showed a 4.4% increased risk of NAFPD for each unit increase in apnea-hypopnea index (AHI) after adjusting for BMI and hypertension.

CONCLUSION

The prevalence of NAFPD was higher in the OSA group than that in the control group, and chronic intermittent hypoxia was strongly associated with pancreatic fat infiltration; AHI, BMI, and hypertension were independent risk factors for NAFPD. The NAFPD group had a higher prevalence of obesity and some other diseases.

Obstructive sleep apnea -related hypertension: a review of the literature and clinical management strategy

Obstructive Sleep Apnea (OSA) and hypertension have a high rate of co-occurrence, with OSA being a causative factor for hypertension. Sympathetic activity due to intermittent hypoxia and/or fragmented sleep is the most important mechanisms triggering the elevation in blood pressure in OSA. OSA-related hypertension is characterized by resistant hypertension, nocturnal hypertension, abnormal blood pressure variability, and vascular remodeling. In particular, the prevalence of OSA is high in patients with resistant hypertension, and the mechanism proposed includes vascular remodeling due to the exacerbation of arterial stiffness by OSA. Continuous positive airway pressure therapy is effective at lowering blood pressure, however, the magnitude of the decrease in blood pressure is relatively modest, therefore, patients often need to also take antihypertensive medications to achieve optimal blood pressure control. Antihypertensive medications targeting sympathetic pathways or the renin-angiotensin-aldosterone system have theoretical potential in OSA-related hypertension, Therefore, beta-blockers and renin-angiotensin system inhibitors may be effective in the management of OSA-related hypertension, but current evidence is limited. The characteristics of OSA-related hypertension, such as nocturnal hypertension and obesity-related hypertension, suggests potential for angiotensin receptor-neprilysin inhibitor (ARNI), sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucose-dependent insulinotropic polypeptide receptor/ glucagon-like peptide-1 receptor agonist (GIP/GLP-1 RA). Recently, OSA has been considered to be caused not only by upper airway anatomy but also by several non-anatomic mechanisms, such as responsiveness of the upper airway response, ventilatory control instability, and reduced sleep arousal threshold. Elucidating the phenotypic mechanisms of OSA may potentially advance more personalized hypertension treatment strategies in the future. Clinical characteristics and management strategy of OSA-related hypertension. OSA obstructive sleep apnea, BP blood pressure, ABPM ambulatory blood pressure monitoring, CPAP continuous positive airway pressure, LVH left ventricular hypertrophy, ARB: angiotensin II receptor blocker, SGLT2i Sodium-glucose cotransporter 2 inhibitors, ARNI angiotensin receptor-neprilysin inhibitor, CCB calcium channel blocker, GIP/GLP-1 RA glucose-dependent insulinotropic polypeptide receptor and glucagon-like peptide-1 receptor agonist.

Outcomes and Predictors of Success Following Multilevel Surgery in Positional and Nonpositional Obstructive Sleep Apnea

OBJECTIVE

To assess the surgical outcomes and identify predictors of surgical success in patients with positional and non-positional obstructive sleep apnea following multilevel airway surgery.

STUDY DESIGN

Retrospective cohort study.

SETTING

Singe-tertiary medical center.

METHODS

This study included 158 patients with obstructive sleep apnea who underwent multilevel airway surgery. Patients were divided into 2 groups according to position dependency: "positional patients" group (n = 100), and "nonpositional patients" group (n = 58). The characteristics and surgical outcomes of the 2 groups were compared.

RESULTS

The nonpositional group included younger and more obese patients in comparison to the positional group. Moreover, the nonpositional group had more severe disease than the positional group. Both groups showed overall improvement after surgery, and the surgical success rate did not differ significantly between the 2 groups (nonpositional, 41.4% vs positional, 48.0%; P = .424). Notably, 69.0% of patients belonging to the non-positional group converted to positional group postoperatively. Logistic regression analysis revealed that larger tonsil size, female sex, and higher mean O2 saturation were associated with higher success rate in the positional group, whereas larger tonsil size was associated with surgical success in the nonpositional group.

