Consequences of Obstructive Sleep Apnea: Cardiovascular Risk of Obstructive Sleep Apnea and Whether Continuous Positive Airway Pressure Reduces that Risk

Association and interaction effect of shift work and the risk for obstructive sleep apnea on diabetes mellitus in middle-aged Korean workers

PURPOSE

To investigate the association of shift work and the risk for obstructive sleep apnea (OSA) with diabetes mellitus (DM), and the interaction effect of shift work and the risk for OSA on DM.

METHODS

Data from the Korea National Health and Nutrition Examination Survey (KNHANES) 2019-2021 were used. The participants were 3012 employees aged 40 to 59 years. Shift work was assessed using self-reporting questionnaires. The risk for OSA was assessed by STOP-BANG score. The distribution of demographic factors was calculated using the chi-square test. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were calculated using multivariable logistic regression. An interaction effect between shift work and the risk for OSA on DM was evaluated using relative excess risk owing to interaction (RERI) and attributable proportion (AP) with 95% CIs. The synergic index (SI) was also calculated.

RESULTS

Shift work and the risk for OSA were each significantly associated with DM. There was also a significant interaction effect between shift work and the risk for OSA on DM. The RERI was 0.543 (95% CI 0.205-1.361) and the AP was 0.230 (95% CI 0.145-0.342). The SI was 1.662 (95% CI 1.481-1.843).

CONCLUSIONS

There was an association and a significant interaction effect of shift work and the risk for OSA on DM. The management of OSA in shift workers should be implemented to prevent DM.

Prolonged intermittent hypoxia differentially regulates phrenic motor neuron serotonin receptor expression in rats following chronic cervical spinal cord injury

Low-dose (< 2 h/day), acute intermittent hypoxia (AIH) elicits multiple forms of serotonin-dependent phrenic motor plasticity and is emerging as a promising therapeutic strategy to restore respiratory and non-respiratory motor function after spinal cord injury (SCI). In contrast, high-dose (> 8 h/day), chronic intermittent hypoxia (CIH) undermines some forms of serotonin-dependent phrenic motor plasticity and elicits pathology. CIH is a hallmark of sleep disordered breathing, which is highly prevalent in individuals with cervical SCI. Interestingly, AIH and CIH preconditioning differentially impact phrenic motor plasticity. Although mechanisms of AIH-induced plasticity in the phrenic motor system are well-described in naïve rats, we know little concerning how these mechanisms are affected by chronic SCI or intermittent hypoxia preconditioning. Thus, in a rat model of chronic, incomplete cervical SCI (lateral spinal hemisection at C2 (C2Hx), we assessed serotonin type 2A, 2B and 7 receptor expression in and near phrenic motor neurons and compared: 1) intact vs. chronically injured rats; and 2) the impact of preconditioning with varied "doses" of intermittent hypoxia (IH). While there were no effects of chronic injury or intermittent hypoxia alone, CIH affected multiple receptors in rats with chronic C2Hx. Specifically, CIH preconditioning (8 h/day; 28 days) increased serotonin 2A and 7 receptor expression exclusively in rats with chronic C2Hx. Understanding the complex, context-specific interactions between chronic SCI and CIH and how this ultimately impacts phrenic motor plasticity is important as we leverage AIH-induced motor plasticity to restore breathing and other non-respiratory motor functions in people with chronic SCI.

An Obstructive Sleep Apnea - A Novel Public Health Threat

In patients with obstructive sleep apnea (OSA) during obstructive events, episodes of hypoxia and hypercapnia may modulate the autonomic nervous system (ANS) by increasing sympathetic tone and irritability, which contributes to sympathovagal imbalance and ultimately dysautonomia. Because OSA can alter ANS function through biochemical changes, we can assume that heart rate variability (HRV) will be altered in patients with OSA. Most studies show that in both the time and frequency domains, patients with OSA have higher sympathetic components and lower parasympathetic dominance than healthy controls. These results confirm autonomic dysfunction in these patients, but also provide new therapeutic directions. Respiratory methods that modulate ANS, e.g., cardiorespiratory biofeedback, could be beneficial for these patients. Heart rate variability assessment can be used as a tool to evaluate the effectiveness of OSA treatment due to its association with autonomic impairment.

Clinical considerations and pathophysiological associations among obesity, weight loss, heart failure, and hypertension

PURPOSE OF REVIEW

To describe the relationship between three pandemics: hypertension, obesity, and heart failure. From pathophysiology to treatment, understanding how these disease entities are linked can lead to breakthroughs in their prevention and treatment. The relevance of this review lies in its discussion of novel pharmacological and surgical treatment strategies for obesity and hypertension, and their role in the prevention and treatment of heart failure.

