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Sankaranarayanan R, Bansal A, Yanamaladoddi VR, Sarvepalli SS, Vemula SL, Aramadaka S, Mannam R. Atrial Fibrillation in Obstructive Sleep Apnea Patients: Mechanisms, Risk Factors, and Management Strategies. Cureus 2023; 15:e36282. [PMID: 37073195 PMCID: PMC10105971 DOI: 10.7759/cureus.36282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2023] [Indexed: 03/19/2023] Open
Abstract
Obstructive sleep apnea (OSA) is identified by apnea or hypopnea of the upper respiratory tract, which is associated with decreased oxygen saturation or awakening from sleep. A severe and prevalent association with OSA is atrial fibrillation (AF). This review article outlined numerous studies to understand the pathogenic pathways linked with developing OSA-associated AF and the therapeutic and preventive options available to reduce AF. The article looked for multiple risk factors common to OSA and AF. In addition, it has reviewed several therapeutic modalities such as continuous positive air pressure (CPAP), weight loss, upper airway stimulation (UAS), and other novel treatment options to find their efficiency in decreasing the outcome of AF in OSA patients. Since OSA often goes undiagnosed, this article emphasizes the importance of early screening in patients with AF and other comorbid conditions such as obesity, advanced age, diabetes, hypertension, and many more. The article focuses on the importance of preventive approaches that can be easily implemented, such as behavioral modifications.
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Combined Airway and Bariatric Surgery (CABS) for Obstructive Sleep Apnea Patients with Morbid Obesity: A Comprehensive Alternative Preliminary Study. J Clin Med 2022; 11:jcm11237078. [PMID: 36498653 PMCID: PMC9738588 DOI: 10.3390/jcm11237078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/18/2022] [Accepted: 11/27/2022] [Indexed: 12/03/2022] Open
Abstract
Although continuous positive airway pressure is the gold standard for obstructive sleep apnea (OSA), it does not improve obesity. By contrast, bariatric surgery significantly improves obesity but with sustained OSA in the majority of patients. This study proposes a comprehensive technique—combined airway and bariatric surgery (CABS)—to improve both obesity and OSA. The aims of the study are to evaluate the feasibility, safety and efficacy of CABS in morbidly obese OSA patients. The retrospective study enrolled 20 morbidly obese OSA patients (13 males; median age, 44 years; median apnea−hypopnea index (AHI), 63.2 event/h; median body mass index (BMI), 41.4 kg/m2). The study population was divided into two groups based on patients’ volition after shared decision making. The bariatric surgery (BS) group included laparoscopic sleeve gastrectomy (LSG, n = 8) and laparoscopic Roux-en-Y gastric bypass (LRYGB, n = 2). CABS involved bariatric surgery—LSG (n = 8) and LRYGB (n = 2) in conjunction with airway surgery (concurrent nasal/palatal/lingual surgery [n = 8], concurrent palatal/lingual surgery [n = 2]). Patients received a home sleep apnea test at baseline and one year after surgery. The two patient groups were not different in age, sex, preoperative AHI or preoperative BMI. There was no airway compromise, wound bleeding or infection throughout the postoperative period. One year after surgery, patients in both groups achieved significant improvement in AHI and BMI. Furthermore, the improvement in AHI was significantly higher (p = 0.04) in the CABS group than in the BS group despite the insignificant change in BMI reduction (p = 0.63) between the two groups. In the CABS group, the BMI dropped from 40.4 to 28.4 kg/m2 (p < 0.0001) and the AHI decreased from 75.1 to 4.5 event/h (p = 0.0004). The classic success rate for OSA was 90% and the cure rate was 60% in the CABS group. A perioperative assessment of CABS group patients also revealed a significant improvement in the Epworth sleepiness scale, minimal O2 saturation, snoring index and heart rate. CABS is feasible and safe in treating OSA with morbid obesity. CABS achieves more reduction in AHI than BS alone with high success and cure rates for OSA. CABS can also significantly improve quality of life and general health and offers a comprehensive alternative for morbidly obese OSA patients.
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Sleep Breathing Disorders in Heart Failure. Cardiol Clin 2022; 40:183-189. [DOI: 10.1016/j.ccl.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Naito R, Kasai T, Dohi T, Takaya H, Narui K, Momomura SI. Factors Associated With the Improvement of Left Ventricular Systolic Function by Continuous Positive Airway Pressure Therapy in Patients With Heart Failure With Reduced Ejection Fraction and Obstructive Sleep Apnea. Front Neurol 2022; 13:781054. [PMID: 35359656 PMCID: PMC8960234 DOI: 10.3389/fneur.2022.781054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 02/14/2022] [Indexed: 11/25/2022] Open
Abstract
Background Obstructive sleep apnea (OSA) is a potential risk factor in cardiovascular diseases, including arrhythmia, coronary artery disease, and heart failure (HF). Continuous positive airway pressure (CPAP) therapy is an effective therapy for OSA and the underlying HF, partly through a 5–9% increase in the left ventricular ejection fraction (LVEF). However, the data on the factors associated with the efficacy of CPAP on LVEF in patients with HF complicated by OSA are scarce. This study aimed to investigate whether LVEF improves in patients with OSA and HF after 1 month of CPAP therapy, and to clarify which factors are associated with the degree of LVEF improvement. Method This was a prospective, single-arm, open-label study. We enrolled moderate-to-severe patients with OSA and HF who were being followed up at the cardiovascular center of Toranomon Hospital (Tokyo, Japan). The parameters of sleep study and LVEF were assessed at the baseline and after 1 month of CPAP. The multivariate regression analyses, with changes in LVEF as a dependent variable, were performed to determine the factors that were associated with the degree of LVEF improvement. Results We analyzed 55 consecutive patients with OSA and HF (mean age: 60.7 ± 12.2 years, mean LVEF value: 37.2 ± 9.8%). One month of CPAP treatment decreased the apnea-hypopnea index (AHI) from 45.3 ± 16.1 to 5.4 ± 4.1 per hour, and the LVEF improved from 37.2 ± 9.8 to 43.2 ± 11.7%. The multivariate regression analyses demonstrated that age and body mass index (BMI) were significant determinants of LVEF improvement. Conclusion The LVEF improved significantly after 1 month of CPAP therapy in Japanese patients with OSA and HF. Multivariate regression analyses indicated that an improvement in LVEF was likely to be observed in young patients with obesity.
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Affiliation(s)
- Ryo Naito
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Takatoshi Kasai
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Sleep Center, Toranomon Hospital, Tokyo, Japan
- *Correspondence: Takatoshi Kasai
| | - Tomotaka Dohi
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | | | - Koji Narui
- Sleep Center, Toranomon Hospital, Tokyo, Japan
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Lévy P, Naughton MT, Tamisier R, Cowie MR, Bradley TD. Sleep Apnoea and Heart Failure. Eur Respir J 2021; 59:13993003.01640-2021. [PMID: 34949696 DOI: 10.1183/13993003.01640-2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 09/07/2021] [Indexed: 11/05/2022]
Abstract
Heart Failure (HF) and Sleep-Disordered-Breathing (SDB) are two common conditions that frequently overlap and have been studied extensively in the past three decades. Obstructive Sleep Apnea (OSA) may result in myocardial damage, due to intermittent hypoxia increased sympathetic activity and transmural pressures, low-grade vascular inflammation and oxidative stress. On the other hand, central sleep apnoea and Cheyne-Stokes respiration (CSA-CSR) occurs in HF, irrespective of ejection fraction either reduced (HFrEF), preserved (HFpEF) or mildly reduced (HFmrEF). The pathophysiology of CSA-CSR relies on several mechanisms leading to hyperventilation, breathing cessation and periodic breathing. Pharyngeal collapse may result at least in part from fluid accumulation in the neck, owing to daytime fluid retention and overnight rostral fluid shift from the legs. Although both OSA and CSA-CSR occur in HF, the symptoms are less suggestive than in typical (non-HF related) OSA. Overnight monitoring is mandatory for a proper diagnosis, with accurate measurement and scoring of central and obstructive events, since the management will be different depending on whether the sleep apnea in HF is predominantly OSA or CSA-CSR. SDB in HF are associated with worse prognosis, including higher mortality than in patients with HF but without SDB. However, there is currently no evidence that treating SDB improves clinically important outcomes in patients with HF, such as cardiovascular morbidity and mortality.
