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Jaspan VN, Greenberg GS, Parihar S, Park CM, Somers VK, Shapiro MD, Lavie CJ, Virani SS, Slipczuk L. The Role of Sleep in Cardiovascular Disease. Curr Atheroscler Rep 2024:10.1007/s11883-024-01207-5. [PMID: 38795275 DOI: 10.1007/s11883-024-01207-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2024] [Indexed: 05/27/2024]
Abstract
PURPOSE OF REVIEW Sleep is an important component of cardiovascular (CV) health. This review summarizes the complex relationship between sleep and CV disease (CVD). Additionally, we describe the data supporting the treatment of sleep disturbances in preventing and treating CVD. RECENT FINDINGS Recent guidelines recommend screening for obstructive sleep apnea in patients with atrial fibrillation. New data continues to demonstrate the importance of sleep quality and duration for CV health. There is a complex bidirectional relationship between sleep health and CVD. Sleep disturbances have systemic effects that contribute to the development of CVD, including hypertension, coronary artery disease, heart failure, and arrhythmias. Additionally, CVD contributes to the development of sleep disturbances. However, more data are needed to support the role of screening for and treatment of sleep disorders for the prevention of CVD.
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Affiliation(s)
- Vita N Jaspan
- Division of Cardiology, Montefiore Health System/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Garred S Greenberg
- Division of Cardiology, Montefiore Health System/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Siddhant Parihar
- Division of Cardiology, Montefiore Health System/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Christine M Park
- Division of Cardiology, Montefiore Health System/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Virend K Somers
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Michael D Shapiro
- Center for Preventive Cardiology, Section On Cardiovascular Medicine, Wake Forest University Baptist Medical Center, Winston-Salem, NC, USA
| | - Carl J Lavie
- Ochsner Clinical School, John Ochsner Heart and Vascular Institute, The University of Queensland School of Medicine, New Orleans, LA, USA
| | - Salim S Virani
- Office of the Vice Provost (Research), The Aga Khan University, Karachi, Pakistan
- Division of Cardiology, The Texas Heart Institute/Baylor College of Medicine, Houston, TX, USA
- Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA
| | - Leandro Slipczuk
- Division of Cardiology, Montefiore Health System/Albert Einstein College of Medicine, Bronx, NY, USA.
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Qayoumi P, Coronel R, Folke F, Arulmurugananthavadivel A, Parveen S, Yonis H, Meaidi A, Lamberts M, Schou M, Torp-Pedersen C, Hilmar Gislason G, Eroglu TE. Sleep apnea, the risk of out-of-hospital cardiac arrest, and potential benefits of continuous positive airway pressure therapy: A nationwide study. Resuscitation 2024; 198:110174. [PMID: 38479652 DOI: 10.1016/j.resuscitation.2024.110174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 02/28/2024] [Accepted: 03/05/2024] [Indexed: 03/23/2024]
Abstract
OBJECTIVE Patients with sleep apnea (SA) are at increased cardiovascular risk. However, little is known about the risk of out-of-hospital cardiac arrest (OHCA) in patients with SA. Therefore, we studied the relation between SA patients who did and did not receive continuous positive airway pressure (CPAP) therapy with OHCA in the general population. METHODS Using nationwide databases, we conducted a nested case-control study with OHCA-cases of presumed cardiac causes and age/sex/OHCA-date matched non-OHCA-controls from the general population. Conditional logistic regression models with adjustments for well-known OHCA risk factors were performed to generate odds ratio (OR) of OHCA comparing patients with SA receiving and not receiving CPAP therapy with individuals without SA. RESULTS We identified 46,578 OHCA-cases and 232,890 matched non-OHCA-controls [mean: 71 years, 68.8% men]. Compared to subjects without SA, having SA without CPAP therapy was associated with increased odds of OHCA after controlling for relevant confounders (OR:1.20, 95%-Cl:1.06-1.36), while having SA with CPAP therapy was not associated with OHCA (OR:1.04, 95%-Cl:0.93-1.36). Regardless of CPAP therapy, age and sex did not significantly influence our findings. Our findings were confirmed in: (I) patients with neither ischemic heart disease nor heart failure (untreated SA, OR:1.24, 95%-CI:1.04-1.47; SA with CPAP, OR:1.08, 95%-CI:0.93-1.25); and (II) in patients without cardiovascular disease (untreated SA, OR:1.33, 95%-CI:1.07-1.65; SA with CPAP, OR:1.14, 95%-CI:0.94-1.39). CONCLUSION SA not treated with CPAP was associated with OHCA, while no increased risk of OHCA was found for SA patients treated with CPAP.