RECENT FINDINGS

Novel medications such as GLP-1 agonists have demonstrated sustained weight loss in patients with obesity, and concurrent improvements in their cardiometabolic profile, and possibly also reductions in hypertension-related comorbidities including heart failure. Surgical therapies including laparoscopic bariatric surgery represent an important treatment strategy in obese patients, and recent studies describe their use even in patients with advanced heart failure, including those with ventricular assist devices.

SUMMARY

These developments have deep implications on our efforts to understand, mitigate, and ultimately prevent the three pandemics, and offer promising improvements to quality of life, survival, and the cost burden of these diseases.

The potential of tRF-21-U0EZY9X1B plasmatic level as a biomarker of children with obstructive sleep apnea-hypopnea syndrome

PURPOSE

We investigated changes in plasma transfer RNA related fragments (tRF) in children with obstructive sleep apnea-hypopnea syndrome (OSAHS) and the potential value as a disease marker.

METHODS

Firstly, we randomly selected five plasma samples from the case group and the control group for high-throughput RNA sequencing. Secondly, we screened one tRF with different expression between the two groups, amplified it by quantitative reverse transcription-PCR (qRT-PCR) and sequenced the amplified product. After confirming that the qRT-PCR results were consistent with the sequencing results and the sequence of the amplified product contained the original sequence of the tRF, we performed qRT-PCR on all samples. Then we analyzed the diagnostic value of the tRF and its correlation with some clinical data.

RESULTS

A total of 50 OSAHS children and 38 control children were included in this study. There were significant differences in height, serum creatinine (SCR) and total cholesterol (TC) between the two groups. The plasma expression levels of tRF-21-U0EZY9X1B (tRF-21) were significantly different between the two groups. Receiver operating characteristic curve (ROC) showed that it had valuable diagnostic index, with area under the curve (AUC) of 0.773, 86.71% and 63.16% sensitivity and specificity.

CONCLUSIONS

The expression levels of tRF-21 in the plasma of OSAHS children decreased significantly which were closely related to hemoglobin, mean corpuscular hemoglobin, triglyceride and creatine kinase-MB, may become novel biomarkers for the diagnosis of pediatric OSAHS.

Circadian rhythm and clinical characteristics in patients with acute myocardial infarction combined with obstructive sleep apnea

OBJECTIVE

The present study aimed to investigate the circadian rhythm and clinical characteristics of patients with acute myocardial infarction (AMI) combined with obstructive sleep apnea (OSA).

METHODS

Patients with AMI combined with OSA were enrolled in the study, and those that met the inclusion criteria were divided into three time-period groups based on their sleep-wake rhythm (22:00-5:59, 6:00-13:59, and 14:00-21:59). The differences between the three groups of patients in sleep-monitoring data, blood routine, biochemical indicators, and coronary angiographic parameters were analyzed and compared. Count data were expressed as the number of cases, and the chi-square test was used for statistical analysis. Continuous data were expressed as mean ± standard deviation, and analysis of variance was used for the statistical analysis of these data. The characteristics of circadian rhythm and clinical features in patients with AMI combined with OSA were analyzed.

RESULTS

Of the 148 patients, 90/148 (61%) had chest pain and 58/148 (39%) had non-chest pain symptoms. In the 22:00-05:59 group, there were 70/148 (47%) patients with AMI (of these, 46/70 [66%] had chest pain). In the 06:00-13:59 period group, there were 44/148 (30%) patients with AMI (of these, 26/44 [60%] had chest pain). In the 14:00-21:59 period group, there were 34/148 (23%) patients with AMI (of these, 17/34 [50%] had chest pain). There was no statistically significant difference in the apnea-hypopnea index (AHI) and SYNTAX score between patients in the 22:00-5:59 and 6:00-13:59 groups. However, the AHI and SYNTAX scores in the 22:00-5:59 and 6:00-13:59 groups were higher than those in the 14:00-21:59 group, and the differences were statistically significant. In patients in the 22:00-5:59 group, the levels of serum D-dimer (DD), hemoglobin (Hb), and oxygen desaturation index (ODI3) were higher, the sleep mean oxygen saturation (MeanSaO2 ) was lower and the percentage of nighttime spent with oxygen saturation of less than 90% (Tsat90 ) and less than 85% (Tsat85 ) was longer.

CONCLUSION

The peak period for the onset of AMI in patients with OSA was 22:00-5:59, and the incidence of chest pain was high. During this period, patients had higher DD and Hb, higher ODI3, lower MeanSaO2 during sleep, and longer TSat90 and TSat85 . During the 22:00-5:59 and 6:00-13:59 periods, patients had higher AHI and a higher SYNTAX score.