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Affiliation(s)
- Patrick Lévy
- Univ Grenoble Alpes, Inserm, HP2 laboratory, Grenoble, France .,CHU Grenoble Alpes, Physiology, EFCR, Grenoble, France.,All authors contributed equally to the manuscript
| | - Matt T Naughton
- Alfred Hospital, Department of Respiratory Medicine and Monash University, Melbourne, Australia.,All authors contributed equally to the manuscript
| | - Renaud Tamisier
- Univ Grenoble Alpes, Inserm, HP2 laboratory, Grenoble, France.,CHU Grenoble Alpes, Physiology, EFCR, Grenoble, France.,All authors contributed equally to the manuscript
| | - Martin R Cowie
- Royal Brompton Hospital and Faculty of Lifesciences & Medicine, King"s College London, London, UK.,All authors contributed equally to the manuscript
| | - T Douglas Bradley
- Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Centre for Sleep Medicine and Circadian Biology of the University of Toronto and Department of Medicine of the University Health Network Toronto General Hospital, Canada.,All authors contributed equally to the manuscript
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Floras JS. The 2021 Carl Ludwig Lecture. Unsympathetic autonomic regulation in heart failure: patient-inspired insights. Am J Physiol Regul Integr Comp Physiol 2021; 321:R338-R351. [PMID: 34259047 DOI: 10.1152/ajpregu.00143.2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Defined as a structural or functional cardiac abnormality accompanied by symptoms, signs, or biomarkers of altered ventricular pressures or volumes, heart failure also is a state of autonomic disequilibrium. A large body of evidence affirms that autonomic disturbances are intrinsic to heart failure; basal or stimulated sympathetic nerve firing or neural norepinephrine (NE) release more often than not exceed homeostatic need, such that an initially adaptive adrenergic or vagal reflex response becomes maladaptive. The magnitude of such maladaptation predicts prognosis. This Ludwig lecture develops two theses: the elucidation and judiciously targeted amelioration of maladaptive autonomic disturbances offers opportunities to complement contemporary guideline-based heart failure therapy, and serendipitous single-participant insights, acquired in the course of experimental protocols with entirely different intent, can generate novel insight, inform mechanisms, and launch entirely new research directions. I précis six elements of our current synthesis of the causes and consequences of maladaptive sympathetic disequilibrium in heart failure, shaped by patient-inspired epiphanies: arterial baroreceptor reflex modulation, excitation stimulated by increased cardiac filling pressure, paradoxical muscle sympathetic activation as a peripheral neurogenic constraint on exercise capacity, renal sympathetic restraint of natriuresis, coexisting sleep apnea, and augmented chemoreceptor reflex sensitivity and then conclude by envisaging translational therapeutic opportunities.
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Affiliation(s)
- John S Floras
- University Health Network and Sinai Health Division of Cardiology, Toronto General Hospital Research Institute and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Shah NA, Reid M, Kizer JR, Sharma RK, Shah RV, Kundel V, Ambale-Venkatesh B, Fayad ZA, Shea SJ, Kaplan RC, Lima JAC, Redline S. Sleep-disordered breathing and left ventricular scar on cardiac magnetic resonance: results of the Multi-Ethnic Study of Atherosclerosis. J Clin Sleep Med 2021; 16:855-862. [PMID: 32029066 DOI: 10.5664/jcsm.8340] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
STUDY OBJECTIVES The objectives of this study were to evaluate the independent association between sleep-disordered breathing (SDB) using overnight polysomnography and left ventricular (LV) scar using cardiac magnetic resonance (CMR) with late-gadolinium enhancement in a community-based cohort of the Multi-Ethnic Study of Atherosclerosis. METHODS Our analytical sample includes 934 participants from the fifth examination of the Multiethnic Study of Atherosclerosis who underwent both polysomnography and CMR. SDB was categorized as follows: no-SDB (apnea-hypopnea index [AHI] < 5 events/h), mild SDB (5 events/h ≤ AHI < 15 events/h), and moderate-severe SDB (AHI ≥ 15 events/h). LV scar was considered present if there was presence of scar on CMR (late-gadolinium enhancement > 0%). Logistic regression with multivariable adjustment for confounders (age, sex, race/ethnicity, body mass index, and cardiometabolic risk factors) was used to examine the independent association of SDB with LV scar. Confounders were identified using directed acyclic graphs. RESULTS The mean age of our sample was 67.0 ± 8.5 years (SD), with 49% (n = 461) females and a prevalence of SDB (AHI ≥ 5 events/h) of 63% (n = 590). LV scar was more prevalent in individuals with SDB (9.5%) versus those without SDB (3.8%; P < .01), and 88% of all LV scars were clinically unrecognized. After multivariable adjustment, both mild SDB and moderate-severe SDB were independently associated with LV scar (odds ratio, 2.53; 95% confidence interval, 1.13-5.64 and odds ratio, 2.31; 95% confidence interval, 1.01-5.24, respectively). CONCLUSIONS In a community-based cohort, SDB (including mild) is independently associated with a more than 2-fold increase in the odds of LV scar presence measured using CMR with late-gadolinium enhancement. Most LV scars were clinically unrecognized. The impact of SDB treatment on subclinical myocardial infarction needs to be investigated in future studies.