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Affiliation(s)
- Pelpika Qayoumi
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Ruben Coronel
- Amsterdam UMC, Academic Medical Center, University of Amsterdam, Department of Experimental and Clinical Cardiology, Heart Centre, Amsterdam Cardiovascular Sciences, Meibergdreef 9, Amsterdam, The Netherlands
| | - Fredrik Folke
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Copenhagen University Hospital -Copenhagen Emergency Medical Services, Copenhagen, Denmark
| | | | - Saaima Parveen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Harman Yonis
- Department of Cardiology, Nordsjællands Hospital, Hillerød, Denmark
| | - Amani Meaidi
- Department of Cardiology, Nordsjællands Hospital, Hillerød, Denmark
| | - Morten Lamberts
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Morten Schou
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | | | - Gunnar Hilmar Gislason
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark; The Danish Heart Foundation, Copenhagen, Denmark
| | - Talip E Eroglu
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark.
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Wang Y, Buayiximu K, Zhu T, Yan R, Zhu Z, Ni J, Du R, Zhu J, Wang X, Ding F, Yan X, Qu X, Li P, Zhang R, Xu Z, Quan W. Day-night pattern of acute ST-segment elevation myocardial infarction onset in patients with obstructive sleep apnea. J Clin Sleep Med 2024; 20:765-775. [PMID: 38174863 PMCID: PMC11063706 DOI: 10.5664/jcsm.10990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 12/27/2023] [Accepted: 12/28/2023] [Indexed: 01/05/2024]
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) is associated with acute nocturnal hemodynamic and neurohormonal abnormalities that may increase the risk of coronary events, especially during the nighttime. This study sought to investigate the day-night pattern of acute ST-segment elevation myocardial infarction (STEMI) onset in patients with OSA and its impact on cardiovascular adverse events. METHODS We prospectively enrolled 397 patients with STEMI, for which the time of onset of chest pain was clearly identified. All participants were categorized into non-OSA (n = 280) and OSA (n = 117) groups. The association between STEMI onset time and major adverse cardiovascular and cerebrovascular events was estimated by Cox proportional hazards regression. RESULTS STEMI onset occurred from midnight to 5:59 am in 33% of patients with OSA, as compared with 15% in non-OSA patients (P < .01). For individuals with OSA, the relative risk of STEMI from midnight to 5:59 am was 2.717 [95% confidence interval (CI) 1.616 - 4.568] compared with non-OSA patients. After a median of 2.89 ± 0.78 years follow-up, symptom onset time was found to be significantly associated with risk of major adverse cardiovascular and cerebrovascular events in patients with OSA, while there was no significant association observed in non-OSA patients. Compared with STEMI presenting during noon to 5:59 pm, the hazard ratios for major adverse cardiovascular and cerebrovascular events in patients with OSA were 4.683 (95% CI 2.024 - 21.409, P = .027) for midnight to 5:59 am and 6.964 (95% CI 1.379 - 35.169, P = .019) for 6 pm to midnight, whereas the hazard ratios for non-OSA patients were 1.053 (95% CI 0.394 - 2.813, P = .917) for midnight to 5:59 am and 0.745 (95% CI 0.278 - 1.995, P = .558) for 6 pm to midnight. CONCLUSIONS Patients with OSA exhibited a peak incidence of STEMI between midnight and 5:59 am, which showed an independent association with cardiovascular adverse events. CITATION Wang Y, Buayiximu K, Zhu T, et al. Day-night pattern of acute ST-segment elevation myocardial infarction onset in patients with obstructive sleep apnea. J Clin Sleep Med. 2024;20(5):765-775.