The Efficacy of Twin-Block Appliances for the Treatment of Obstructive Sleep Apnea in Children: A Systematic Review and Meta-Analysis

Objective

To evaluate the efficacy of twin-block appliance in the treatment of children with obstructive sleep apnea (OSA).

Methods

Two independent reviewers conducted a systematic review of seven databases from database establishment until October 16, 2021. There were no language restrictions. The outcomes were changes in apnea-hypopnea index (AHI), oxyhemoglobin desaturation index (ODI), and lowest arterial oxygen saturation (lowest SaO2). National Institute for Health and Clinical Excellence (NICE) tool was used to assess the quality of the studies included.

Results

A total of 207 articles were screened for relevance, and 6 of them met the inclusion criteria for our meta-analysis. Four of the studies were case series, 1 was nonrandomized control trial, and 1 was a randomized crossover clinical trial. After twin-block therapy, there was a significant decrease in AHI (4.35 events/hour, 95% CI: 4.04, 4.66, p ≤ 0.001). The lowest SaO2 significantly increased by 9.17% (95% CI: 12.05, 6.28, p ≤ 0.001). Sensitivity analysis by excluding studies one by one showed stable and favorable results in lowest SaO2 and AHI.

Conclusions

Results from the meta-analysis showed that the use of twin-block appliance significantly decreased AHI and significantly increased lowest SaO2. Hence, twin-block appliance therapy may be an effective method for the treatment of pediatric OSA. Further large sample size randomized controlled trials are needed to assess this treatment efficacy in children with obstructive sleep apnea.

Obstructive sleep apnoea and left ventricular diastolic dysfunction among first responders to the 9/11 World Trade Center terrorist attack: a cross-sectional study

OBJECTIVES

Obstructive sleep apnoea (OSA) is often linked to cardiovascular disease. A limited number of studies have reported an association between OSA and left ventricular diastolic dysfunction (LVDD). However, prior studies were performed on small patient populations. Studies have shown a high prevalence of OSA among first responders to the 9/11 World Trade Center (WTC) terrorist attack. We investigated the relationship between OSA and LVDD in a large population of WTC responders.

DESIGN

Cross-sectional study.

SETTING

One-time screening programme as part of the WTC-CHEST Study (NCT10466218), performed at a quaternary medical centre in New York City, from November 2011 to June 2014.

PARTICIPANTS

A total of 1007 participants with mean age of 51 years of mostly non-Hispanic white men were evaluated. Patients from the WTC Health Program-Clinical Center of Excellence, who were over the age of 39 years, were eligible to participate.

RESULTS

Evaluation of those without OSA diagnosis showed no significant association with LVDD when comparing those screened (Berlin Questionnaire) as OSA high risk versus OSA low risk (p=0.101). Among those diagnosed with LVDD, there was a significant association when comparing those with and without patient-reported OSA (OR 1.50, 95% CI 1.13 to 2.00, p=0.005), but the significance was not maintained after adjusting for pertinent variables (OR 1.3, 0.94 to 1.75, p=0.119). Notably, comparing those with OSA diagnosis and those low risk of OSA, the OR for LVDD was significant (1.69, 1.24 to 2.31, p=0.001), and after adjusting for waist-hip ratio, diabetes and coronary artery calcium score percentile, the relationship remained significant (OR 1.45, 1.03 to 2.04, p=0.032).

CONCLUSION

The strong association of OSA with LVDD in this population may inform future guidelines to recommend screening for LVDD in high-risk asymptomatic patients with OSA.

Effects of Apnea, Obesity, and Statin Therapy on Proprotein Convertase Subtilisin/Kexin 9 Levels in Patients with Obstructive Sleep Apnea

OBJECTIVES

Obstructive sleep apnea (OSA) is a common condition closely related to obesity, insulin resistance, dyslipidemia, and cardiovascular disease. The aim of this study was to explore the possible relationship between OSA and proprotein convertase subtilisin/kexin type 9 (PCSK9).

METHODS

Full-night polysomnography was performed on 150 participants who were divided into three groups: controls, OSA patients on statin therapy, and OSA patients not on statin therapy. Biochemical markers, plasma low-density lipoprotein (LDL) and high-density lipoprotein (HDL) subclasses, and PCSK9 were determined.

