Cardiovascular Mortality in Obstructive Sleep Apnea in the Elderly: Role of Long-Term Continuous Positive Airway Pressure Treatment

Obstructive sleep apnoea and risks of all-cause mortality: preliminary evidence from prospective cohort studies

PURPOSE

A meta-analysis of prospective cohort studies was conducted to clarify the association between obstructive sleep apnoea (OSA) and future risk of all-cause mortality.

METHODS

Eligible studies were identified by searching the PubMed and EMBASE databases up to July 2015. Pooled hazard ratios (HRs) and their corresponding 95 % confidence intervals (CIs) were calculated to estimate the association between OSA and risk of all-cause mortality. Sources of heterogeneity were identified by subgroup and meta-regression analyses.

RESULTS

Twelve prospective cohort studies involving 34,382 participants were included in this meta-analysis. The pooled HR of all-cause mortality was 1.262 (95 % CI 1.093-1.431) with significant heterogeneity. Subgroup analyses indicated that the pooled HRs of all-cause mortality in patients with mild, moderate and severe OSA were 0.945 (95 % CI 0.810-1.081), 1.178 (95 % CI 0.978-1.378) and 1.601 (95 % CI 1.298-1.902), respectively. OSA severity could be a possible sources of heterogeneity. Existing publication bias produced a minor contribution to effect size.

CONCLUSION

Severe, but not mild to moderate, OSA is significantly associated with increased risk of all-cause mortality.

Age- and gender-specific associations between sleep duration and incident hypertension in a Chinese population: the Kailuan study

The objective of this study was to explore the age- and sex-dependent association between sleep duration and incident hypertension in a Chinese population. The Kailuan prospective cohort study recruited 101 510 participants. Those participants were followed for an average of 3.98 years and the data obtained from 32 137 participants out of 101 510 were analyzed in this study. Sleep duration was categorized as five groups of⩽5, 6, 7, 8 and ⩾9 h. Cox proportional-hazards models were used to analyze the association of sleep duration with incident hypertension. The 3.98 years' follow-up data showed that 12 732 out of 32 137 participants developed hypertension. Short duration of sleep (⩽5 h per night) was associated with an increased risk of hypertension in woman (hazard ratio (HR) 1.27; 95% confidence interval (CI) 1.02 to 1.58) and participants aged <60 years (HR 1.11; 95% CI 1.02-1.21), when compared with the group reported with 7 h of sleep per day. This study suggested that short sleep duration could cause an increased risk of hypertension in Chinese females and population aged <60 years.

Can Continuous Positive Airway Pressure Reduce the Risk of Stroke in Obstructive Sleep Apnea Patients? A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

Obstructive sleep apnea (OSA) has been shown to increase the risk of stroke. Although continuous positive airway pressure (CPAP) is considered the treatment of choice for OSA, whether treating OSA with CPAP reduces the risk of stroke remains unclear. We aimed to evaluate the effects of CPAP on incidence of stroke in patients with OSA.

MATERIALS AND METHODS

We conducted a systematic review and meta-analysis of all published studies that provided the number of incident strokes in OSA patients in light of their treatment status with CPAP.

RESULTS

We identified 8 relevant studies: one randomized controlled study (RCT), 5 cohort studies, and 2 studies using administrative health data. The two overlapping cohort studies in women and the elderly and the 2 studies using administrative health data had analyzed the impact of CPAP on stroke apart from cardiac events, whereas the others had focused on the overall cardiovascular events. Based on a meta-analysis of the cohort studies, treatment with CPAP was associated with a lower incidence of stroke and cardiac events with relative risks of 0.27 [0.14-0.53], and 0.54 [0.38-0.75], respectively, although this could not be reproduced in the RCT and the studies using administrative data.

CONCLUSIONS

Treating with CPAP in patients with OSA might decrease the risk of stroke, although there is some conflicting evidence. Such effect was more pronounced in stroke than in cardiac events. Future studies analyzing stroke apart from cardiac disease would be of interest.

Continuous positive airway pressure and survival of very elderly persons with moderate to severe obstructive sleep apnea

OBJECTIVE

There is evidence of a beneficial effect of long-term continuous positive airway pressure (CPAP) on survival in elderly persons with obstructive sleep apnea (OSA), although the usual age cut off is between 60 and 70 years of age. Our objective was to determine this effect in very elderly patients (ie, those ≥80 years of age).

METHODS

An observational study of a historic cohort of very elderly persons with moderate to severe OSA (apnea-hypopnea index ≥20) and the effect of long-term CPAP on their survival was performed. Two groups were formed: one prescribed CPAP treatment (≥4 hours per night), and one without CPAP treatment. Survival analyses, including Kaplan-Meier curves and Cox models, were carried out to determine the association of long-term CPAP with longer survival,

RESULTS

A total of 155 very elderly persons (84 men and 71 women, mean age 81.5 ± 1.5 years) were followed up for 53 months (interquartile range, 41-77 months); 83 deaths occurred. CPAP was prescribed to 132 patients, and adherence was observed in 79 (60%). Kaplan-Meier curves showed longer survival in the treated OSA group (91 months, 95% confidence interval [CI] = 76-106) than in the untreated OSA group (52 months, 95% CI 41-64), which was statistically significant (log-rank 16.9, p < 0.0001). Although history of stroke was significantly associated with higher mortality (hazard ratio [HR] = 2.18, 95% CI = 1.14-4.17, p = 0.02), CPAP treatment was associated with higher survival rates (HR = 0.46, 95% CI = 0.27-0.78, p = 0.004) in an adjusted Cox analysis.