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Affiliation(s)
- Neomi A Shah
- Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
| | - Michelle Reid
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jorge R Kizer
- Departments of Medicine, Epidemiology and Biostatistics, San Francisco Veterans Affairs Health Care System and University of California San Francisco, San Francisco, California
| | - Ravi K Sharma
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ravi V Shah
- Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Vaishnavi Kundel
- Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Zahi A Fayad
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Steven J Shea
- Columbia University Mailman School of Public Health, Department of Epidemiology, New York, New York.,Department of Medicine, Vagelos College of Physicians and Surgeons, New York, New York
| | - Robert C Kaplan
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York.,Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Joao A C Lima
- Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, Maryland
| | - Susan Redline
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Taylor KS, Keir DA, Haruki N, Kimmerly DS, Millar PJ, Murai H, Floras JS. Comparison of Cortical Autonomic Network-Linked Sympathetic Excitation by Mueller Maneuvers and Breath-Holds in Subjects With and Without Obstructive Sleep Apnea. Front Physiol 2021; 12:678630. [PMID: 34122146 PMCID: PMC8188800 DOI: 10.3389/fphys.2021.678630] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 04/16/2021] [Indexed: 11/15/2022] Open
Abstract
In healthy young volunteers, acquisition of blood oxygen level-dependent (BOLD) magnetic resonance (MR) and muscle sympathetic nerve (MSNA) signals during simulation of obstructive or central sleep apnea identified cortical cardiovascular autonomic regions in which the BOLD signal changed synchronously with acute noradrenergic excitation. In the present work, we tested the hypothesis that such Mueller maneuvers (MM) and breath-holds (BH) would elicit greater concomitant changes in mean efferent nerve firing and BOLD signal intensity in patients with moderate to severe obstructive sleep apnea (OSA) relative to age- and sex-matched individuals with no or only mild OSA (Apnea Hypopnea Index, AHI, <15 events/h). Forty-six participants, 24 with OSA [59 ± 8 years; AHI 31 ± 18 events/h (mean ± SD); seven women] and 22 without (58 ± 11 years; AHI 7 ± 4; nine women), performed a series of three MM and three BH, in randomly assigned order, twice: during continuous recording of MSNA from the right fibular nerve and, on a separate day, during T2∗-weighted echo planar functional MR imaging. MSNA at rest was greater in those with OSA (65 ± 19 vs. 48 ± 17 bursts per 100 heart beats; p < 0.01). MM and BH elicited similar heart rate, blood pressure, and MSNA responses in the two cohorts; group mean BOLD data were concordant, detecting no between-group differences in cortical autonomic region signal activities. The present findings do not support the concept that recurring episodes of cyclical apnea during sleep alter cortical or peripheral neural responsiveness to their simulation during wakefulness by volitional Mueller maneuvers or breath-holds.
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Affiliation(s)
- Keri S Taylor
- University Health Network and Mount Sinai Hospital Department of Medicine, Toronto General Hospital Research Institute and the Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Daniel A Keir
- University Health Network and Mount Sinai Hospital Department of Medicine, Toronto General Hospital Research Institute and the Department of Medicine, University of Toronto, Toronto, ON, Canada.,School of Kinesiology, The University of Western Ontario, London, ON, Canada
| | - Nobuhiko Haruki
- University Health Network and Mount Sinai Hospital Department of Medicine, Toronto General Hospital Research Institute and the Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Derek S Kimmerly
- University Health Network and Mount Sinai Hospital Department of Medicine, Toronto General Hospital Research Institute and the Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Kinesiology, Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Philip J Millar
- University Health Network and Mount Sinai Hospital Department of Medicine, Toronto General Hospital Research Institute and the Department of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Health and Nutritional Sciences, University of Guelph, Guelph, ON, Canada
| | - Hisayoshi Murai
- University Health Network and Mount Sinai Hospital Department of Medicine, Toronto General Hospital Research Institute and the Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - John S Floras
- University Health Network and Mount Sinai Hospital Department of Medicine, Toronto General Hospital Research Institute and the Department of Medicine, University of Toronto, Toronto, ON, Canada
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Wheeler JA, Tutrow KD, Ebenroth ES, Gaston B, Bandyopadhyay A. Heart failure is not a determinant of central sleep apnea in the pediatric population. Pediatr Pulmonol 2021; 56:1092-1102. [PMID: 33434409 PMCID: PMC8035286 DOI: 10.1002/ppul.25242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 11/20/2020] [Accepted: 12/13/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND/OBJECTIVES Adults with heart failure (HF) have high prevalence of central sleep apnea (CSA). While this has been repeatedly investigated in adults, there is a deficiency of similar research in pediatric populations. The goal of this study was to compare prevalence of CSA in children with and without HF and correlate central apneic events with heart function. METHODS Retrospective analysis of data from children with and without HF was conducted. Eligible children were less than 18 years old with echocardiogram and polysomnogram within 6 months of each other. Children were separated into groups with and without HF based on left ventricular ejection fraction (LVEF). Defining CSA as central apnea-hypopnea index (CAHI) more than 1/hour, the cohort was also classified into children with and without CSA for comparative study. RESULTS A total of 120 children (+HF: 19, -HF: 101) were included. The +HF group was younger, with higher prevalence of trisomy 21, muscular dystrophy, oromotor incoordination, and structural heart disease. The +HF group had lower apnea-hypopnea index (median: 3/hour vs. 8.6/hour) and lower central apnea index (CAI) (median: 0.2/hour vs. 0.55/hour). Prevalence of CSA was similar in both groups (p = .195). LogCAHI was inversely correlated to age (Pearson correlation coefficient: -0.245, p = .022). Children with CSA were younger and had higher prevalence of prematurity (40% vs. 5.3%). There was no significant difference in LVEF between children with and without CSA. After excluding children with prematurity, relationship between CAHI and age was no longer sustained. CONCLUSIONS In contrast to adults, there is no difference in prevalence of CSA in children with and without HF. Unlike in adults, LVEF does not correlate with CAI in children. Overall, it appears that central apneic events may be more a function of age and prematurity rather than of heart function.
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Affiliation(s)
| | | | - Eric S. Ebenroth
- Indiana University School of Medicine, Division of Pediatric Cardiology
| | - Benjamin Gaston
- Indiana University School of Medicine, Section of Pediatric Pulmonology, Allergy and Sleep Medicine
| | - Anuja Bandyopadhyay
- Indiana University School of Medicine, Section of Pediatric Pulmonology, Allergy and Sleep Medicine
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Chen J, Gu H, Wurster RD, Cheng ZJ. The protective role of SOD1 overexpression in central mediation of bradycardia following chronic intermittent hypoxia in mice. Am J Physiol Regul Integr Comp Physiol 2021; 320:R317-R330. [PMID: 33296277 PMCID: PMC7988771 DOI: 10.1152/ajpregu.00147.2020] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 10/27/2020] [Accepted: 12/03/2020] [Indexed: 01/07/2023]
Abstract
Obstructive sleep apnea (OSA) is a highly prevalent sleep disorder that is associated with many cardiovascular complications. Similar to OSA, chronic intermittent hypoxia (CIH) (a model for OSA) leads to oxidative stress and impairs baroreflex control of the heart rate (HR) in rodents. The baroreflex arc includes the aortic depressor nerve (ADN), vagal efferent, and central neurons. In this study, we used mice as a model to examine the effects of CIH on baroreflex sensitivity, aortic baroreceptor afferents, and central and vagal efferent components of the baroreflex circuitry. Furthermore, we tested whether human Cu/Zn Superoxide Dismutase (SOD1) overexpression in transgenic mice offers protection against CIH-induced deficit of the baroreflex arc. Wild-type C57BL/6J and SOD1 mice were exposed to room air (RA) or CIH and were then anesthetized, ventilated, and catheterized for measurement of mean arterial pressure (MAP) and HR. Compared with wild-type RA control, CIH impaired baroreflex sensitivity but increased maximum baroreceptor gain and bradycardic response to vagal efferent stimulation. Additionally, CIH reduced the bradycardic response to ADN stimulation, indicating a diminished central regulation of bradycardia. Interestingly, SOD1 overexpression prevented CIH-induced attenuation of HR responses to ADN stimulation and preserved HR responses to vagal efferent stimulation in transgenic mice. We suggest that CIH decreased central mediation of the baroreflex and SOD1 overexpression may prevent the CIH-induced central deficit.