CONCLUSION

Both nonpositional and positional groups showed improvements following multilevel airway surgery, and surgery induced a transition from nonpositional to positional group. Given that the factors related to surgical success differed between the two groups, surgeons should consider position dependency and these distinct factors during decision-making.

Mitigating Increased Cardiovascular Risk in Patients with Obstructive Sleep Apnea Using GLP-1 Receptor Agonists and SGLT2 Inhibitors: Hype or Hope?

Obstructive sleep apnea (OSA) is a prevalent condition associated with increased cardiovascular risk, particularly in individuals with comorbid obesity and type 2 diabetes (T2D). Despite the widespread use of continuous positive airway pressure (CPAP) for OSA management, adherence remains suboptimal, and CPAP has not consistently demonstrated reductions in surrogate cardiovascular events. Recently, attention has focused on glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter-2 (SGLT2) inhibitors as potential therapeutic agents for mitigating cardiovascular risk in OSA patients. These agents, originally developed for T2D management, have demonstrated pleiotropic effects, including significant weight loss, blood pressure reduction, and amelioration of endothelial dysfunction and arterial stiffness, along with anti-inflammatory benefits, which may be particularly beneficial in OSA. Emerging clinical evidence suggests that GLP-1RAs and SGLT2 inhibitors can reduce OSA severity and improve daytime sleepiness, potentially reversing the adverse cardiovascular effects observed in OSA. This review explores the pathophysiological mechanisms linking OSA with cardiovascular disease and evaluates the potential therapeutic roles of GLP-1RAs and SGLT2 inhibitors in addressing cardiovascular risk in OSA patients. Further research, including long-term clinical trials, is necessary to establish the effectiveness of these therapies in reducing cardiovascular events and improving patients' reported outcomes in this population.

Nr1d1 inhibition mitigates intermittent hypoxia-induced pulmonary hypertension via Dusp1-mediated Erk1/2 deactivation and mitochondrial fission attenuation

Intermittent hypoxia (IH) precipitates pulmonary vasoconstriction, culminating in the onset of pulmonary hypertension (PH) among individuals afflicted with sleep apnea. While Nuclear receptor subfamily 1 group D member 1 (Nr1d1) is progressively recognized as pivotal regulator of cellular physiology, the role in the pathogenesis of IH-induced PH remains largely uncharted. The expression of Nr1d1 was examined in IH-induced rodent PH and in IH-treated PASMCs. To elucidate the contribution of Nr1d1 to the development of IH-induced PH, we employed siRNA to modulate Nr1d1 expression in vitro and employed serotype 1 adeno-associated virus (AAV1) in vivo. Nr1d1 levels were elevated in IH-induced rodents PH lung tissues and IH-treated PASMCs. Knocking down Nr1d1 by AAV1 effectively inhibited PH progression in chronic IH-induced PH models. Mechanistic investigations identified dual specificity phosphatase 1 (Dusp1), as a direct target that Nr1d1 trans-repressed, mediating Nr1d1's regulatory influence on Erk1/2/Drp1 signaling. Nr1d1 deficiency ameliorates mitochondrial dysfunction and fission by restoring Dusp1 dysregulation and Drp1 phosphorylation. Activation of Erk1/2 with PMA reversed the Dusp1-mediated regulation of Drp1 phosphorylation, indicating the involvement of the Erk1/2 pathway in Drp1 phosphorylation controlled by Dusp1. Meanwhile, intermittent hypoxia induced more severe PH in Dusp1 knockout mice compared with wild-type mice. Our data unveil a novel role for Nr1d1 in IH-induced PH pathogenesis and an undisclosed Nr1d1-Dusp1 axis in PASMCs mitochondrial fission regulation.