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Affiliation(s)
- Yueying Wang
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Keremu Buayiximu
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tianqi Zhu
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Renyu Yan
- Department of Geriatrics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhengbin Zhu
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jingwei Ni
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Run Du
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jinzhou Zhu
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaoqun Wang
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fenghua Ding
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaoxiang Yan
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xuezheng Qu
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ping Li
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ruiyan Zhang
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhihong Xu
- Department of Geriatrics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weiwei Quan
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Ebrahimian S, Sillanmäki S, Hietakoste S, Kulkas A, Töyräs J, Bailón R, Hernando D, Lombardi C, Grote L, Bonsignore MR, Saaresranta T, Pépin JL, Leppänen T, Kainulainen S. Beat-to-beat cardiac repolarization lability increases during hypoxemia and arousals in obstructive sleep apnea patients. Am J Physiol Heart Circ Physiol 2024; 326:H1094-H1104. [PMID: 38426864 DOI: 10.1152/ajpheart.00760.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 02/27/2024] [Accepted: 02/27/2024] [Indexed: 03/02/2024]
Abstract
Obstructive sleep apnea (OSA) is associated with the progression of cardiovascular diseases, arrhythmias, and sudden cardiac death (SCD). However, the acute impacts of OSA and its consequences on heart function are not yet fully elucidated. We hypothesized that desaturation events acutely destabilize ventricular repolarization, and the presence of accompanying arousals magnifies this destabilization. Ventricular repolarization lability measures, comprising heart rate corrected QT (QTc), short-time-variability of QT (STVQT), and QT variability index (QTVI), were calculated before, during, and after 20,955 desaturations from lead II electrocardiography signals of 492 patients with suspected OSA (52% men). Variations in repolarization parameters were assessed during and after desaturations, both with and without accompanying arousals, and groupwise comparisons were performed based on desaturation duration and depth. Regression analyses were used to investigate the influence of confounding factors, comorbidities, and medications. The standard deviation (SD) of QT, mean QTc, SDQTc, and STVQT increased significantly (P < 0.01), whereas QTVI decreased (P < 0.01) during and after desaturations. The changes in SDQT, mean QTc, SDQTc, and QTVI were significantly amplified (P < 0.01) in the presence of accompanying arousals. Desaturation depth was an independent predictor of increased SDQTc (β = 0.405, P < 0.01), STVQT (β = 0.151, P < 0.01), and QTVI (β = 0.009, P < 0.01) during desaturation. Desaturations cause acute changes in ventricular repolarization, with deeper desaturations and accompanying arousals independently contributing to increased ventricular repolarization lability. This may partially explain the increased risk of arrhythmias and SCD in patients with OSA, especially when the OSA phenotype includes high hypoxic load and fragmented sleep.NEW & NOTEWORTHY Nocturnal desaturations are associated with increased ventricular repolarization lability. Deeper desaturations with accompanying arousals increase the magnitude of alterations, independent of confounding factors, comorbidities, and medications. Changes associated with desaturations can partially explain the increased risk of arrhythmias and sudden cardiac death in patients with OSA, especially in patients with high hypoxic load and fragmented sleep. This highlights the importance of detailed electrocardiogram analytics for patients with OSA.