RESULTS

PCSK9 was highest in OSA patients on statins compared to the control group and to OSA patients not on statins (p = 0.036 and p = 0.039, respectively), after adjustment for body mass index (BMI). LDL diameter was greater in OSA patients not on statins compared to OSA patients on statins (p = 0.032). PCSK9 was highest in the group of patients with all three risk factors (diagnosed OSA, statins, BMI ≥25 kg/m2) compared to groups with no, one, and two risk factors (p = 0.031, p = 0.001, and p = 0.029, respectively). Presence of OSA, statin therapy, and BMI ≥25 kg/m2 when combined were independently associated with higher levels of PCSK9 when adjusted for antihypertensive therapy, small dense LDL, and HDL 3c subclass (odds ratio = 2.849; interquartile range [1.026-7.912], p = 0.044).

CONCLUSION

Statin therapy was closely related to PCSK9. OSA along with obesity and statin use induces elevation of PCSK9.

H3K23/H3K36 hypoacetylation and HDAC1 up-regulation are associated with adverse consequences in obstructive sleep apnea patients

The aim of this study is to determine the roles of global histone acetylation (Ac)/methylation (me), their modifying enzymes, and gene-specific histone enrichment in obstructive sleep apnea (OSA). Global histone modifications, and their modifying enzyme expressions were assessed in peripheral blood mononuclear cells from 56 patients with OSA and 16 matched subjects with primary snoring (PS). HIF-1α gene promoter-specific H3K36Ac enrichment was assessed in another cohort (28 OSA, 8 PS). Both global histone H3K23Ac and H3K36Ac expressions were decreased in OSA patients versus PS subjects. H3K23Ac expressions were further decreased in OSA patients with prevalent hypertension. HDAC1 expressions were higher in OSA patients, especially in those with excessive daytime sleepiness, and reduced after more than 6 months of continuous positive airway pressure treatment. H3K79me3 expression was increased in those with high C-reactive protein levels. Decreased KDM6B protein expressions were noted in those with a high hypoxic load, and associated with a higher risk for incident cardiovascular events or hypertension. HIF-1α gene promoter-specific H3K36Ac enrichment was decreased in OSA patients versus PS subjects. In vitro intermittent hypoxia with re-oxygenation stimuli resulted in HDAC1 over-expression and HIF-1α gene promoter-specific H3K36Ac under-expression, while HDAC1 inhibitor, SAHA, reversed oxidative stress through inhibiting NOX1. In conclusions, H3K23/H3K36 hypoacetylation is associated with the development of hypertension and disease severity in sleep-disordered breathing patients, probably through up-regulation of HDAC1, while H3K79 hypermethylation is associated with higher risk of cardiovascular diseases, probably through down-regulation of KDM6B.

Profile of Solriamfetol in the Management of Excessive Daytime Sleepiness Associated with Narcolepsy or Obstructive Sleep Apnea: Focus on Patient Selection and Perspectives

Excessive sleepiness (ES) is a symptom of obstructive sleep apnea (OSA) and narcolepsy that has severe consequences. Wake-promoting drugs and stimulants are utilized as accessory treatment in OSA to reduce propensity to sleep but they do not improve sleep-disordered breathing. Solriamfetol is a first-line therapeutic agent to combat sleepiness in OSA and narcolepsy patients that is approved both by the Food and Drug Administration (FDA) and the European Medicines Agency (EMA). For excessively sleepy adult patients with OSA despite primary treatment or narcolepsy patients without cataplexy, solriamfetol may be used as initial therapy or as replacement therapy in patients who fail treatment or experience unacceptable side effects with modafinil, armodafinil, pitolisant, or stimulants. It can also be used as add-on therapy in OSA or narcolepsy patients when ES is only partially controlled with modafinil, armodafinil, pitolisant, sodium oxybate, or stimulants. Solriamfetol is a phenylalanine derivative whose wake-promoting action may be mediated through its selective dopamine and norepinephrine reuptake inhibition. This paper reviews the profile of solriamfetol in treating ES associated with OSA or narcolepsy and discusses patient selection and clinical perspectives. Mechanism of action, pharmacology, pharmacokinetics, clinical efficacy, and tolerability of solriamfetol are described. The Treatment of OSA and Narcolepsy Excessive Sleepiness (TONES) solriamfetol trials demonstrated the efficacy of solriamfetol in reducing propensity to sleep and maintaining wakefulness, with significant improvements in mean maintenance of wakefulness test (MWT) sleep latencies and significant reduction in Epworth Sleepiness Scale (ESS) scores compared to placebo. With solriamfetol, significantly higher percentages of patients showed improvement in patient's and clinician's global impression of change.

Use of the WatchPAT to detect occult residual sleep-disordered breathing in patients on CPAP for obstructive sleep apnea

STUDY OBJECTIVES

To determine the accuracy of the apnea-hypopnea index (AHI) as measured by continuous positive airway pressure (CPAP) machines by simultaneously employing a home sleep apnea testing device (WatchPAT 200, Itamar Medical, Israel [WPAT]) in patients suspected of having residual sleep-disordered breathing (SDB).