CONCLUSIONS

CPAP treatment might be associated with a longer survival in very elderly persons with moderate to severe OSA.

Continuous positive airway pressure reduces blood pressure in patients with obstructive sleep apnea; a systematic review and meta-analysis with 1000 patients

BACKGROUND

Obstructive sleep apnea (OSA) may lead to the development of hypertension and therapy with continuous positive airway pressure (CPAP) can promote reduction in blood pressure.

OBJECTIVE

The objective of this study is to review systematically the effects of CPAP on blood pressure in patients with OSA.

METHODS

The search was conducted in the following databases, from their beginning until February 2013: MEDLINE, Embase, Cochrane CENTRAL, Lilacs and PEDro. In addition, a manual search was performed on references of published studies. Randomized clinical trials (RCTs) that used CPAP compared with placebo CPAP or subtherapeutic CPAP for treatment of patients with OSA and that evaluated office SBP and DBP and 24-h ambulatory blood pressure were selected.

RESULTS

Sixteen RCTs were included among 3409 publications, totaling 1166 patients. The use of CPAP resulted in reductions in office SBP [-3.20  mmHg; 95% confidence interval (CI) -4.67 to -1.72] and DBP (-2.87  mmHg; 95% CI -5.18 to -0.55); in night-time SBP (-4.92  mmHg; 95% CI -8.70 to -1.14); in mean 24-h blood pressure (-3.56  mmHg; 95% CI -6.79 to -0.33), mean night-time blood pressure (-2.56  mmHg; 95% CI -4.43 to -0.68) and 24-h DBP (-3.46  mmHg; 95% CI -6.75 to -0.17). However, no significant change was observed in daytime SBP (-0.74  mmHg; 95% CI -3.90 to 2.41) and daytime DBP (-1.86  mmHg; 95% CI -4.55 to 0.83).

CONCLUSION

Treatment with CPAP promoted significantly but small reductions in blood pressure in individuals with OSA. Further studies should be performed to evaluate the effects of long-term CPAP and the impact on cardiovascular risk.

Long-term adherence to continuous positive airway pressure therapy in non-sleepy sleep apnea patients

OBJECTIVE

The effectiveness of continuous positive airway pressure (CPAP) therapy greatly depends on consistent use. However, data regarding adherence in non-sleepy obstructive sleep apnea (OSA) patients are scarce. The aim of this study was to assess long-term adherence and predictors of CPAP compliance in a large sample of non-sleepy OSA patients.

METHODS

We conducted a prospective, multicenter study comprising 357 non-sleepy patients (Epworth Sleepiness Scale score <11) with moderate-to-severe OSA (apnea-hypopnea index [AHI] of ≥20) who began CPAP therapy between May 2004 and May 2006; follow-up ended in May 2009. Non-compliance was scored as CPAP dropout or average cumulative CPAP use of <4 hours per night. Multivariate Cox regression analysis was performed to identify independent predictors of poor CPAP adherence.

RESULTS

Patients were followed up for a median of four years (interquartile range [IQR] = 3.0-4.4). At the end of the study period, 230 patients (64.4%) fulfilled the criteria for good CPAP compliance, whereas 127 patients (35.6%) were considered non-compliant. The median CPAP use was five hours per night (interquartile range = 2.18-6.25). Multivariate analysis showed that interactions between the AHI and the percentage of nighttime spent with an O2 saturation of <90% (TC90) (p = 0.010) and between the AHI and hypertension at baseline (p = 0.029) predicted long-term compliance with CPAP.

CONCLUSION

This study demonstrates that CPAP treatment is feasible in non-sleepy, moderate-to-severe OSA patients. Good CPAP adherence was predicted by greater OSA severity as measured by both the AHI and TC90 and by the presence of hypertension at baseline in patients with higher AHI levels.

Prevalence of obstructive sleep apnea among patients with coronary artery disease in Saudi Arabia

BACKGROUND

Despite the association between obstructive sleep apnea (OSA) and coronary artery disease (CAD), few studies have investigated this issue in Saudi Arabia.

OBJECTIVES

This study aimed to identify the prevalence of OSA among CAD patients.

SUBJECTS AND METHODS

This was a cross-sectional (descriptive) study conducted at King Abdul-Aziz University Hospital in Jeddah, Saudi Arabia from April 2012 to December 2013. All consecutive patients referred to the cardiac catheterization lab for coronary angiography who exhibited evidence of CAD were included in this study. This study was conducted in two stages. During the first stage, each participant was interviewed individually. The administered interview collected data pertaining to demographics, comorbidities, and the STOP-BANG questionnaire score. The second stage of this study consisted of a diagnostic overnight polysomnography (PSG) of 50% of the subjects at high risk for OSA according to the STOP-BANG questionnaire.

RESULTS

Among the patients with CAD (N = 156), 128 (82%) were categorized as high risk for developing OSA. PSG was conducted on 48 patients. The estimated prevalence of OSA in the study sample was 56.4%. Approximately 61% of the documented sleep apnea patients suffered from moderate to severe OSA.

CONCLUSION

This local study concurs with reports in the literature indicating that OSA is very common among CAD patients.