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Affiliation(s)
- Jin Chen
- Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, Florida
| | - He Gu
- Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, Florida
| | - Robert D Wurster
- Department of Cellular and Molecular Physiology, Stritch School of Medicine, Loyola University, Maywood, Illinois
| | - Zixi Jack Cheng
- Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, Florida
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Hamaoka T, Murai H, Takata S, Hirai T, Sugimoto H, Mukai Y, Okabe Y, Tokuhisa H, Takashima SI, Usui S, Sakata K, Kawashiri MA, Sugiyama Y, Nakatsumi Y, Takamura M. Different prognosis between severe and very severe obstructive sleep apnea patients; Five year outcomes. J Cardiol 2020; 76:573-579. [PMID: 32620307 DOI: 10.1016/j.jjcc.2020.06.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 04/26/2020] [Accepted: 05/25/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is characterized by augmented sympathetic nerve activity. In our previous study, patients with OSA and an apnea-hyperpnea index (AHI)>55events/h showed increased single-unit muscle sympathetic nerve activity compared to patients with OSA and AHI of 30-55events/h. However, the prognostic impact in these patients remains unclear. METHODS Ninety-one OSA patients were included. All patients who had indication for continuous positive airway pressure (CPAP) were treated with CPAP. Patients were divided into three groups: mild/moderate OSA (S), AHI<30events/h (n=44); severe OSA (SS), AHI 30-55events/h (n=29); and very severe OSA (VSS), AHI>55events/h (n=18). The primary endpoint was a composite outcome composed of death, cardiovascular events, stroke, and heart failure with hospitalization. RESULTS In the 5-year follow-up, the primary event rate in the SS group [3 events (7%)] was the same as that in the S group [3 events (10%)]. However, the VSS group showed a significantly higher primary event rate among the three groups [6 events (33%), p<0.05]. In Cox regression analysis, the VSS group had the highest hazard ratio compared to other risk factors. CONCLUSIONS CPAP was effective for preventing cardiovascular disease in patients with severe OSA, however patients with very severe OSA still had a high event rate, indicating that CPAP treatment might be insufficient to reduce the OSA-related risk burden in patients with very severe OSA. Additional systemic medical treatment for CPAP might be needed in patients with very severe OSA.
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Affiliation(s)
- Takuto Hamaoka
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Hisayoshi Murai
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan; Kanazawa Municipal Hospital, Kanazawa, Japan.
| | | | - Tadayuki Hirai
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Hiroyuki Sugimoto
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Yusuke Mukai
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Yoshitaka Okabe
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Hideki Tokuhisa
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Shin-Ichiro Takashima
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Soichiro Usui
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Kenji Sakata
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Masa-Aki Kawashiri
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Yu Sugiyama
- Kanazawa Municipal Hospital, Kanazawa, Japan
| | | | - Masayuki Takamura
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
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12
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Gupta A, Quan SF, Oldenburg O, Malhotra A, Sharma S. Sleep-disordered breathing in hospitalized patients with congestive heart failure: a concise review and proposed algorithm. Heart Fail Rev 2019; 23:701-709. [PMID: 29850982 DOI: 10.1007/s10741-018-9715-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Congestive heart failure (CHF) is the most common cause of hospital admission in the USA costing the taxpayers billions of dollars. Sleep-disordered breathing (SDB) is a common co-morbid condition associated with CHF with prevalence estimated to be 60-70%. Despite substantial evidence supporting the negative impact of SDB on CHF, the condition is underrecognized and undertreated. Patients admitted to the hospital with CHF and SDB are prime candidates for intervention with positive airway pressure (PAP) therapy as they form a "captive audience," and timely intervention and education may mitigate sub-optimal outcomes. In conclusion, this review explores emerging data on the cost effectiveness and outcome of early intervention with PAP in hospitalized CHF patients.
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Affiliation(s)
| | - Stuart F Quan
- Harvard Medical School, Boston, MA, USA.,Albert Einstein Medical Center, Klein Building, Suite 363, 5501 Old York Road, Philadelphia, PA, 19141, USA
| | | | | | - Sunil Sharma
- Albert Einstein Medical Center, Klein Building, Suite 363, 5501 Old York Road, Philadelphia, PA, 19141, USA.
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Pak VM, Strouss L, Yaggi HK, Redeker NS, Mohsenin V, Riegel B. Mechanisms of reduced sleepiness symptoms in heart failure and obstructive sleep apnea. J Sleep Res 2018; 28:e12778. [PMID: 30421541 DOI: 10.1111/jsr.12778] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 08/27/2018] [Accepted: 09/10/2018] [Indexed: 11/29/2022]
Abstract
Patients with both heart failure and obstructive sleep apnea often have poor, repeatedly disrupted sleep, and yet they frequently do not complain of excessive daytime sleepiness. Understanding this lack of perceived sleepiness is crucial for the case identification and treatment of obstructive sleep apnea in the heart failure population at high risk of this disease, especially given the association between untreated obstructive sleep apnea and mortality among patients with heart failure. In this review, we present epidemiologic evidence concerning the lack of sleepiness symptoms in heart failure and obstructive sleep apnea, explore possible mechanistic explanations for this relationship, assess the benefits of treatment in this population, discuss implications for clinical practice and explore directions for future research.
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Affiliation(s)
- Victoria M Pak
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Department of Biobehavioral Research Collaborative, School of Nursing, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA.,Yale School of Nursing, West Haven, Connecticut, USA.,Emory Nell Hodgson School of Nursing, Atlanta, Georgia, USA
| | - Lisa Strouss
- Jefferson Medical Center, Philadelphia, Pennsylvania, USA
| | - Henry K Yaggi
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Vahid Mohsenin
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Barbara Riegel
- Department of Biobehavioral Research Collaborative, School of Nursing, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
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Gronda E, Francis D, Zannad F, Hamm C, Brugada J, Vanoli E. Baroreflex activation therapy: a new approach to the management of advanced heart failure with reduced ejection fraction. J Cardiovasc Med (Hagerstown) 2018; 18:641-649. [PMID: 28737621 PMCID: PMC5555968 DOI: 10.2459/jcm.0000000000000544] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Chronic heart failure is a common clinical condition characterized by persistent excessive sympathetic nervous system activation. The derangement of the sympathetic activity has relevant implications for disease progression and patient survival. Aiming to positively impact patient outcome, autonomic nervous system modulatory therapies have been developed and tested in animal and clinical studies. As a general gross assumption, direct vagal stimulation and baroreflex activation are considered equivalent. This assumption does not take into account the fact that direct cervical vagal nerve stimulation involves activation of both afferent and efferent fibers innervating not only the heart, but the entire visceral system, leading to undesired responses to and from this compartment. The different action of baroreflex activation is based on generating a centrally mediated reduction of sympathetic outflow and increasing parasympathetic activity to the heart via a physiological reflex pathway. Thus, baroreflex activation rebalances the unbalanced autonomic nervous system via a specific path. Independent and complementary investigations have shown that sympathetic nerve activity can be rebalanced via control of the arterial baroreflex in heart failure patients. Results from recent pioneering research studies support the hypothesis that baroreflex activation can add significant therapeutic benefit on top of guideline-directed medical therapy in patients with advanced heart failure. In the present review, baroreflex activation therapy results are discussed, focusing on critical aspects like patient selection rationale to support clinician orientation in opting for baroreflex activation therapy when, on top of current guideline-directed medical treatment, other therapies are to be considered.