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Affiliation(s)
- Serajeddin Ebrahimian
- Department of Technical Physics, University of Eastern Finland, Kuopio, Finland
- Diagnostic Imaging Center, Kuopio University Hospital, Kuopio, Finland
| | - Saara Sillanmäki
- Diagnostic Imaging Center, Kuopio University Hospital, Kuopio, Finland
- Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Salla Hietakoste
- Department of Technical Physics, University of Eastern Finland, Kuopio, Finland
- Diagnostic Imaging Center, Kuopio University Hospital, Kuopio, Finland
| | - Antti Kulkas
- Department of Technical Physics, University of Eastern Finland, Kuopio, Finland
- Department of Clinical Neurophysiology, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Juha Töyräs
- Department of Technical Physics, University of Eastern Finland, Kuopio, Finland
- School of Electrical Engineering and Computer Science, The University of Queensland, Brisbane, Australia
- Science Service Center, Kuopio University Hospital, Kuopio, Finland
| | - Raquel Bailón
- Biomedical Signal Interpretation and Computational Simulation (BSICoS) Group, Aragón Institute of Engineering Research (I3A), IIS Aragón, University of Zaragoza, Zaragoza, Spain
- Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Madrid, Spain
| | - David Hernando
- Biomedical Signal Interpretation and Computational Simulation (BSICoS) Group, Aragón Institute of Engineering Research (I3A), IIS Aragón, University of Zaragoza, Zaragoza, Spain
- Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Madrid, Spain
| | - Carolina Lombardi
- IRCCS Istituto Auxologico Italiano, Department of Cardiovascular, Neural and Metabolic Sciences, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Ludger Grote
- Department of Sleep Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
- Sleep and Vigilance Laboratory, Department of Internal Medicine, University of Gothenburg, Gothenburg, Sweden
| | | | - Tarja Saaresranta
- Division of Medicine, Department of Pulmonary Diseases, Turku University Hospital, University of Turku, Turku, Finland
- Sleep Research Centre, Department of Pulmonary Diseases and Clinical Allergology, University of Turku, Turku, Finland
| | - Jean-Louis Pépin
- Inserm U1300, HP2 Laboratory, University of Grenoble Alpes, Grenoble, France
| | - Timo Leppänen
- Department of Technical Physics, University of Eastern Finland, Kuopio, Finland
- Diagnostic Imaging Center, Kuopio University Hospital, Kuopio, Finland
- School of Electrical Engineering and Computer Science, The University of Queensland, Brisbane, Australia
| | - Samu Kainulainen
- Department of Technical Physics, University of Eastern Finland, Kuopio, Finland
- Diagnostic Imaging Center, Kuopio University Hospital, Kuopio, Finland
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Resende Martinez AB, Barbosa GR, Lopes MR, Barbosa RHDA. Sleep apnea and sudden death in the non-cardiac population: A systematic review. Rev Port Cardiol 2024; 43:279-290. [PMID: 38309430 DOI: 10.1016/j.repc.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 01/11/2024] [Accepted: 01/25/2024] [Indexed: 02/05/2024] Open
Abstract
INTRODUCTION Obstructive sleep apnea (OSA) is one of the main risk factors for cardiovascular diseases and is associated with both morbidity and mortality. OSA has also been linked to arrhythmias and sudden death. OBJECTIVE To assess whether OSA increases the risk of sudden death in the non-cardiac population. METHODS This is a systematic review of the literature. The descriptors "sudden death" and "sleep apnea" and "tachyarrhythmias" and "sleep apnea" were searched in the PubMed/Medline and SciELO databases. RESULTS Thirteen articles that addressed the relationship between OSA and the development of tachyarrhythmias and/or sudden death with prevalence data, electrocardiographic findings, and a relationship with other comorbidities were selected. The airway obstruction observed in OSA triggers several systemic repercussions, e.g., changes in intrathoracic pressure, intermittent hypoxia, activation of the sympathetic nervous system and chemoreceptors, and release of catecholamines. These mechanisms would be implicated in the appearance of arrhythmogenic factors, which could result in sudden death. CONCLUSION There was a cause-effect relationship between OSA and cardiac arrhythmias. In view of the pathophysiology of OSA and its arrhythmogenic role, studies have shown a higher risk of sudden death in individuals who previously had heart disease. On the other hand, there is little evidence about the occurrence of sudden death in individuals with OSA and no heart disease, and OSA is not a risk factor for sudden death in this population.