New developments in the use of positive airway pressure for obstructive sleep apnea

Obstructive sleep apnea (OSA) is a disorder which afflicts a large number of individuals around the world. OSA causes sleepiness and is a major cardiovascular risk factor. Since its inception in the early 1980's, continuous positive airway pressure (CPAP) has emerged as the major treatment of OSA, and it has been shown to improve sleepiness, hypertension, and a number of cardiovascular indices. Despite its successes, adherence with treatment remains a major limitation. Herein we will review the evidence behind the use of positive airway pressure (PAP) therapy, its various modes, and the methods employed to improve adherence. We will also discuss the future of PAP therapy in OSA and personalization of care.

The impact of sleep on age-related sarcopenia: Possible connections and clinical implications

Sarcopenia is a geriatric condition that comprises declined skeletal muscle mass, strength and function, leading to the risk of multiple adverse outcomes, including death. Its pathophysiology involves neuroendocrine and inflammatory factors, unfavorable nutritional habits and low physical activity. Sleep may play a role in muscle protein metabolism, although this hypothesis has not been studied extensively. Reductions in duration and quality of sleep and increases in prevalence of circadian rhythm and sleep disorders with age favor proteolysis, modify body composition and increase the risk of insulin resistance, all of which have been associated with sarcopenia. Data on the effects of age-related slow-wave sleep decline, circadian rhythm disruptions and obstructive sleep apnea (OSA) on hypothalamic-pituitary-adrenal (HPA), hypothalamic-pituitary-gonadal (HPG), somatotropic axes, and glucose metabolism indicate that sleep disorder interventions may affect muscle loss. Recent research associating OSA with the risk of conditions closely related to the sarcopenia process, such as frailty and sleep quality impairment, indirectly suggest that sleep can influence skeletal muscle decline in the elderly. Several protein synthesis and degradation pathways are mediated by growth hormone (GH), insulin-like growth factor-1 (IGF-1), testosterone, cortisol and insulin, which act on the cellular and molecular levels to increase or reestablish muscle fiber, strength and function. Age-related sleep problems potentially interfere intracellularly by inhibiting anabolic hormone cascades and enhancing catabolic pathways in the skeletal muscle. Specific physical exercises combined or not with nutritional recommendations are the current treatment options for sarcopenia. Clinical studies testing exogenous administration of anabolic hormones have not yielded adequate safety profiles. Therapeutic approaches targeting sleep disturbances to normalize circadian rhythms and sleep homeostasis may represent a novel strategy to preserve or recover muscle health in older adults. Promising research results regarding the associations between sleep variables and sarcopenia biomarkers and clinical parameters are required to confirm this hypothesis.

Age-Related Differences in Sleep-Wake Symptoms of Adults Undergoing Polysomnography

OBJECTIVES

To evaluate age-related differences in sleep-wake symptoms.

DESIGN

Cross-sectional.

SETTING

Technologist-attended, laboratory-based polysomnography (PSG).

PARTICIPANTS

Community-dwelling adults aged 20 to 89 (N = 201): 52 aged 18 to 39, 72 aged 40 to 59, and 77 aged 60 and older.

MEASUREMENTS

Medical burden (Charlson Comorbidity Index, medications, health status), PSG-defined sleep disorders (sleep-disordered breathing (SDB), sleep-associated hypoxemia, periodic limb movements in sleep (PLMS)), sleep-wake symptoms (Epworth Sleepiness Scale (ESS), Insomnia Severity Index (ISI), fatigue (Facit-F Scale)).

RESULTS

Medical burden increased significantly with age (Charlson Comorbidity Index and number of medications, P < .001; health status, P = .005). Severity of sleep disorders also increased significantly with age (SDB and hypoxemia, P < .001; PLMS, P = .008). Conversely, sleep-wake symptoms decreased with age (daytime drowsiness (ESS ≥ 10), P = .02; insomnia (ISI ≥ 8), P = .04; fatigue, P < .001). In adjusted models, a 1-year increase in age was significantly associated with a 4% decrease in the odds of having daytime drowsiness (odds ratio (OR) = 0.96, 95% confidence interval (CI) = 0.93-0.98). Similarly, but only in those with mild SDB, a 1-year increase in age was significantly associated with a 5% decrease in the odds of having insomnia (OR = 0.95, 95% CI = 0.92-0.99).

CONCLUSION

Older age was characterized by less-severe sleep-wake symptoms (daytime drowsiness, insomnia, fatigue), despite an age-related increase in disease severity (medical burden, sleep disorders). Because the increase in disease severity included well-established risk factors for having sleep-wake symptoms, the age-related decrease in sleep-wake symptoms may reflect a decrease in symptom awareness.

Effect of telemetric monitoring in the first 30 days of continuous positive airway pressure adaptation for obstructive sleep apnoea syndrome – a controlled pilot study

Obstructive sleep apnoea syndrome (OSAS) is characterised by repetitive collapse of the upper airway during sleep. Continuous positive airway pressure (CPAP) applied via a mask is the standard treatment for OSAS. CPAP adherence is crucial in therapy to prevent the deleterious consequences of OSAS. We hypothesised that a combination of supervision by telemetry together with targeted telephone support in the first month of CPAP would increase CPAP adherence and treatment success. A total of 113 OSAS patients followed by telemetry-triggered interventions used the device for 5.3 h/night on 28/30 nights, significantly more than the 110 OSAS patients in the control group with 4.6 h/night and 27/30 nights. Telemetry-triggered interventions have a significant impact on adherence rate in early CPAP treatment. These results can be reached with an acceptable additional effort.