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Affiliation(s)
- Edoardo Gronda
- aCardiovascular Department, IRCCS Multimedica, Sesto San Giovanni, Milan, Italy bNational Heart and Lung Institute, Imperial College London, London, UK cUnité 1116, Department of Cardiology, Centre d'Investigations Cliniques, INSERM, CHU de Nancy, Université de Lorraine, Nancy, France dKerckhoff Heart Center, Bad Nauheim Medical Clinic I, University of Giessen, Giessen, Germany eCardiovascular Institute, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain fDepartment of Molecular Medicine, University of Pavia, Pavia, Italy
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15
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Hamaoka T, Murai H, Kaneko S, Usui S, Okabe Y, Tokuhisa H, Kato T, Furusho H, Sugiyama Y, Nakatsumi Y, Takata S, Takamura M. Single-Unit Muscle Sympathetic Nerve Activity Reflects Sleep Apnea Severity, Especially in Severe Obstructive Sleep Apnea Patients. Front Physiol 2016; 7:66. [PMID: 26973534 PMCID: PMC4773439 DOI: 10.3389/fphys.2016.00066] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 02/12/2016] [Indexed: 01/19/2023] Open
Abstract
Obstructive sleep apnea syndrome (OSAS) is associated with augmented sympathetic nerve activity, as assessed by multi-unit muscle sympathetic nerve activity (MSNA). However, it is still unclear whether single-unit MSNA is a better reflection of sleep apnea severity according to the apnea-hypopnea index (AHI). One hundred and two OSAS patients underwent full polysomnography and single- and multi-unit MSNA measurements. Univariate and multivariate regression analysis were performed to determine which parameters correlated with OSAS severity, which was defined by the AHI. Single- and multi-unit MSNA were significantly and positively correlated with AHI severity. The AHI was also significantly correlated with multi-unit MSNA burst frequency (r = 0.437, p < 0.0001) and single-unit MSNA spike frequency (r = 0.632, p < 0.0001). Multivariable analysis revealed that SF was correlated most significantly with AHI (T = 7.27, p < 0.0001). The distributions of multiple single-unit spikes per one cardiac interval did not differ between patients with an AHI of <30 and those with and AHI of 30–55 events/h; however, the pattern of each multiple spike firing were significantly higher in patients with an AHI of >55. These results suggest that sympathetic nerve activity is associated with sleep apnea severity. In addition, single-unit MSNA is a more accurate reflection of sleep apnea severity with alternation of the firing pattern, especially in patients with very severe OSAS.
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Affiliation(s)
- Takuto Hamaoka
- Department of Disease Control and Homeostasis, Graduate School of Medical Science, Kanazawa University Kanazawa, Japan
| | - Hisayoshi Murai
- Department of Disease Control and Homeostasis, Graduate School of Medical Science, Kanazawa University Kanazawa, Japan
| | - Shuichi Kaneko
- Department of Disease Control and Homeostasis, Graduate School of Medical Science, Kanazawa University Kanazawa, Japan
| | - Soichiro Usui
- Department of Disease Control and Homeostasis, Graduate School of Medical Science, Kanazawa University Kanazawa, Japan
| | - Yoshitaka Okabe
- Department of Disease Control and Homeostasis, Graduate School of Medical Science, Kanazawa University Kanazawa, Japan
| | - Hideki Tokuhisa
- Department of Disease Control and Homeostasis, Graduate School of Medical Science, Kanazawa University Kanazawa, Japan
| | - Takeshi Kato
- Department of Disease Control and Homeostasis, Graduate School of Medical Science, Kanazawa University Kanazawa, Japan
| | - Hiroshi Furusho
- Department of Disease Control and Homeostasis, Graduate School of Medical Science, Kanazawa University Kanazawa, Japan
| | | | | | | | - Masayuki Takamura
- Department of Disease Control and Homeostasis, Graduate School of Medical Science, Kanazawa University Kanazawa, Japan
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Weak association between sleep bruxism and obstructive sleep apnea. A sleep laboratory study. Sleep Breath 2015; 20:703-9. [PMID: 26564168 DOI: 10.1007/s11325-015-1284-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 10/01/2015] [Accepted: 10/21/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE No definitive associations or causal relationships have been determined between obstructive sleep apnea-hypopnea (OSAH) and sleep bruxism (SB). The purpose of this study was to investigate, in a population reporting awareness of both OSAH and SB, the associations between each specific breathing and jaw muscle event. METHODS Polysomnography and audio-video data of 59 patients reporting concomitant OSAH and SB history were analyzed. Masseteric bursts after sleep onset were scored and classified into three categories: (1) sleep rhythmic masticatory muscle activity with SB (RMMA/SB), (2) sleep oromotor activity other than RMMA/SB (Sleep-OMA), and (3) wake oromotor activity after sleep onset (Wake-OMA). Spearman's rank correlation coefficient analyses were performed. Dependent variables were the number of RMMA/SB episodes, RMMA/SB bursts, Sleep-OMA, and Wake-OMA; independent variables were apnea-hypopnea index (AHI), arousal index(AI), body mass index(BMI), gender, and age. RESULTS Although all subjects had a history of both SB and OSAH, sleep laboratory results confirmed that these conditions were concomitant in only 50.8 % of subjects. Moderate correlations were found in the following combinations (p < 0.05); RMMA/SB episode with AI, RMMA/SB burst with AI and age, Sleep-OMA burst with AHI, and Wake-OMA burst with BMI. CONCLUSIONS The results suggest that (1) sleep arousals in patients with concomitant SB and OSAH are not strongly associated with onset of RMMA/SB and (2) apnea-hypopnea events appear to be related to higher occurrence of other types of sleep oromotor activity, and not SB activity. SB genesis and OSAH activity during sleep are probably influenced by different mechanisms.
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Abstract
Heart failure (HF) is one of the most prevalent and costly diseases in the United States. Sleep apnea is now recognized as a common, yet underdiagnosed, comorbidity of HF. This article discusses the unique qualities that sleep apnea has when it occurs in HF and explains the underlying pathophysiology that illuminates why sleep apnea and HF frequently occur together. The authors provide an overview of the treatment options for sleep apnea in HF and discuss the relative efficacies of these treatments.
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Affiliation(s)
- David Rosen
- Pulmonary Medicine, Montefiore Medical Center, 111 E 210 Street, Bronx, NY 10467, USA.
| | - Francoise Joelle Roux
- Connecticut Multispecialty Group, Division of Pulmonary, Critical Care and Sleep Medicine, 85 Seymour Street, Suite 923, Hartford, CT 06106, USA
| | - Neomi Shah
- Pulmonary Medicine, Montefiore Medical Center, 111 E 210 Street, Bronx, NY 10467, USA
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Konecny T, Khanna AD, Novak J, Jama AA, Zawadowski GM, Orban M, Pressman G, Bukartyk J, Kara T, Cetta F, Borlaug BA, Somers VK, Reeder GS. Interatrial pressure gradients during simulated obstructive sleep apnea: a catheter-based study. Catheter Cardiovasc Interv 2014; 84:1138-45. [PMID: 24677689 DOI: 10.1002/ccd.25433] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Revised: 01/27/2014] [Accepted: 02/08/2014] [Indexed: 11/07/2022]
Abstract
OBJECTIVES We set to measure the interatrial pressure gradient during simulated obstructive sleep apnea (OSA). BACKGROUND OSA occurs when a sleeping patient attempts to inhale against an obstructed airway. How this event affects the interatrial pressure gradient has not been defined. We hypothesized that simulated OSA in a conscious subject (Mueller maneuver [MM], inspiration against obstruction) would promote increased right-to-left pressure gradient, and then the substrate for right-to-left atrial shunting. METHODS Selected patients underwent simultaneous measurement of airway and atrial pressures (both left and right atrium [LA, RA]) using high-fidelity micromanometry at rest, during MM, and during VM, during right heart catheterization. RESULTS Ten patients (age 55 ± 11 years, two women) were successfully studied. During the onset of MM, RA pressure transiently but consistently exceeded LA pressure in response to the steep decline in intrathoracic pressure (maximum RA-LA pressure gradient increased from 0.1 ± 1.4 mm Hg at baseline to 7.0 ± 4.3 mm Hg during MM, P < 0.001). The maximum right-to-left atrial pressure gradient during Mueller maneuver was higher than that achieved during the Valsalva maneuver release (P < 0.007). CONCLUSIONS The onset of MM increased right-to-left pressure gradient across the atrial septum, likely as a result of greater blood return to the RA from extrathoracic veins. The RA-LA pressure gradient achieved during MM was greater than that observed during VM. These findings delineate the hemodynamic substrate for right to left shunting during OSA.