The Role of Oxidative Stress and the Potential Therapeutic Benefits of Aronia melanocarpa Supplementation in Obstructive Sleep Apnea Syndrome: A Comprehensive Literature Review

Obstructive sleep apnea (OSA) is a sleep disorder characterized by repeated episodes of apnea and hypopnea, leading to inflammation and oxidative stress that contribute to numerous health complications, including cardiovascular diseases. Continuous positive airway pressure (CPAP) is a standard for treating OSA and is effective in reducing inflammation and oxidative stress. Aronia melanocarpa (a black chokeberry), a deciduous shrub belonging to the Rosaceae family and native to eastern North America that is rich in polyphenols, has garnered attention for its therapeutic potential due to its ability to neutralize reactive oxygen species (ROS) and modulate inflammatory pathways, such as NF-κB. This review supports the hypothesis that combining CPAP with black chokeberry supplementation might provide a more comprehensive approach to treating OSA, reducing the risk of health complications by further reducing oxidative stress. In conclusion, Aronia melanocarpa has potential benefits as an adjunct therapy in the treatment of OSA, enhancing overall health and well-being. This review compiles the latest scientific findings on the benefits of black chokeberry supplementation, its application in OSA treatment, and its potential use in the treatment of other conditions linked to oxidative stress.

Impact of a Case-Based Sleep Apnoea Education on the Knowledge, Attitudes and Confidence of Dental Hygiene Students-A Multicentre Intervention Study

OBJECTIVE

This pilot study aimed to explore knowledge, attitudes and confidence levels of Obstructive Sleep Apnoea (OSA) before and after case-based education among dental hygiene students. Moreover, to give an international perspective, this study included students from the US and Scandinavia.

METHODS

A longitudinal multicentre study assessed dental hygiene students' OSA knowledge, attitudes and confidence through a case-based education model. Students from six dental hygiene programmes in the US, Norway and Sweden participated from 2021 to 2022. The intervention group (N = 89) received preview material, live synchronous OSA lecture, case-based screening of fictitious patients and clinical practice using the STOP-Bang screening tool. Controls (N = 70) followed the standard curriculum. The Obstructive Sleep Apnoea Knowledge and Attitudes (OSAKA) questionnaire, comprising 18 knowledge and five attitude/confidence questions, was used. Reliability was assessed and nonparametric tests determined OSAKA knowledge score differences among the baseline, 6 months and 12 months intervals.

RESULTS

The intervention increased OSA knowledge with the largest increase in proportions of correct responses occurring between the baseline and 6 months and all single items showing a higher proportion of correct answers at 12 months compared to the baseline. Students' attitudes regarding the importance of OSAKA and confidence in managing patients increased from the baseline to both 6 months and 12 months.

CONCLUSION

The case based educational intervention increased OSA knowledge and improved attitudes and confidence among dental hygiene students. The results also determined that the OSAKA questionnaire can be used in a setting with dental hygiene students to provide an overview of their knowledge, attitudes and confidence toward OSA. Current sleep medicine education in dental hygiene programmes is limited, suggesting the need for enhanced and sustained educational interventions to address this knowledge gap.

A Study of the Relationship Between Objective Tests to Diagnose Erectile Dysfunction and Markers of Cardiovascular Disease

Background: Erectile dysfunction (ED) can stem from various organic and functional causes but is often linked to vascular health and cardiovascular disease. Limited data exist on how cardiovascular disease markers correlate with objective ED tests like the Nocturnal Penile Tumescence and Rigidity (NPTR) test and Penile Color Doppler Ultrasound (PCDU). Methods: A prospective observational study was performed, and 58 men with ED were assessed using the International Index of Erectile Function-15 (IIEF-15), NPTR test, and PCDU. Peripheral vascular health was evaluated through carotid intima-media thickness (cIMT) and brachial flow-mediated dilation (FMD). Results: Out of the participants, 44 had normal NPTR results, while 14 had abnormal results. The group with abnormal NPTR results was significantly older and had higher rates of hypertension and diabetes. Although the IIEF-15 scores were similar between the two groups, those with abnormal NPTR results had a lower peak systolic velocity (PSV) and a higher prevalence of impaired PSV. Correlations between the IIEF, NPTR, PCDU, and peripheral vascular markers lost significance after the age adjustment. Conclusions: This study suggests that abnormal NPTR results, combined with cardiovascular risk factors, may signal vascular ED and generalized vasculopathy, highlighting the need for cardiovascular assessment. An accurate ED diagnosis should integrate clinical evaluation with multiple tests while considering aging as a key risk factor.