Translational approaches to understanding metabolic dysfunction and cardiovascular consequences of obstructive sleep apnea

Obstructive sleep apnea (OSA) is known to be independently associated with several cardiovascular diseases including hypertension, myocardial infarction, and stroke. To determine how OSA can increase cardiovascular risk, animal models have been developed to explore the underlying mechanisms and the cellular and end-organ targets of the predominant pathophysiological disturbance in OSA-intermittent hypoxia. Despite several limitations in translating data from animal models to the clinical arena, significant progress has been made in our understanding of how OSA confers increased cardiovascular risk. It is clear now that the hypoxic stress associated with OSA can elicit a broad spectrum of pathological systemic events including sympathetic activation, systemic inflammation, impaired glucose and lipid metabolism, and endothelial dysfunction, among others. This review provides an update of the basic, clinical, and translational advances in our understanding of the metabolic dysfunction and cardiovascular consequences of OSA and highlights the most recent findings and perspectives in the field.

Is There a Relationship Between Snoring Sound Intensity and Frequency and OSAS Severity?

Objectives:

We investigated the relationship between snoring sounds and severity of obstructive sleep apnea syndrome (OSAS).

Methods:

A total number of 103 snoring patients (60 males and 43 females) were evaluated by means of polysomnographic findings and snoring sound recordings. Snoring sound intensity was assessed using fast Fourier transform (FFT) method by measuring maximal frequency (Fmax) and average snoring sound intensity level (SSIL).

Results:

Maximal frequency and SSIL are correlated with apnea-hypopnea index (AHI), REM AHI, and severity of the OSAS. So, as the severity of the OSAS increased, so did the Fmax and SSIL of the snoring recordings, meaning patients started snoring louder with more frequency. In older patients, in females, in severe OSAS group, and in patients with higher body mass index (BMI), AHI and AHI REM values and SSIL and Fmax values increased. As mean oxygen (O2) saturation and lowest O2 saturation decreased, SSIL and Fmax values increased.

Conclusion:

Maximal frequency and SSIL analysis of the snoring sound increased in severe OSAS patients. People should be aware of the importance of snoring sounds. In particular, patients with snoring sounds increasing in intensity and of higher frequency should discuss with their physicians the possibility of OSAS.

Objectively measured sleep characteristics and prevalence of coronary artery calcification: the Multi-Ethnic Study of Atherosclerosis Sleep study

BACKGROUND

We tested whether objectively measured indices of obstructive sleep apnoea (OSA) and sleep quality are associated with coronary artery calcification (CAC) prevalence independent of obesity, a classic confounder.

METHODS

1465 Multi-Ethnic Study of Atherosclerosis participants (mean age 68 years), who were free of clinical cardiovascular disease, had both coronary CT and in-home polysomnography and actigraphy performed. OSA categories were defined by the Apnea-Hypopnea Index (AHI). Prevalence ratios (PRs) for CAC >0 and >400 (high burden) were calculated.

RESULTS

Participants with severe OSA (AHI ≥30; 14.6%) were more likely to have prevalent CAC, relative to those with no evidence of OSA, after adjustment for demographics and smoking status (PR 1.16; 95% CI 1.06 to 1.26), body mass index (1.11; 1.02 to 1.21) and traditional cardiovascular risk factors (1.10; 1.01 to 1.19). Other markers of hypoxaemia tended to be associated with a higher prevalence of CAC >0. For CAC >400, a higher prevalence was observed with both a higher arousal index and less slow-wave sleep. Overall, associations were somewhat stronger among younger participants, but did not vary by sex or race/ethnicity.

CONCLUSIONS

In this population-based multi-ethnic sample, severe OSA was associated with subclinical coronary artery disease (CAC >0), independent of obesity and traditional cardiovascular risk factors. Furthermore, the associations of the arousal index and slow-wave sleep with high CAC burden suggest that higher nightly sympathetic nervous system activation is also a risk factor. These findings highlight the potential importance of measuring disturbances in OSA as well as sleep fragmentation as possible risk factors for coronary artery disease.

Obstructive Sleep Apnea, Oxidative Stress, and Cardiovascular Disease: Evidence from Human Studies

Obstructive sleep apnea (OSA) is a frequent disease mainly affecting obese people and caused by repetitive collapse of the upper airways during sleep. The increased morbidity and mortality of OSA are mainly thought to be the consequence of its adverse effects on cardiovascular (CV) health. In this context, oxidative stress induced by nocturnal intermittent hypoxia has been identified to play a major role. This is suggested by biomarker studies in OSA patients showing excessively generated reactive oxygen species from leukocytes, reduced plasma levels of nitrite and nitrate, increased lipid peroxidation, and reduced antioxidant capacity. Biopsy studies complement these findings by demonstrating reduced endothelial nitric oxide synthase expression and increased nitrotyrosine immunofluorescence in the vasculature of these patients. Furthermore, oxidative stress in OSA correlates with surrogate markers of CV disease such as endothelial function, intima-media thickness, and high blood pressure. Continuous positive airway pressure therapy reverses oxidative stress in OSA. The same may be true for antioxidants; however, more studies are needed to clarify this issue.