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Affiliation(s)
- Tomas Konecny
- Department of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota; Department of Cardiology International Clinical Research Center (ICRC), St. Anne's Hospital, Brno, Czech Republic
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Kimmerly DS, Morris BL, Floras JS. Apnea-induced cortical BOLD-fMRI and peripheral sympathoneural firing response patterns of awake healthy humans. PLoS One 2013; 8:e82525. [PMID: 24358198 PMCID: PMC3865029 DOI: 10.1371/journal.pone.0082525] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Accepted: 11/03/2013] [Indexed: 12/30/2022] Open
Abstract
End-expiratory breath-holds (BH) and Mueller manoeuvres (MM) elicit large increases in muscle sympathetic nerve activity (MSNA). In 16 healthy humans (9♀, 35±4 years) we used functional magnetic resonance imaging with blood oxygen level-dependent (BOLD) contrast to determine the cortical network associated with such sympathoexcitation. We hypothesized that increases in MSNA evoked by these simulated apneas are accompanied by BOLD contrast changes in the insular cortex, thalamus and limbic cortex. A series of 150 whole-brain images were collected during 3 randomly performed 16-second end-expiratory BHs and MMs (-30 mmHg). The identical protocol was repeated separately with MSNA recorded from the fibular nerve. The time course of the sympathoexcitatory response to both breathing tasks were correlated with whole-brain BOLD signal changes. Brain sites demonstrating both positive (activation) and negative (deactivation) correlations with the MSNA time course were identified. Sympathetic burst incidence increased (p<0.001) from 29±6 (rest) to 49±6 (BH) and 47±6 bursts/100 heartbeats (MM). Increased neural activity (Z-scores) was identified in the right posterior and anterior insular cortices (3.74, 3.64), dorsal anterior cingulate (3.42), fastigial and dentate cerebellar nuclei (3.02, 3.34). Signal intensity decreased in the left posterior insula (3.28) and ventral anterior cingulate (3.01). Apnea both activates and inhibits elements of a cortical network involved in the generation of sympathetic outflow. These findings identify a neuroanatomical substrate to guide future investigations into central mechanisms contributing to disorders characterized by elevated basal MSNA and exaggerated sympathetic responses to simulated apneas such as sleep apnea and heart failure.
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Affiliation(s)
- Derek S. Kimmerly
- Clinical Cardiovascular Physiology Laboratory, University Health Network and Mount Sinai Hospital Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- School of Health and Human Performance, Faculty of Health Professions, Dalhousie University, Halifax, Nova Scotia, Canada
- * E-mail:
| | - Beverley L. Morris
- Clinical Cardiovascular Physiology Laboratory, University Health Network and Mount Sinai Hospital Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - John S. Floras
- Clinical Cardiovascular Physiology Laboratory, University Health Network and Mount Sinai Hospital Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Portable recording for detecting sleep disorder breathing in patients under the care of a heart failure clinic. Clin Res Cardiol 2013; 102:535-42. [DOI: 10.1007/s00392-013-0563-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Accepted: 04/03/2013] [Indexed: 10/27/2022]
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Floras JS, Arcand J. Neurocirculatory responses to carbohydrates in patients with heart failure and healthy controls: more similar than different. Can J Cardiol 2012; 29:144-6. [PMID: 22819359 DOI: 10.1016/j.cjca.2012.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Revised: 05/23/2012] [Accepted: 05/23/2012] [Indexed: 10/28/2022] Open
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Mechanisms of sleep-disordered breathing: causes and consequences. Pflugers Arch 2011; 463:213-30. [DOI: 10.1007/s00424-011-1055-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Revised: 10/14/2011] [Accepted: 10/26/2011] [Indexed: 11/27/2022]
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Influence of the severity of obstructive sleep apnea on heart rate. J Cardiol 2010; 56:27-34. [DOI: 10.1016/j.jjcc.2010.01.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2009] [Revised: 01/05/2010] [Accepted: 01/26/2010] [Indexed: 11/21/2022]
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Abstract
Obstructive sleep apnea (OSA) is present in at least 2% to 4% of the general population. Central sleep apnea (CSA), though less common, is highly prevalent in patients with heart failure. Both forms of sleep apnea exert strong modulatory effects on the autonomic nervous system at night through a number of mechanisms including central respiratory-cardiac coupling in the brainstem, chemoreflex stimulation, baroreflexes, and reflexes relating to lung inflation. Arousals also contribute to the autonomic disturbance. Although sleep is normally a time when parasympathetic modulation of the heart predominates and myocardial electrical stability is enhanced, OSA and CSA disturb this quiescence, creating an autonomic profile in which both profound vagal activity leading to bradyarrhythmias, and sympatho-excitation favoring ventricular ectopy are observed. The resulting tendency toward cardiac arrhythmia may directly contribute to sudden cardiac death and premature mortality in patients with sleep apnea. Therapy consists largely of treatment with continuous positive airway pressure, which has been shown to improve autonomic profile and reduce nocturnal arrhythmias.
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Orban M, Bruce CJ, Pressman GS, Leinveber P, Romero-Corral A, Korinek J, Konecny T, Villarraga HR, Kara T, Caples SM, Somers VK. Dynamic changes of left ventricular performance and left atrial volume induced by the mueller maneuver in healthy young adults and implications for obstructive sleep apnea, atrial fibrillation, and heart failure. Am J Cardiol 2008; 102:1557-61. [PMID: 19026314 DOI: 10.1016/j.amjcard.2008.07.050] [Citation(s) in RCA: 115] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2008] [Revised: 07/17/2008] [Accepted: 07/17/2008] [Indexed: 11/30/2022]
Abstract
Using the Mueller maneuver (MM) to simulate obstructive sleep apnea (OSA), our aim was to investigate acute changes in left-sided cardiac morphologic characteristics and function which might develop with apneas occurring during sleep. Strong evidence supports a relation between OSA and both atrial fibrillation and heart failure. However, acute effects of airway obstruction on cardiac structure and function have not been well defined. In addition, it is unclear how OSA might contribute to the development of atrial fibrillation and heart failure. Echocardiography was used in healthy young adults to measure various parameters of cardiac structure and function. Subjects were studied at baseline, during, and immediately after performance of the MM and after a 10-minute recovery. Continuous heart rate, blood pressure, and pulse oximetry measurements were made. During the MM, left atrial (LA) volume index markedly decreased. Left ventricular (LV) end-systolic dimension increased in association with a decrease in LV ejection fraction. On release of the maneuver, there was a compensatory increase in blood flow to the left side of the heart, with stroke volume, ejection fraction, and cardiac output exceeding baseline. After 10 minutes of recovery, all parameters returned to baseline. In conclusion, sudden imposition of severe negative intrathoracic pressure led to an abrupt decrease in LA volume and a decrease in LV systolic performance. These changes reflected an increase in LV afterload. Repeated swings in afterload burden and chamber volumes may have implications for the future development of atrial fibrillation and heart failure.