Remote Monitoring of Sympathovagal Imbalance During Sleep and Its Implications in Cardiovascular Risk Assessment: A Systematic Review

Nocturnal sympathetic overdrive is an early indicator of cardiovascular (CV) disease, emphasizing the importance of reliable remote patient monitoring (RPM) for autonomic function during sleep. To be effective, RPM systems must be accurate, non-intrusive, and cost-effective. This review evaluates non-invasive technologies, metrics, and algorithms for tracking nocturnal autonomic nervous system (ANS) activity, assessing their CV relevance and feasibility for integration into RPM systems. A systematic search identified 18 relevant studies from an initial pool of 169 publications, with data extracted on study design, population characteristics, technology types, and CV implications. Modalities reviewed include electrodes (e.g., electroencephalography (EEG), electrocardiography (ECG), polysomnography (PSG)), optical sensors (e.g., photoplethysmography (PPG), peripheral arterial tone (PAT)), ballistocardiography (BCG), cameras, radars, and accelerometers. Heart rate variability (HRV) and blood pressure (BP) emerged as the most promising metrics for RPM, offering a comprehensive view of ANS function and vascular health during sleep. While electrodes provide precise HRV data, they remain intrusive, whereas optical sensors such as PPG demonstrate potential for multimodal monitoring, including HRV, SpO2, and estimates of arterial stiffness and BP. Non-intrusive methods like BCG and cameras are promising for heart and respiratory rate estimation, but less suitable for continuous HRV monitoring. In conclusion, HRV and BP are the most viable metrics for RPM, with PPG-based systems offering significant promise for non-intrusive, continuous monitoring of multiple modalities. Further research is needed to enhance accuracy, feasibility, and validation against direct measures of autonomic function, such as microneurography.

Unveiling the Impact of Respiratory Event-Related Hypoxia on Heart Sound Intensity During Sleep Using Novel Wearable Technology

Purpose

Cardiovascular disorders are the leading cause of mortality worldwide with obstructive sleep apnea (OSA) as the independent risk factor. Heart sounds are strong modalities to obtain clinically relevant information regarding the functioning of the heart valves and blood flow. The objective of this study was to use a small wearable device to record and investigate the changes in heart sounds during respiratory events (reduction and cessation of breathings) and their association with oxyhemoglobin desaturation (hypoxemia).

Patients and Methods

Sleep assessment and tracheal respiratory and heart sounds were recorded simultaneously from 58 individuals who were suspected of having OSA. Sleep assessment was performed using in-laboratory polysomnography. Tracheal respiratory and heart sounds were recorded over the suprasternal notch using a small device with embedded microphone and accelerometer called the Patch. Heart sounds were extracted from bandpass filtered tracheal sounds using smoothed Hilbert envelope on decomposed signal. For each individual, data from 20 obstructive events during Non-Rapid Eye Movement stage-2 of sleep were randomly selected for analysis.

Results

A significant increase in heart sounds' intensities from before to after the termination of respiratory events was observed. Also, there was a significant positive correlation between the magnitude of hypoxemia and the increase in heart sounds' intensities (r>0.82, p<0.001). In addition, the changes in heart sounds were significantly correlated with heart rate and blood pressure.

Conclusion

Our results indicate that heart sound analysis can be used as an alternative modality for assessing the cardiovascular burden of sleep apnea, which may indicate the risk of cardiovascular disorders.

mTOR in the Development of Hypoxic Pulmonary Hypertension Associated with Cardiometabolic Risk Factors

The pathophysiology of pulmonary hypertension is complex and multifactorial. It is a disease characterized by increased pulmonary vascular resistance at the level due to sustained vasoconstriction and remodeling of the pulmonary arteries, which triggers an increase in the mean pulmonary artery pressure and subsequent right ventricular hypertrophy, which in some cases can cause right heart failure. Hypoxic pulmonary hypertension (HPH) is currently classified into Group 3 of the five different groups of pulmonary hypertensions, which are determined according to the cause of the disease. HPH mainly develops as a product of lung diseases, among the most prevalent causes of obstructive sleep apnea (OSA), chronic obstructive pulmonary disease (COPD), or hypobaric hypoxia due to exposure to high altitudes. Additionally, cardiometabolic risk factors converge on molecular mechanisms involving overactivation of the mammalian target of rapamycin (mTOR), which correspond to a central axis in the development of HPH. The aim of this review is to summarize the role of mTOR in the development of HPH associated with metabolic risk factors and its therapeutic alternatives, which will be discussed in this review.