Obstructive sleep apnoea in the elderly: role of continuous positive airway pressure treatment

Almost all the information about the effect of continuous positive airway pressure (CPAP) in patients with obstructive sleep apnoea (OSA) comes from clinical trials involving only middle-aged patients. The objective of this study was to assess the effect of CPAP treatment in elderly patients with severe OSA on clinical, quality-of-life and neurocognitive spheres. We performed an open-label, randomised, multicentre clinical trial in a consecutive clinical cohort of 224 elderly (≥70 years old) patients with confirmed severe OSA (apnoea-hypopnea index ≥30) randomised to receive CPAP (n=115) or no CPAP (n=109) for 3 months. A sleep study was performed by either full polysomnography or respiratory polygraphy. CPAP titration was performed by an autoCPAP device. The primary endpoint was quality of life (Quebec Sleep Questionnaire) and secondary endpoints included sleep-related symptoms, presence of anxiety/depression, office-based blood pressure and some neurocognitive tests. The mean±sd age was 75.5±3.9 years. The CPAP group achieved a greater improvement in all quality-of-life domains (p<0.001; effect size: 0.41-0.98), sleep-related symptoms (p<0.001; effect size 0.31-0.91) as well as anxiety (p=0.016; effect size 0.51) and depression (p<0.001; effect size: 0.28) indexes and some neurocognitive tests (digit symbol test (p=0.047; effect size: 0.20) and Trail Making Test A (p=0.029; effect size: 0.44)) in an intention-to-treat analysis. In conclusion, CPAP treatment resulted in an improvement in quality of life, sleep-related symptoms, anxiety and depression indexes and some neurocognitive aspects in elderly people with severe OSA.

Protective Effect of Long-Term CPAP Therapy on Cognitive Performance in Elderly Patients with Severe OSA: The PROOF Study

OBJECTIVE

Obstructive sleep apnea syndrome (OSA) leads to a deterioration in cognitive functions, with regard to memory and executive functions. However, few studies have investigated the impact of treatment on these cognitive functions in elderly subjects.

METHODS

The study was conducted in a large cohort of subjects aged 65 years or older (the PROOF cohort). Subjects were not diagnosed or treated for OSA. Subjects underwent a polygraphic recording. Cognitive performance was assessed in all OSA subjects at baseline and 10 years later, whether or not they were receiving continuous positive airway pressure (CPAP) therapy.

RESULTS

A group of 126 patients were analyzed. Only 26% of them were treated, with therapy initiated at the discretion of the primary care physician. Among treated subjects, self-reported compliance with therapy was good (> 6 h/night on average), and 66% of them reported an improvement in their quality of life. Patients receiving CPAP treatment had a higher apneahypopnea index (p = 0.006), a higher oxygen desaturation index (p < 0.001), and experienced more pronounced daytime repercussions (p = 0.004). These patients showed a statistically significant improvement in mental agility (similarities test; p < 0.0001) and memory performance (Grober and Buschke delayed free recall; p = 0.02).

CONCLUSION

CPAP treatment is associated with the maintenance of memory performance over time.

Relationship Between Sleep Apnea and Cancer

In the light of relationships reported between hypoxemia (tissue hypoxia) and cancer, Abrams et al. concluded in 2008 that sleep apnea-hypopnea syndrome (SAHS) and its main consequence, intermittent hypoxia, could be related with increased susceptibility to cancer or poorer prognosis of a pre-existing tumor. This pathophysiological association was confirmed in animal studies. Two large independent historical cohort studies subsequently found that the degree of nocturnal hypoxia in patients with SAHS was associated with higher cancer incidence and mortality. This finding has been confirmed in almost all subsequent studies, although the retrospective nature of some requires that they be considered as hypothesis-generating only. The relationship between sleep apnea and cancer, and the pathophysiological mechanisms governing it, could be clarified in the near future in a currently on-going study in a large group of melanoma patients.

Association of electrocardiographic left ventricular hypertrophy with incident cardiovascular disease in Japanese older hypertensive patients

BACKGROUND

Our aim was to assess whether electrocardiographic left ventricular hypertrophy (ECG-LVH) is associated with a higher risk of cardiovascular disease (CVD) events, independent of 24-hour blood pressure (BP) and circulating levels of norepinephrine and hemostatic factors.

METHODS

In 514 older hypertensive patients (mean age 72.3 years; 37% men), we assessed ambulatory BP values, circulating levels of norepinephrine and hemostatic factors (plasma fibrinogen, prothrombin fragment 1+2 (F1+2), von Willebrand factor (vWF), and plasminogen activator inhibitor-1 (PAI-1)), and the presence or absence of ECG-LVH (Sokolow-Lyon voltage ≥ 3.5 mV). The incidence of CVD events (i.e., myocardial infarction and stroke) was prospectively ascertained.

RESULTS

During an average 41 months of follow-up (1,751 person-years), 43 stroke and 3 myocardial infarction events occurred. At baseline, patients with ECG-LVH had higher mean 24-hour BP (148.8/83.8mm Hg vs. 135.7/77.2mm Hg) and circulating norepinephrine levels (404.6 pg/ml vs. 336.3 pg/ml) compared to those without ECG-LVH; the differences remained unchanged after adjustment for age, gender, smoking status, presence of diabetes, and antihypertensive medication uses at follow-up time (all P < 0.01). Cox proportional hazards models suggested that the hazard ratio (HR; 95% confidence interval (CI)) of CVD events for those with ECG-LVH was 4.4 (2.3-8.2), and the association between ECG-LVH and incident CVD events remained significant after adjustment for high 24-hour BP (≥130/80mm Hg), nocturnal SBP, circulating norepinephrine and fibrinogen levels (HRs, 3.5-4.2, all P < 0.001).

CONCLUSIONS

In older hypertensive patients, ECG-LVH was associated with a higher risk of CVD events, independent of ambulatory BP parameters and circulating norepinephrine and fibrinogen levels.