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Affiliation(s)
- Marek Orban
- Department of Internal Medicine, Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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Yan B, Li L, Harden SW, Gozal D, Lin Y, Wead WB, Wurster RD, Cheng ZJ. Chronic intermittent hypoxia impairs heart rate responses to AMPA and NMDA and induces loss of glutamate receptor neurons in nucleus ambiguous of F344 rats. Am J Physiol Regul Integr Comp Physiol 2008; 296:R299-308. [PMID: 19020286 DOI: 10.1152/ajpregu.90412.2008] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Chronic intermittent hypoxia (CIH), as occurs in sleep apnea, impairs baroreflex-mediated reductions in heart rate (HR) and enhances HR responses to electrical stimulation of vagal efferent. We tested the hypotheses that HR responses to activation of alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionate (AMPA) and N-methyl-D-aspartate (NMDA) receptors in the nucleus ambiguous (NA) are reduced in CIH-exposed rats and that this impairment is associated with degeneration of glutamate receptor (GluR)-immunoreactive NA neurons. Fischer 344 rats (3-4 mo) were exposed to room air (RA) or CIH for 35-50 days (n = 18/group). At the end of the exposures, AMPA (4 pmol, 20 nl) and NMDA (80 pmol, 20 nl) were microinjected into the same location of the left NA (-200 microm to +200 microm relative to caudal end of area postrema; n = 6/group), and HR and arterial blood pressure responses were measured. In addition, brain stem sections at the level of -800, -400, 0, +400, and +800 microm relative to obex were processed for AMPA and NMDA receptor immunohistochemistry. The number of NA neurons expressing AMPA receptors and NMDA receptors (NMDARs) was quantified. Compared with RA, we found that after CIH 1) HR responses to microinjection of AMPA into the left NA were reduced (RA -290 +/- 30 vs. CIH -227 +/- 15 beats/min, P < 0.05); 2) HR responses to microinjection of NMDA into the left NA were reduced (RA -302 +/- 16 vs. CIH -238 +/- 27 beats/min, P < 0.05); and 3) the number of NMDAR1, AMPA GluR1, and AMPA GluR2/3-immunoreactive cells in the NA was reduced (P < 0.05). These results suggest that degeneration of NA neurons expressing GluRs contributes to impaired baroreflex control of HR in rats exposed to CIH.
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Affiliation(s)
- Binbin Yan
- Biomolecular Science Center, Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, 4000 Central Florida Parkway, Orlando, FL 32816, USA
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Tourneux P, Cardot V, Museux N, Chardon K, Léké A, Telliez F, Libert JP, Bach V. Influence of thermal drive on central sleep apnea in the preterm neonate. Sleep 2008; 31:549-56. [PMID: 18457243 DOI: 10.1093/sleep/31.4.549] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The incidence of apnea in neonates depends on a number of factors, including sleep state and thermoregulation. OBJECTIVE To assess the role of thermal drive (body heat loss [BHL]) in the mechanisms underlying short episodes of central apnea during active and quiet sleep in neonates. MATERIAL AND METHOD Twenty-two neonates (postconceptional age: 36.3 +/- 0.9 weeks) were exposed at thermoneutral (incubator temperature: 32.5 degrees C), warm (34.2 degrees C), and cool (30.4 degrees C) conditions during 3 consecutive morning naps. Oxygen consumption (VO2), skin and rectal temperatures, and central apnea were scored during active sleep and quiet sleep. The thermal drive was expressed as BHL calculated using indirect partitional calorimetry. RESULTS As expected, apnea occurred more frequently in active sleep than in quiet sleep (P < 0.001). The frequency of apnea in active sleep was higher in the warm condition (P < 0.05). In contrast, apnea episodes were less frequent (P < 0.05) and shorter (P < 0.05) for cool exposure, during which VO2 and rectal temperature increased. The frequency (P < 0.001, r2 = 0.31), mean (P < 0.05, r2 = 0.06), and maximum (P < 0.001, r2 = 0.19) durations of apnea were correlated with the BHL: the greater the BHL (body cooling), the less frequent and the shorter the apnea episodes. In contrast, no relationship between apnea and mean skin or rectal temperature was observed. CONCLUSION Apneic events were more closely related to BHL than to body temperatures. In cool exposure, the decreases in the duration and frequency of apneic episodes suggest that these events depend on the metabolic drive (which is proportional to energy expenditure).
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Affiliation(s)
- Pierre Tourneux
- PériTox (EA 3901-UM INERIS), Faculty of Medicine, Jules Verne University of Picardy, Amiens, France.
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Treatment of sleep disordered breathing in congestive heart failure. Heart Fail Rev 2008; 14:195-203. [PMID: 18618242 DOI: 10.1007/s10741-008-9099-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2008] [Accepted: 06/18/2008] [Indexed: 10/21/2022]
Abstract
In patients with congestive heart failure, sleep disordered breathing occurs commonly and is associated with an increased mortality. In addition to central sleep apnea (Cheyne-Stokes respiration), obstructive sleep apnea is more prevalent in patients with congestive heart failure than in the general population. As a result, a number of treatments have been investigated, with varying results. While many therapies may improve the severity of sleep disordered breathing, only positive pressure ventilation has been shown to improve cardiac function. Newer forms of positive pressure ventilation, such as adaptive servo-ventilation, appear to be even more effective at correcting central sleep apnea. Whether any of these treatments have an effect on transplant-free survival is presently unknown and awaits further study.
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Ng ACC, Freedman SB. Sleep disordered breathing in chronic heart failure. Heart Fail Rev 2008; 14:89-99. [PMID: 18548345 DOI: 10.1007/s10741-008-9096-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2008] [Accepted: 05/13/2008] [Indexed: 12/12/2022]
Abstract
Heart failure is a growing problem, placing an increasing burden on public health resources and continuing to exert a high toll in mortality and morbidity. Sleep disordered breathing (SDB) is also a major public health problem and is associated with an increased risk of fatal and non-fatal cardiovascular events. Current evidence suggests SDB, particularly central SDB, is more prevalent in patients with chronic heart failure (CHF) than in the general population, but is under-diagnosed as SDB symptoms are less prevalent in CHF. This is further hampered by the absence of a simple and accurate screening tool and limited access to sleep facilities to diagnose SDB in the large numbers of patients with CHF. The presence of SDB in patients with CHF imposes increased haemodynamic burdens and results in autonomic abnormalities. Central SDB is an independent marker of worse prognosis, and evidence is increasing that obstructive SDB is also associated with higher mortality in patients with CHF. Optimal treatment of central SDB in these patients remains uncertain. While evidence of efficacy of positive pressure ventilation is stronger in obstructive SDB, improvement in survival for patients with both CHF and SDB awaits definitive trials. This paper summarizes our current understanding of the pathophysiology of SDB in CHF, and the cardiovascular consequences, and reviews the evidence for the beneficial effects of treatment of SDB in patients with CHF.