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Solhjoo S, Haigney MC, Siddharthan T, Koch A, Punjabi NM. Sleep-Disordered Breathing Destabilizes Ventricular Repolarization. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2023.02.10.23285789. [PMID: 36824787 PMCID: PMC9949208 DOI: 10.1101/2023.02.10.23285789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Rationale Sleep-disordered breathing (SDB) increases the risk of cardiac arrhythmias and sudden cardiac death. Objectives To characterize the associations between SDB, intermittent hypoxemia, and the beat-to-beat QT variability index (QTVI), a measure of ventricular repolarization lability associated with a higher risk for cardiac arrhythmias, sudden cardiac death, and mortality. Methods Three distinct cohorts were used for the current study. The first cohort, used for cross-sectional analysis, was a matched sample of 122 participants with and without severe SDB. The second cohort, used for longitudinal analysis, consisted of a matched sample of 52 participants with and without incident SDB. The cross-sectional and longitudinal cohorts were selected from the Sleep Heart Health Study participants. The third cohort comprised 19 healthy adults exposed to acute intermittent hypoxia and ambient air on two separate days. Electrocardiographic measures were calculated from one-lead electrocardiograms. Results Compared to those without SDB, participants with severe SDB had greater QTVI (-1.19 in participants with severe SDB vs. -1.43 in participants without SDB, P = 0.027), heart rate (68.34 vs. 64.92 beats/minute; P = 0.028), and hypoxemia burden during sleep as assessed by the total sleep time with oxygen saturation less than 90% (TST90; 11.39% vs. 1.32%, P < 0.001). TST90, but not the frequency of arousals, was a predictor of QTVI. QTVI during sleep was predictive of all-cause mortality. With incident SDB, mean QTVI increased from -1.23 to -0.86 over 5 years (P = 0.017). Finally, exposing healthy adults to acute intermittent hypoxia for four hours progressively increased QTVI (from -1.85 at baseline to -1.64 after four hours of intermittent hypoxia; P = 0.016). Conclusions Prevalent and incident SDB are associated with ventricular repolarization instability, which predisposes to ventricular arrhythmias and sudden cardiac death. Intermittent hypoxemia destabilizes ventricular repolarization and may contribute to increased mortality in SDB.
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Affiliation(s)
- Soroosh Solhjoo
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- F. Edward Hébert School of Medicine, Bethesda, Maryland, USA
| | - Mark C. Haigney
- F. Edward Hébert School of Medicine, Bethesda, Maryland, USA
- Military Cardiovascular Outcomes Research (MiCOR), Bethesda, Maryland, USA
| | | | - Abigail Koch
- University of Miami Miller School of Medicine, Miami, Florida, USA
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Atluri N, Dulko E, Jedrusiak M, Klos J, Osuru HP, Davis E, Beenhakker M, Kapur J, Zuo Z, Lunardi N. Anatomical Substrates of Rapid Eye Movement Sleep Rebound in a Rodent Model of Post-sevoflurane Sleep Disruption. Anesthesiology 2024; 140:729-741. [PMID: 38157434 PMCID: PMC10939895 DOI: 10.1097/aln.0000000000004893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