Impacts of comorbidities on the association between arterial stiffness and obstructive sleep apnea in the elderly

BACKGROUND

Although the impact of obstructive sleep apnea (OSA) on cardiovascular risk is reasonably well established in middle-aged patients, the debate persists as to whether OSA also increases this risk in the elderly. Arterial stiffness has been used as an early independent predictor of cardiovascular risk.

STUDY OBJECTIVES

We sought to determine whether OSA has significant effects on the arterial stiffness in the elderly population and evaluate the impact of comorbidities on the association between arterial stiffness and OSA.

METHODS

We performed a cross-sectional study in a university hospital. Elderly participants (≥60 years) were invited to participate in our study between November 2010 and January 2013. OSA was diagnosed using gold standard polysomnography and arterial stiffness was assessed by brachial-ankle pulse wave velocity (baPWV), cardio-ankle vascular index (CAVI) and central systolic and diastolic blood pressure (cSBP and cDBP). The high-sensitivity C-reactive protein (hs-CRP) level was also measured.

RESULTS

We found no significant association between the severity of OSA and the arterial stiffness-related parameters cSBP, cDBP, baPWV, CAVI and hs-CRP. However, in patients with no comorbid medical conditions or use of medications (n = 101), we showed a modest association between OSA and arterial stiffness-related parameters and hs-CRP.

CONCLUSION

We conclude that OSA is associated with increased arterial stiffness in an otherwise healthy elderly population, although the association was obviated by comorbidities and medications perhaps due to ceiling effects.

The effect of nasal surgery on continuous positive airway pressure device use and therapeutic treatment pressures: a systematic review and meta-analysis

BACKGROUND

The relationship between nasal surgery and its effect on continuous positive airway pressure (CPAP) device therapeutic treatment pressures and CPAP device use has not been previously systematically examined.

STUDY OBJECTIVES

To conduct a systematic review and meta-analysis evaluating the effect of isolated nasal surgery on therapeutic CPAP device pressures and use in adults with obstructive sleep apnea (OSA).

METHODS

MEDLINE, Scopus, Web of Science, and The Cochrane Library were searched through July 15, 2014. The MOOSE consensus statement and PRISMA statement were followed.

RESULTS

Eighteen studies (279 patients) reported CPAP data after isolated nasal surgery. Seven studies (82 patients) reported preoperative and postoperative mean therapeutic CPAP device pressures and standard deviations (SD), which reduced from 11.6 ± 2.2 to 9.5 ± 2.0 centimeters of water pressure (cwp) after nasal surgery. Pooled random effects analysis demonstrated a statistically significant pressure reduction, with a mean difference (MD) of -2.66 cwp (95% confidence interval (CI), -3.65 to -1.67); P < 0.00001. Eleven studies (153 patients) reported subjective, self-reported data for CPAP use; and a subgroup analysis demonstrated that 89.1% (57 of 64 patients) who were not using CPAP prior to nasal surgery subsequently accepted, adhered to, or tolerated it after nasal surgery. Objective, device meter-based hours of use increased in 33 patients from 3.0 ± 3.1 to 5.5 ± 2.0 h in the short term (<6 mo of follow-up).

CONCLUSION

Isolated nasal surgery in patients with OSA and nasal obstruction reduces therapeutic CPAP device pressures and the currently published literature's objective and subjective data consistently suggest that it also increases CPAP use in select patients.

Mechanisms and clinical consequences of untreated central sleep apnea in heart failure

Central sleep apnea (CSA) is a highly prevalent, though often unrecognized, comorbidity in patients with heart failure (HF). Data from HF population studies suggest that it may present in 30% to 50% of HF patients. CSA is recognized as an important contributor to the progression of HF and to HF-related morbidity and mortality. Over the past 2 decades, an expanding body of research has begun to shed light on the pathophysiologic mechanisms of CSA. Armed with this growing knowledge base, the sleep, respiratory, and cardiovascular research communities have been working to identify ways to treat CSA in HF with the ultimate goal of improving patient quality of life and clinical outcomes. In this paper, we examine the current state of knowledge about the mechanisms of CSA in HF and review emerging therapies for this disorder.

All-cause mortality from obstructive sleep apnea in male and female patients with and without continuous positive airway pressure treatment: a registry study with 10 years of follow-up

BACKGROUND

More information is needed about the effect on mortality of continuous positive airway pressure (CPAP) in patients with obstructive sleep apnea (OSA), especially in women.

METHODS

We employed a historical cohort study design, using data from 25,389 patients with a diagnosis of OSA selected from the Danish National Patient Registry for the period 1999-2009. We used Cox proportional hazard function to evaluate the all-cause mortality from OSA in middle-aged and elderly males and females who were treated, or not, with CPAP.

RESULTS

Female OSA patients had a lower mortality than males, irrespective of whether they received CPAP treatment. CPAP treatment improved survival, as illustrated by the hazard ratio of 0.62 (P<0.001). This effect was dependent on gender: CPAP had no significant effect on 20- to 39-year-old males and females, but the overall mortality in this age group was small. Survival was increased by CPAP in 40- to 59-year-old and ≥60-year-old males, but no such effect was observed in females. Positive predictors of survival were young age, female gender, higher educational level, and low 3-year prior comorbidity as estimated by the Charlson Comorbidity Index. Negative predictors for survival were male gender, age ≥60 years, no CPAP treatment, prior comorbidity, and low educational level.