Prognostic implications of obstructive sleep apnea in patients with unstable angina stratified by remnant cholesterol and triglyceride: a prospective cohort study

BACKGROUND

The prognostic significance of obstructive sleep apnea (OSA) in patients with unstable angina (UA) based on remnant cholesterol (RC) or triglyceride (TG) levels remains unclear. This study aims to evaluate the effects of the interaction between RC, TG, and OSA on cardiovascular outcomes in UA patients.

METHODS

In this prospective cohort study, OSA was diagnosed when apnea-hypopnea index of ≥ 15 events/h. Patients with high RC (HRC, n = 370) or high TG (HTG, n = 362) included RC or TG in the highest tertile, and those in the middle and lowest tertiles were defined as normal RC (NRC, n = 736) or normal TG (NTG, n = 744). The primary endpoint was major adverse cardiovascular and cerebrovascular events (MACCE), including cardiovascular death, myocardial infarction, ischemia stroke, ischemia-driven revascularization, or hospitalization for UA.

RESULTS

A total of 1,106 eligible UA patients were enrolled, among which 560 (50.6%) had OSA. RC and TG levels were increased in OSA patients, but there was no difference in the prevalence of OSA between the NRC and HRC or NTG and HTG groups. During a median follow-up of 1.9 (1.1, 3.0) years, OSA was associated with an increased risk of MACCE occurrence compared to non-OSA in UA patients with HRC (adjusted HR 2.06; 95% CI 1.20-3.51, P = 0.008), but not in those with NRC (adjusted HR 1.21; 95% CI 0.84-1.75, P = 0.297). The incremental risk in HRC was attributable to higher rates of hospitalization for UA and ischemia-driven revascularization. Results for HTG and NTG were similar.

CONCLUSION

OSA was associated with a worse prognosis in UA patients with HRC or HTG, emphasizing the necessity of identifying OSA presence in this population.

TRIAL REGISTRATION

Clinicaltrials.gov; No: NCT03362385.

Associations between longitudinal changes in sleep stages and risk of cognitive decline in older men

STUDY OBJECTIVES

To investigate the relationships between longitudinal changes in sleep stages and the risk of cognitive decline in older men.

METHODS

This study included 978 community-dwelling older men who participated in the first (2003-2005) and second (2009-2012) sleep ancillary study visits of the Osteoporotic Fractures in Men Study. We examined the longitudinal changes in sleep stages at the initial and follow-up visits, and the association with concurrent clinically relevant cognitive decline during the 6.5-year follow-up.

RESULTS

Men with low to moderate (quartile 2, Q2) and moderate increase (Q3) in N1 sleep percentage had a reduced risk of cognitive decline on the modified mini-mental state examination compared to those with a substantial increase (Q4) in N1 sleep percentage. Additionally, men who experienced a low to moderate (Q2) increase in N1 sleep percentage had a lower risk of cognitive decline on the Trails B compared with men in the reference group (Q4). Furthermore, men with the most pronounced reduction (Q1) in N2 sleep percentage had a significantly higher risk of cognitive decline on the Trails B compared to those in the reference group (Q4). No significant association was found between changes in N3 and rapid eye movement sleep and the risk of cognitive decline.

CONCLUSIONS

Our results suggested that a relatively lower increase in N1 sleep showed a reduced risk of cognitive decline. However, a pronounced decrease in N2 sleep was associated with concurrent cognitive decline. These findings may help identify older men at risk of clinically relevant cognitive decline.