BACKGROUND Previous research suggests that sevoflurane anesthesia may prevent the brain from accessing rapid eye movement (REM) sleep. If true, then patterns of neural activity observed in REM-on and REM-off neuronal populations during recovery from sevoflurane should resemble those seen after REM sleep deprivation. In this study, the authors hypothesized that, relative to controls, animals exposed to sevoflurane present with a distinct expression pattern of c-Fos, a marker of neuronal activation, in a cluster of nuclei classically associated with REM sleep, and that such expression in sevoflurane-exposed and REM sleep-deprived animals is largely similar. METHODS Adult rats and Targeted Recombination in Active Populations mice were implanted with electroencephalographic electrodes for sleep-wake recording and randomized to sevoflurane, REM deprivation, or control conditions. Conventional c-Fos immunohistochemistry and genetically tagged c-Fos labeling were used to quantify activated neurons in a group of REM-associated nuclei in the midbrain and basal forebrain. RESULTS REM sleep duration increased during recovery from sevoflurane anesthesia relative to controls (157.0 ± 24.8 min vs. 124.2 ± 27.8 min; P = 0.003) and temporally correlated with increased c-Fos expression in the sublaterodorsal nucleus, a region active during REM sleep (176.0 ± 36.6 cells vs. 58.8 ± 8.7; P = 0.014), and decreased c-Fos expression in the ventrolateral periaqueductal gray, a region that is inactive during REM sleep (34.8 ± 5.3 cells vs. 136.2 ± 19.6; P = 0.001). Fos changes similar to those seen in sevoflurane-exposed mice were observed in REM-deprived animals relative to controls (sublaterodorsal nucleus: 85.0 ± 15.5 cells vs. 23.0 ± 1.2, P = 0.004; ventrolateral periaqueductal gray: 652.8 ± 71.7 cells vs. 889.3 ± 66.8, P = 0.042). CONCLUSIONS In rodents recovering from sevoflurane, REM-on and REM-off neuronal activity maps closely resemble those of REM sleep-deprived animals. These findings provide new evidence in support of the idea that sevoflurane does not substitute for endogenous REM sleep. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Navya Atluri
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | - Elzbieta Dulko
- Neuroscience Graduate Program, University of Virginia, Charlottesville, VA, USA
| | - Michal Jedrusiak
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | - Joanna Klos
- Max Planck Institute for Biological Intelligence, Munich, Germany
| | - Hari P Osuru
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | - Eric Davis
- Department of Internal Medicine, University of Virginia, Charlottesville, VA, USA
| | - Mark Beenhakker
- Department of Pharmacology, University of Virginia, Charlottesville, VA, USA
| | - Jaideep Kapur
- Department of Neurology, University of Virginia, Charlottesville, VA, USA
| | - Zhiyi Zuo
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | - Nadia Lunardi
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
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Lins-Filho O, Germano-Soares AH, Aguiar JLP, de Almedia JRV, Felinto EC, Lyra MJ, Leite DB, Drager LF, Farah BQ, Pedrosa RP. Effect of 12-week high-intensity interval training on hemodynamic variables at rest and during exercise in patients with obstructive sleep apnoea. J Hypertens 2024; 42:742-745. [PMID: 38230605 DOI: 10.1097/hjh.0000000000003654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
This study aimed to investigate the impact of 12 weeks of high-intensity interval training (HIIT) on hemodynamic variables at rest and during exercise in patients with obstructive sleep apnoea. Twenty-six obese adults with moderate-to-severe OSA (AHI = 42 ± 22.9 e/h) were randomly assigned to HIIT or a control group. Sleep parameters, ambulatorial, aortic, and during-exercise SBP and DBP were assessed at baseline and after 12 weeks. Generalized estimated equations assessed differences between groups over time. When compared with control group, HIIT reduced AHI (17.1 ± 6.2; e/h, P < 0.01), SBP nighttime (10.2 ± 5.0 mmHg; P = 0.034), DBP nighttime (7.9 ± 4.0 mmHg; P = 0.038), DBP aortic (5.5 ± 2.9 mmHg; P = 0.048), and SBP max (29.6 ± 11.8 mmHg; P = 0.045). In patients with OSA, 12 weeks of HIIT decreases sleep apnoea severity and blood pressure in rest and during exercise.