CONCLUSION

CPAP therapy is associated with reduced all-cause mortality in middle-aged and elderly males, but no significant effect was found in females.

Polysomnographic predictors of persistent continuous positive airway pressure adherence in patients with moderate and severe obstructive sleep apnea

Extensive use of continuous positive airway pressure (CPAP) has positive clinical benefits for most patients with obstructive sleep apnea (OSA). However, patient adherence is a major limiting factor to the effectiveness of CPAP treatment. This study determined the potential and quantifiable factors affecting the willingness of patients with OSA to undertake CPAP treatment by comparing the polysomnographic parameters recorded during diagnosis and titration. Patients with moderate and severe OSA who attended diagnostic polysomnography (PSG) and CPAP titration at the sleep center of China Medical University Hospital (CMUH) were included in the study. A total of 312 patients were divided into persistent users and nonusers of CPAP according to their use of in-home CPAP following titration and a 7-day CPAP trial. Multivariate logistic regression analyses were used to define the potential polysomnographic predictors of persistent CPAP adherence, and odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Most patients were men older than 50 years who were overweight or obese. Among the patients, 146 (46.8%) became persistent CPAP users. A 10% improvement of oxygen desaturation index (ODI) and a 10% increment in deep sleep percentage increased the chance of persistent CPAP use 1.18-fold and 1.07-fold, respectively. In addition, the improved ODI and deep sleep during CPAP titration increased the chance of persistent CPAP user. The polysomnographic parameters obtained from diagnosis and during titration can facilitate the prediction of persistent CPAP use.

Cardiovascular risk in patients with sleep apnoea with or without continuous positive airway pressure therapy: follow-up of 4.5 million Danish adults

BACKGROUND

The prognostic significance of age and continuous positive airway pressure (CPAP) therapy on cardiovascular disease in patients with sleep apnoea has not been assessed previously.

METHODS

Using nationwide databases, the entire Danish population was followed from 2000 until 2011. First-time sleep apnoea diagnoses and use of CPAP therapy were determined. Incidence rate ratios (IRRs) of ischaemic stroke and myocardial infarction (MI) were analysed using Poisson regression models.

RESULTS

Amongst 4.5 million individuals included in the study, 33 274 developed sleep apnoea (mean age 53, 79% men) of whom 44% received persistent CPAP therapy. Median time to initiation of CPAP therapy was 88 days (interquartile range 34-346). Patients with sleep apnoea had more comorbidities compared to the general population. Crude rates of MI and ischaemic stroke were increased for sleep apnoea patients (5.4 and 3.6 events per 1000 person-years compared to 4.0 and 3.0 in the general population, respectively). Relative to the general population, risk of MI [IRR 1.71, 95% confidence interval (CI) 1.57-1.86] and ischaemic stroke (IRR 1.50, 95% CI 1.35-1.66) was significantly increased in patients with sleep apnoea, in particular in patients younger than 50 years (IRR 2.12, 95% CI 1.64-2.74 and IRR 2.34, 95% CI 1.77-3.10, respectively). Subsequent CPAP therapy was not associated with altered prognosis.

CONCLUSIONS

Sleep apnoea is associated with increased risk of ischaemic stroke and MI, particularly in patients younger than 50 years of age. CPAP therapy was not associated with a reduced rate of stroke or MI.

Sleep apnea in the elderly

PURPOSE OF REVIEW

Sleep apnea syndrome (SAS) in the elderly presents varied clinical symptoms and also has many complications. Moreover, there are many hospital departments related to these symptoms. This article uses literature to provide an outline on SAS observed in the elderly.

RECENT FINDINGS

SAS sufferers often have complications with so-called lifestyle-related diseases, such as hypertension, hyperlipidemia, diabetes mellitus and metabolic syndrome. These symptoms, along with SAS, recede as a result of continuous positive airway pressure treatment. Some have also reported recession of depression symptoms and delay in deterioration of cognitive functions.

SUMMARY

The elderly tends to develop SAS through coexistence of chronic respiratory organ disorders, increase in upper airway collapse, strokes, cardiovascular diseases, hypertension, diabetes mellitus and other physiological anatomical changes that accompany aging. However, judgment on the severity and effects regarding prognosis by each remedy used in the diagnosis and treatment of SAS in the elderly is still being developed, and it is considered necessary to accumulate more evidence and establish new standards.

Sleep apnea-hypopnea syndrome and type 2 diabetes. A reciprocal relationship?

Epidemiological data suggest that sleep apnea-hypopnea syndrome (SAHS) is independently associated with the development of insulin resistance and glucose intolerance. Moreover, despite significant methodological limitations, some studies report a high prevalence of SAHS in patients with type 2 diabetes mellitus (DM2). A recent meta-analysis shows that moderate-severe SAHS is associated with an increased risk of DM2 (relative risk=1.63 [1.09 to 2.45]), compared to the absence of apneas and hypopneas. Common alterations in various pathogenic pathways add biological plausibility to this relationship. Intermittent hypoxia and sleep fragmentation, caused by successive apnea-hypopnea episodes, induce several intermediate disorders, such as activation of the sympathetic nervous system, oxidative stress, systemic inflammation, alterations in appetite-regulating hormones and activation of the hypothalamic-pituitary-adrenal axis which, in turn, favor the development of insulin resistance, its progression to glucose intolerance and, ultimately, to DM2. Concomitant SAHS seems to increase DM2 severity, since it worsens glycemic control and enhances the effects of atherosclerosis on the development of macrovascular complications. Furthermore, SAHS may be associated with the development of microvascular complications: retinopathy, nephropathy or diabetic neuropathy in particular. Data are still scant, but it seems that DM2 may also worsen SAHS progression, by increasing the collapsibility of the upper airway and the development of central apneas and hypopneas.