METHODS

Patients with new, recurrent, or worsening signs, symptoms, or comorbidities associated with obstructive sleep apnea underwent home sleep apnea testing using WPAT while simultaneously using CPAP at their usual prescribed settings. CPAP AHI and WPAT AHI, respiratory disturbance index, and oximetry readings were then compared.

RESULTS

We identified an elevated AHI with WPAT testing in nearly half of patients with clinically suspected residual SDB and a normal CPAP AHI. WPAT detected additional respiratory events as well, including rapid eye movement-related apneas, respiratory effort-related arousals, and hypoxemia.

CONCLUSIONS

WPAT AHI was significantly higher than simultaneous CPAP AHI in nearly half of those patients with clinically suspected residual SDB being treated with CPAP. Additional respiratory disturbances, including rapid eye movement-related respiratory events, respiratory effort-related arousals, and hypoxemia, were elucidated only with the use of the WPAT. Residual SDB may have potential clinical consequences, including reduced CPAP adherence, ongoing hypersomnolence, and other health-related sequelae. Simultaneous WPAT testing of patients with a normal CPAP AHI may represent a valuable tool to detect clinically suspected residual SDB or to ensure adequate treatment in high-risk patients with obstructive sleep apnea in general.

Polysomnographic phenotype as a risk factor for cardiovascular diseases in patients with obstructive sleep apnea syndrome: a retrospective cohort study

Background

Obstructive sleep apnea syndrome (OSAS) is associated with the development of cardiovascular diseases caused by hypoxemia during sleeping. We classified OSAS phenotypes based on polysomnographic findings and aimed to evaluate that the unique phenotypes would be differentially associated with risk of cardiovascular disease.

Methods

This retrospective and observational study assessed adult patients who underwent polysomnography at the Wonju Severance Christian Hospital from November 2008 to February 2018. The OSAS phenotypes were classified as apnea-predominant, hypopnea-predominant, and respiratory effort-related arousal (RERA)-predominant based on the polysomnography results. The polysomnographic data were collected and analysed, and clinical features such as medical history and comorbidities were assessed by a review of the electronic medical records.

Results

A total of 860 adult patients were classified as apnea-predominant (n=220), hypopnea-predominant (n=119), or RERA-predominant (n=275). The hypopnea-predominant group had significantly higher rates of hyperlipidaemia (P<0.001), heart failure (15.5%, P<0.001), and coronary artery disease (20.9%, P=0.005) than the other groups. After classifying the patients according to severity of the hypopnea index, logistic regression analyses adjusted for age, sex, and smoking history revealed that the hypopnea index increased the risk for coronary artery disease and heart failure.

Conclusions

The hypopnea-predominant group would be a specific phenotype that has a differential association with the risks for coronary artery disease and heart failure.

Obstructive sleep apnea is associated with increased rotor burden in patients undergoing focal impulse and rotor modification guided atrial fibrillation ablation

Aims

To assess whether obstructive sleep apnea (OSA) was associated with increased rotor burden among atrial fibrillation (AF) patients.

Methods and results

We studied 33 consecutive patients who were scheduled for focal impulse and rotor modulation (FIRM) ablation at our institution to describe the mapping, ablation, and outcomes, among patients with and without OSA. Patients underwent biatrial FIRM mapping in AF with ablation of stable rotors in addition to conventional ablation lesion sets. Differences between groups were tested with student's t-tests and Fisher's exact tests, as appropriate. Survival analyses were performed using the Kaplan-Meier method. Twelve of the 33 (36%) patients had OSA and 8 (66%) used continuous positive airway pressure ventilation (CPAP). Obstructive sleep apnea patients had a higher body mass index (BMI) (33.6 vs. 28.8 kg/m2, P = 0.01) and were more commonly on beta blockers (67% vs. 29%, P = 0.03) but were otherwise similar regarding baseline characteristics, medication use, and prior AF treatments, including antiarrhythmic drugs and prior ablation. Focal impulse and rotor modulation mapping demonstrated increased rotor burden in the OSA patients (2.6 ± 0.9 vs. 2.0 ± 1.0, P =0.03). The increased rotor burden was more evident in the right atrium (RA) (1.0 ± 0.7 vs. 0.5 ± 0.7, P =0.04 compared with left atrium (1.7 ± 0.8 vs. 1.4 ± 0.7, P = 0.15). There was no correlation between BMI and total number of rotors (r = 0.0961, P = 0.59). Among the population of patients with OSA, CPAP therapy was associated with a lower number of RA rotors (0.8 ± 0.7 vs. 1.5 ± 0.6, P = 0.05) but no significant difference in overall rotors (P = 0.33).