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Affiliation(s)
- Austin Chin Chwan Ng
- Faculty of Medicine, Concord RG Hospital, The University of Sydney, Hospital Road, Concord, 2139 NSW, Australia.
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Yan B, Soukhova-O'Hare GK, Li L, Lin Y, Gozal D, Wead WB, Wurster RD, Cheng ZJ. Attenuation of heart rate control and neural degeneration in nucleus ambiguus following chronic intermittent hypoxia in young adult Fischer 344 rats. Neuroscience 2008; 153:709-20. [PMID: 18417294 DOI: 10.1016/j.neuroscience.2008.01.066] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2007] [Revised: 12/14/2007] [Accepted: 01/13/2008] [Indexed: 12/01/2022]
Abstract
Chronic intermittent hypoxia (CIH) attenuates baroreflex control of heart rate (HR). In this study, we assessed whether CIH exposure reduced nucleus ambiguus (NA) control of HR and induced neural degeneration in the NA. Fischer 344 (age: 3-4 months) rats were exposed to either room air (RA: normoxia) or intermittent hypoxia for 35-50 days. At the end of these exposures, animals were anesthetized with pentobarbital. HR responses to arterial blood pressure (AP) changes induced by phenylephrine (PE) and sodium nitroprusside (SNP) were measured. In another set of rats, HR and AP responses to L-glutamate (L-Glu) microinjections (10 mM, 20 nl) into the left NA and electrical stimulation of the left cervical vagus nerve at 1-30 Hz (0.5 mA, 1 ms) for 20 s were measured. Brainstem slices at the level of -800, -400, 0, +400, +800 microm relative to the obex were processed in additional rats using Nissl staining. The NA was identified by retrogradely labeling vagal motoneurons using the tracer tetramethylrhodamine dextran (TMR-D) which was injected into the ipsilateral nodose ganglion. We found that CIH significantly 1) reduced the baroreflex control of HR (slope RA: -1.2+/-0.2 bpm/mmHg; CIH -0.5+/-0.1 bpm/mmHg; P<0.05); 2) attenuated the HR responses to l-Glu injections into the NA [HR: -280+/-15 (RA) vs. -235+/-16 (CIH) beats/min; P<0.05]; 3) augmented the HR responses to electrical stimulation of the vagus (P<0.05); 4) induced a significant cellular loss in the NA region (P<0.05). Thus, CIH induces a cell loss in the NA region which may contribute to attenuation of baroreflex sensitivity and NA control of HR following CIH.
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Affiliation(s)
- B Yan
- Biomolecular Science Center, Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, FL 32816, USA
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Chwan Ng AC, Freedman SB, Sindone AP. Autonomic abnormalities in congestive heart failure patients with sleep-disordered breathing. J Card Fail 2007; 13:395-400. [PMID: 17602987 DOI: 10.1016/j.cardfail.2007.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2006] [Revised: 02/06/2007] [Accepted: 02/12/2007] [Indexed: 11/15/2022]
Abstract
BACKGROUND The increasing prevalence of chronic heart failure is affecting patients' longevity, quality of life, and health resources, despite advances in management. Recognizing and treating comorbid illnesses is critical. Risk factors such as hypertension and diabetes are treated, but less importance is placed on the role of sleep apnea in heart failure. METHODS AND RESULTS There is a discrepancy between the growing evidence on the potential adverse influence of sleep apnea on heart failure (and vice versa) and incorporating its treatment as part of the management strategy for chronic heart failure. Apneic episodes during sleep can lead to profound disturbances to the sympathetic and parasympathetic nervous system. CONCLUSIONS This review explores the impact of sleep disordered breathing in patients with chronic heart failure, focusing on the autonomic nervous system.
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Ferreira S, Winck J, Bettencourt P, Rocha-Goncalves F. Heart failure and sleep apnoea: to sleep perchance to dream. Eur J Heart Fail 2005; 8:227-36. [PMID: 16185920 DOI: 10.1016/j.ejheart.2005.07.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2004] [Revised: 05/12/2005] [Accepted: 07/26/2005] [Indexed: 11/17/2022] Open
Abstract
Heart failure and sleep apnoea are major health problems with an increasingly recognized association; evidence suggests that sleep apnoea may play a role in the progression of heart failure. However, confounding factors such as obesity, hypertension and coronary heart disease make this relationship uncertain and an independent correlation remains unproven. Diagnosis of sleep apnoea is suboptimal, as it is often asymptomatic and polysomnography is expensive and time-consuming. A simple and reliable screening protocol is required. All heart failure patients should be considered to be at high risk of sleep apnoea, as this association might be linked to adverse outcome. Continuous positive airway pressure has shown some beneficial effects, but long-term outcome and improvement in survival remains to be demonstrated. Despite recent advances in the understanding of the complex relationship between heart failure and sleep apnoea, there are a number of areas requiring further investigation, which may have important implications for the management and prognosis of a significant number of patients.
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Kaneko Y, Floras JS, Usui K, Plante J, Tkacova R, Kubo T, Ando SI, Bradley TD. Cardiovascular effects of continuous positive airway pressure in patients with heart failure and obstructive sleep apnea. N Engl J Med 2003; 348:1233-41. [PMID: 12660387 DOI: 10.1056/nejmoa022479] [Citation(s) in RCA: 676] [Impact Index Per Article: 32.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Obstructive sleep apnea subjects the failing heart to adverse hemodynamic and adrenergic loads and may thereby contribute to the progression of heart failure. We hypothesized that treatment of obstructive sleep apnea by continuous positive airway pressure in patients with heart failure would improve left ventricular systolic function. METHODS Twenty-four patients with a depressed left ventricular ejection fraction (45 percent or less) and obstructive sleep apnea who were receiving optimal medical treatment for heart failure underwent polysomnography. On the following morning, their blood pressure and heart rate were measured by digital photoplethysmography, and left ventricular dimensions and left ventricular ejection fraction were assessed by echocardiography. The subjects were then randomly assigned to receive medical therapy either alone (12 patients) or with the addition of continuous positive airway pressure (12 patients) for one month. The assessment protocol was then repeated. RESULTS In the control group of patients who received only medical therapy, there were no significant changes in the severity of obstructive sleep apnea, daytime blood pressure, heart rate, left ventricular end-systolic dimension, or left ventricular ejection fraction during the study. In contrast, continuous positive airway pressure markedly reduced obstructive sleep apnea, reduced the daytime systolic blood pressure from a mean (+/-SE) of 126+/-6 mm Hg to 116+/-5 mm Hg (P=0.02), reduced the heart rate from 68+/-3 to 64+/-3 beats per minute (P=0.007), reduced the left ventricular end-systolic dimension from 54.5+/-1.8 to 51.7+/-1.2 mm (P=0.009), and improved the left ventricular ejection fraction from 25.0+/-2.8 to 33.8+/-2.4 percent (P<0.001). CONCLUSION In medically treated patients with heart failure, treatment of coexisting obstructive sleep apnea by continuous positive airway pressure reduces systolic blood pressure and improves left ventricular systolic function. Obstructive sleep apnea may thus have an adverse effect in heart failure that can be addressed by targeted therapy.
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Affiliation(s)
- Yasuyuki Kaneko
- Sleep Research Laboratories, Toronto Rehabilitation Institute, Toronto General Hospital, ON M5G 2C4, Canada
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