Sleep in older adults: normative changes, sleep disorders, and treatment options

Approximately 5% of older adults meet criteria for clinically significant insomnia disorders and 20% for sleep apnea syndromes. It is important to distinguish age-appropriate changes in sleep from clinically significant insomnia, with the latter having associated daytime impairments. Non-pharmacologic therapies, such as cognitive-behavioral therapy for insomnia, can be highly effective with sustained benefit. Pharmacologic therapies are also available, but may be associated with psychomotor effects. A high index of suspicion is crucial for effective diagnosis of sleep apnea because symptoms commonly noted in younger patients, such as obesity or loud snoring, may not be present in older patients.

Management of sleep apnea without high pretest probability or with comorbidities by three nights of portable sleep monitoring

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) diagnosis using simplified methods such as portable sleep monitoring (PM) is only recommended in patients with a high pretest probability. The aim is to determine the diagnostic efficacy, consequent therapeutic decision-making, and costs of OSA diagnosis using polysomnography (PSG) versus three consecutive studies of PM in patients with mild to moderate suspicion of sleep apnea or with comorbidity that can mask OSA symptoms.

DESIGN AND SETTING

Randomized, blinded, crossover study of 3 nights of PM (3N-PM) versus PSG. The diagnostic efficacy was evaluated with receiver operating characteristic (ROC) curves. Therapeutic decisions to assess concordance between the two different approaches were performed by sleep physicians and respiratory physicians (staff and residents) using agreement level and kappa coefficient. The costs of each diagnostic strategy were considered.

PATIENTS AND RESULTS

Fifty-six patients were selected. Epworth Sleepiness Scale was 10.1 (5.3) points. Bland-Altman plot for apnea-hypopnea index (AHI) showed good agreement. ROC curves showed the best area under the curve in patients with PSG AHI ≥ 5 [0.955 (confidence interval = 0.862-0.993)]. For a PSG AHI ≥ 5, a PM AHI of 5 would effectively exclude and confirm OSA diagnosis. For a PSG AHI ≥ 15, a PM AHI ≥ 22 would confirm and PM AHI < 7 would exclude OSA. The best agreement of therapeutic decisions was achieved by the sleep medicine specialists (81.8%). The best cost-diagnostic efficacy was obtained by the 3N-PM.

CONCLUSIONS

Three consecutive nights of portable monitoring at home evaluated by a qualified sleep specialist is useful for the management of patients without high pretest probability of obstructive sleep apnea or with comorbidities.

CLINICAL TRIAL REGISTRATION

http://www.clinicaltrials.gov, registration number: NCT01820156.

CITATION

Guerrero A, Embid C, Isetta V, Farre R, Duran-Cantolla J, Parra O, Barbé F, Montserrat JM, Masa JF. Management of sleep apnea without high pretest probability or with comorbidities by three nights of portable sleep monitoring.

Home ventilation therapy in obstructive sleep apnea-hypopnea syndrome

Obstructive sleep apnea-hypopnea is a highly prevalent disease that is often underdiagnosed at present. It has a significant economic and social welfare impact, accounting for a large part of the resources assigned to home respiratory therapies. As part of the 2014 SEPAR Year of the Chronic Patient and Domiciliary Respiratory Care sponsored by the Spanish Society of Pulmonology and Thoracic Surgery, this article reviews the most recent publications on the indications and controversial issues in the treatment of sleep apnea, the latest evidence for indication of various positive pressure devices, and adjustment modes, ranging from the use of empirical formulae or mathematical estimations to modern auto-CPAP equipment, while not forgetting the gold standard of manual titration. Emphasis is placed on the need for monitoring required by patients to ensure treatment adherence and compliance. Finally, other therapies that are not the object of this article are briefly reviewed.

Human factors/usability barriers to home medical devices among individuals with disabling conditions: in-depth interviews with positive airway pressure device users

BACKGROUND

Evidence suggests that medical equipment often fails to accommodate the needs of individuals with disabling conditions. Few studies have focused on the accessibility of home medical devices such as positive airway pressure (PAP), which is a type of home medical equipment prescribed for long-term therapy.

OBJECTIVE

The purpose of this study was to explore in detail the types of difficulties experienced by patients with physical/sensory impairments who use PAP devices, as an initial step in designing a questionnaire to survey users about this topic.

METHODS

In this descriptive study, in-depth interviews were conducted with 19 participants (9 patients with physical/sensory impairment and 10 health care providers). Interviews were coded and analyzed for major topics.

RESULTS

Participants detailed the numerous ways in which current PAP devices fail to meet the needs of individuals with physical/sensory impairments (e.g., tremor, poor depth perception, paresis), by requiring patients to perform manually difficult tasks, such as inserting PAP parts through small apertures, attaching parts using a twisting motion, and lifting arms overhead to apply PAP headgear. These demands contributed to patients' frustration with and reduced usage of the home medical device.

CONCLUSIONS

Our findings suggest that home medical devices such as PAP may not be currently designed to meet the needs of some users with physical/sensory impairments. Additional studies are needed to measure the prevalence and impact of impairment-related barriers on PAP adherence for this common medical equipment.