Conclusion

Obstructive sleep apnea patients demonstrate increased rotor prevalence, driven predominantly by an increase in RA rotors. CPAP therapy was associated with fewer RA rotors.

Insomnia symptoms in primary care: A prospective study focusing on prevalence of undiagnosed co-morbid sleep disordered breathing

OBJECTIVE

To determine prevalence of comorbid undiagnosed sleep disordered breathing (SDB) in chronic insomnia patients, using two complementary methods, one standard and one novel.

METHODS

Using prospective design, adult patients diagnosed with chronic insomnia, treated with prescription pharmacological agents for >3 months without prior objective sleep evaluation or diagnosis of SDB were invited to participate. All patients recorded their sleep for two consecutive nights using level 3 home-sleep-apnea-test (HSAT) device to derive Respiratory Event Index (REI) for OSA diagnosis. The electrocardiogram-signal (ECG) recorded by the same device was analyzed using FDA cleared medical software, Cardiopulmonary Coupling (CPC) to quantify sleep time and identify sleep-quality and pathology.

RESULTS

Of 110 chronic insomnia patients who volunteered between May 2017 and June 2018, 88% were women. Prevalence of moderate-severe SDB (REI > 15) was 25% based on REI-scoring. Surrogate markers of moderate-severe SDB detected by the novel method identified prevalence of 33%, with negative predictive value 96%, reclassifying 10 individuals that HSAT diagnosed with mild SDB with more advanced disease state. Agreement between the methods is 88%.

CONCLUSION

High prevalence and overlap in symptoms between insomnia and SDB warrants objective testing when evaluating sleep complaints before therapy is initiated. Diagnostic caution is even more importantly warranted for female patients presenting insomnia sleep complaints, as SDB may not be initially considered as a biological symptom driver. CPC-analysis can complement standard HSAT or serve as a standalone option to evaluate sleep complaints in individuals presenting insomnia symptoms before therapy is initiated.

CLINICAL TRIAL REGISTRY NAME AND NUMBER

Pilot study: Co-occurrence of Insomnia and Sleep Disordered Breathing (SDB) symptoms: Prospective study focusing on chronic insomnia patients treated with pharmacological agents. Approved by the Bioethics Committee on March 7^th, 2017. VSNb: 17- 047- S1/ ST - GRA - 17029 - PDX - SH http://vsn.is/is/content/17-047.

Heart rate variability in adults with obstructive sleep apnea: a systematic review

Obstructive Sleep Apnea is a common respiratory disorder characterized by recurrent nocturnal episodes of normal breathing interruption due to upper airway total or partial collapse. Obstructive sleep apnea and cardiovascular diseases has similar risk factors, but the first is also a predisposing factor for cardiovascular pathologies independently of individuals demographic characteristics or risk markers. Heart rate variability is a non-invasive method to evaluate the regulation of autonomic nervous system and its a promising marker for health and disease, such as cardiovascular and respiratory diseases. The aim was to review whether heart rate variability is altered in patients with obstructive sleep apnea. We searched in five databases, including BIREME, Cochrane, Scholar Google, MEDLINE/PubMed and Periodics CAPES, and reference lists were also searched. Only cross-sectional studies comparing the heart rate variability of obstructive sleep patients with controls were included. Two authors independently extracted data and assessed trial quality. Twelve studies (513 participants with obstructive sleep apnea and 340 controls) met the inclusion criteria. This review evidence that adults with obstructive sleep apnea may demonstrate diminished vagal tone and higher sympathetic responsiveness.

Cardiovascular outcomes of continuous positive airway pressure therapy for obstructive sleep apnea

Obstructive sleep apnea is a common disorder with increased risk for cardiovascular morbidity and mortality. The first choice of treatment of obstructive sleep apnea is continuous positive airway pressure, which reduces excessive daytime sleepiness and improves quality of life in sleep clinic cohorts. Nevertheless, the majority of patients with cardiovascular disease and concomitant obstructive sleep apnea do not report daytime sleepiness, and adherence to treatment is insufficient particularly in this group. The current article aims to give an updated overview of the impact of continuous positive airway pressure therapy on cardiovascular outcomes mainly based on the observational studies and the recent randomized controlled trials.

Optimal Schedule for Assessing Home BP Variability: The Finn-Home Study

BACKGROUND

Current guidelines make no recommendations on the optimal timing or number of measurements for assessing home blood pressure variability (HBPV). Our aim was to elucidate the optimal schedule for measuring HBPV in relation to cardiovascular risk.

METHODS

In total, 1,706 Finnish adults (56.5 ± 8.5 years; 54% women) self-measured their home blood pressure (HBP) twice in the morning and evening during 7 consecutive days. The participants were followed up for cardiovascular events. We examined the association between HBPV (coefficient of variation based on 2 through 7 measurement days) and cardiovascular events using Cox regression models adjusted for HBP and other cardiovascular risk factors.

RESULTS

During a follow-up of 11.8 ± 3.1 years, 216 cardiovascular events occurred. Systolic morning HBPV based on three (hazard ratio [HR], 1.039; 95% confidence interval, 1.006-1.074, model c statistic 0.737) through seven (HR, 1.057; 95% confidence interval, 1.012-1.104, model c statistic 0.737) measurement days was significantly associated with cardiovascular events. Agreement in classification to normal vs. increased morning day-to-day HBPV between consecutive measurement days became substantial (κ = 0.69 for systolic and κ = 0.68 for diastolic) after the fourth measurement day. The associations of diastolic HBPV, evening HBPV, all-day HBPV, and variability based on first measurements of each measurement occasion, with cardiovascular outcomes were nonsignificant or remained significant only after the sixth measurement day.

CONCLUSIONS

Our results suggest systolic HBP should be measured twice in the morning for at least 3 days when assessing HBPV. Increasing the number of measurement days from 3 to 7 results in marginal improvement in prognostic accuracy.

A review on drug-induced sedation endoscopy - Technique, grading systems and controversies

Sleep disordered breathing (SDB) comprises a spectrum of disorders, ranging from simple snoring to severe obstructive sleep apnoea (OSA), with a significant burden to health care systems in high income countries. If left untreated, OSA has significant cumulative, long-term health consequences. In the 1990s drug induced sedation endoscopy (DISE) has been developed to become a primary tool in the diagnosis and management of OSA. It allows meticulous endoscopic evaluation of the airway and identifies areas of collapse, thereby informing both on the selection of surgical techniques, where efficacy depends entirely on success at relieving obstruction at a certain level and on the usefulness of conservative measures, such as mandibular advancement splints. This article provides a review of the literature on DISE, covering different grading systems and techniques, explaining different rationales and discussing controversies.

Association of subclinical inflammation, glycated hemoglobin and risk for obstructive sleep apnea syndrome

Objective

To investigate the inter-relation between high sensitivity C-reactive protein and glycated hemoglobin in prediction of risk of obstructive sleep apnea.

Methods

We included all individuals participating in a check-up program at the Preventive Medicine Center of Hospital Israelita Albert Einstein in 2014. The Berlin questionnaire for risk of obstructive sleep apnea was used, and the high sensitivity C-reactive protein and glycated hemoglobin levels were evaluated.

Results

The sample included 7,115 participants (age 43.4±9.6 years, 24.4% women). The Berlin questionnaire showed changes in 434 (6.1%) individuals. This finding was associated with high sensitivity C-reactive protein and glycated hemoglobin levels (p<0.001). However, only the association between the Berlin questionnaire result and glycated hemoglobin remained significant in the adjusted multivariate analysis, for the traditional risk factors and for an additional model, including high-density lipoprotein cholesterol and triglycerides.

Conclusion

The glycated hemoglobin, even below the threshold for diagnosis of diabetes, is independently associated with obstructive sleep apnea syndrome, even after adjustment for obesity and C-reactive protein. These findings suggest a possible pathophysiological link between changes in insulin resistance and obstructive sleep apnea syndrome, independently from obesity or low-grade inflammation.

Objetivo

Investigar a inter-relação entre proteína C-reativa de alta sensibilidade e hemoglobina glicada na predição do risco de apneia obstrutiva do sono.

Métodos

Foram incluídos todos os indivíduos participantes do programa de check-up do Centro de Medicina Preventiva Hospital Israelita Albert Einstein em 2014. Foi aplicado o questionário de Berlin sobre risco de apneia do sono, e avaliadas as dosagens de hemoglobina glicada e proteína C-reativa de alta sensibilidade.

Resultados

Foram incluídos 7.115 participantes (idade 43,4±9,6 anos, 24,4% mulheres). A prevalência de alteração no questionário de Berlin foi de 434 (6,1%). A alteração do questionário de Berlin associou-se positivamente aos resultados da proteína C-reativa de alta sensibilidade e da hemoglobina glicada (p<0,001). No entanto, apenas a associação entre o resultado do questionário de Berlin e a hemoglobina glicada permaneceu significativa na análise multivariada ajustada tanto para fatores de risco tradicionais quanto para um modelo adicional, que incluiu também lipoproteína de alta densidade-colesterol (HDL-c) e triglicérides.

Conclusão

A hemoglobina glicada, mesmo em valores abaixo do critério diagnóstico para diabetes mellitus, está associada de forma independente ao risco para síndrome da apneia obstrutiva do sono, mesmo após ajuste para obesidade e proteína C-reativa. Estes achados sugerem possível ligação fisiopatológica entre alterações na resistência insulínica e a síndrome da apneia obstrutiva do sono, que independe da obesidade ou inflamação de baixo grau.

The influence of sleep disordered breathing in REM sleep behavior disorder

OBJECTIVES/BACKGROUND

Because both REM sleep behavior disorder (RBD) and Obstructive Sleep Apnea (OSA) can present with similar symptoms, it is important to understand the influence of OSA in the clinical manifestations of RBD and whether RBD modulates OSA severity. Our objectives were to compare: 1. the intensity of non-motor symptoms between RBD patients with (RBD-OSA) and without OSA (RBD-non-OSA), and 2. polysomnographic features between RBD-OSA and OSA without RBD (OSA-non-RBD) patients.

METHODS

32 RBD cases were divided in two groups according to the presence of moderate to severe OSA [Apnea Hypopnea Index (AIH) > 14] (RBD-OSA vs. RBD-non-OSA). Non-motor symptoms were assessed with Montreal Cognitive Assessment Scale, SCOPA-Sleep and the Non-Motor Symptom Scale (NMSS) for Parkinson's disease. RBD-OSA patients were compared to 20 OSA-non-RBD patients matched for age, AHI and gender.

RESULTS

Compared to RBD-non-OSA (n = 22) patients, RBD-OSA patients (n = 10) showed significantly higher scores in SCOPA-Sleep Daytime and NMSS Attention/Memory, Gastrointestinal and Urinary domains, as well as higher sleep fragmentation, more oxygen desaturation and higher AIH in NREM sleep. RBD-OSA patients presented with less O₂ desaturation, snoring, and BMI when compared to OSA-non-RBD patients.

DISCUSSION

Our data suggests that OSA contributes to hypersomnolence, gastro-intestinal, memory, and urinary complaints in RBD patients. RBD patients seem to have a milder OSA phenotype (possible reflecting a protective role conferred by the maintenance of muscle tone during REM sleep) and to be less prone to obesity and snoring than non-RBD patients.

Development and validation of a Score for Preoperative Prediction of Obstructive Sleep Apnea (SPOSA) and its perioperative outcomes

BACKGROUND

Postoperative respiratory complications (PRCs) are associated with significant morbidity, mortality, and hospital costs. Obstructive sleep apnea (OSA), often undiagnosed in the surgical population, may be a contributing factor. Thus, we aimed to develop and validate a score for preoperative prediction of OSA (SPOSA) based on data available in electronic medical records preoperatively.

METHODS

OSA was defined as the occurrence of an OSA diagnostic code preceded by a polysomnography procedure. A priori defined variables were analyzed by multivariable logistic regression analysis to develop our score. Score validity was assessed by investigating the score's ability to predict non-invasive ventilation. We then assessed the effect of high OSA risk, as defined by SPOSA, on PRCs within seven postoperative days and in-hospital mortality.

RESULTS

A total of 108,781 surgical patients at Partners HealthCare hospitals (2007-2014) were studied. Predictors of OSA included BMI >25 kg*m^-2 and comorbidities, including pulmonary hypertension, hypertension, and diabetes. The score yielded an area under the curve of 0.82. Non-invasive ventilation was significantly associated with high OSA risk (OR 1.44, 95% CI 1.22-1.69). Using a dichotomized endpoint, 26,968 (24.8%) patients were identified as high risk for OSA and 7.9% of these patients experienced PRCs. OSA risk was significantly associated with PRCs (OR 1.30, 95% CI 1.19-1.43).

CONCLUSION

SPOSA identifies patients at high risk for OSA using electronic medical record-derived data. High risk of OSA is associated with the occurrence of PRCs.

Obesity, Cardiovascular Disease and Sleep Disorders: Insights into the Rising Epidemic

Cardiovascular disease (CVD) is the main cause of death among adult men and women in the USA and impacts millions around the globe. Traditional risk factors for CVD include obesity, diabetes, hypertension and dyslipidemia. The modern-day epidemic of obesity not only increased the rate of CVD but also ushered in an additional CVD risk factor to be added to the list; that is obstructive sleep apnea (OSA). In this review, we discuss the growing epidemic of obesity and OSA, highlighting the common pathogenic hypotheses linking these risk factors to CVD. We will also highlight the therapeutic rationale of OSA as a way to reduce CVD risk.