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Affiliation(s)
- Ozeas Lins-Filho
- Laboratório do Sono e Coração, Pronto Socorro Cardiológico de Pernambuco (PROCAPE), Universidade de Pernambuco
- Departamento de Educação Física
| | | | - José Lucas Porto Aguiar
- Laboratório do Sono e Coração, Pronto Socorro Cardiológico de Pernambuco (PROCAPE), Universidade de Pernambuco
- Programa de pós-graduação em educação física, Universidade Federal de Pernambuco
| | - José Ricardo Vieira de Almedia
- Laboratório do Sono e Coração, Pronto Socorro Cardiológico de Pernambuco (PROCAPE), Universidade de Pernambuco
- Programa de pós-graduação em educação física, Universidade Federal de Pernambuco
| | - Elton Carlos Felinto
- Laboratório do Sono e Coração, Pronto Socorro Cardiológico de Pernambuco (PROCAPE), Universidade de Pernambuco
| | | | - Danielle Batista Leite
- Departamento de ergometria, Pronto Socorro Cardiológico de Pernambuco (PROCAPE), Universidade de Pernambuco, Recife
| | - Luciano Ferreira Drager
- Unidade de Hipertensão, Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo
| | - Breno Quintella Farah
- Programa de pós-graduação em educação física, Universidade Federal de Pernambuco
- Departamento de educação física, Universidade Federal Rural de Pernambuco, Recife, Brazil
| | - Rodrigo Pinto Pedrosa
- Laboratório do Sono e Coração, Pronto Socorro Cardiológico de Pernambuco (PROCAPE), Universidade de Pernambuco
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Zhang B, Lu S, Guo H, Xu J, Xiao Z, Tang J. Relationship between ODI and sleep structure of obstructive sleep apnea and cardiac remodeling. Sleep Breath 2024; 28:173-181. [PMID: 37453997 DOI: 10.1007/s11325-023-02872-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 04/27/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE The purpose of the study was to evaluate the quantitative relationship between Oxygen Desaturation Index (ODI) and sleep structure of obstructive sleep apnea (OSA) and cardiac remodeling. METHODS In this study, patients were enrolled from January 2015 to October 2022, and were divided into 3 groups according to AHI: patients with AHI < 15, patients with 15 ≤ AHI < 30, and 260 patients with AHI ≥ 30. Stratified linear regression was used to analyze independent risk factors for cardiac remodeling in OSA. RESULTS A total of 479 patients were enrolled. We found that compared with AHI < 15 group (n = 120), the group with AHI > 30 (n = 260) had increased left atrial anteroposterior diameter, left ventricular end-diastolic internal diameter, left ventricular posterior wall thickness, right ventricular anteroposterior diameter, and interventricular septal thickness (P < 0.05). The group with 15 ≤ AHI ≤ 30 (n = 99) had increased left atrial anteroposterior diameter (P < 0.05). Multivariate linear regression revealed that N2 sleep was an independent risk factor for left ventricular posterior wall thickness, with positive correlation (p < 0.05). N3 sleep was an independent risk factor for transverse right atrial diameter and right ventricular anteroposterior diameter, with negative correlation (P < 0.05). ODI was an independent risk factor for interventricular septal thickness, with positive correlation (P < 0.05). The arousal index was an independent risk factor for increased left atrial anteroposterior diameter, with positive correlation (P < 0.05). CONCLUSIONS Increased ODI is an independent risk factor for interventricular septal thickness, while decreased slow wave sleep is an independent risk factor for right heart remodeling in OSA.
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Affiliation(s)
- Baokun Zhang
- Department of Neurology, Shandong Provincial Qianfoshan Hospital, Cheeloo College of Medicine, Shandong University, NO. 16766 Jingshi Road, Jinan, Shandong, 250012, People's Republic of China
| | - Shanshan Lu
- Department of Neurology, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Institute of Neuroimmunology, Jinan, People's Republic of China
| | - Huiying Guo
- Department of Neurology, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Institute of Neuroimmunology, Jinan, People's Republic of China
| | - Juanjuan Xu
- Department of Neurology, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Institute of Neuroimmunology, Jinan, People's Republic of China
| | - Zhang Xiao
- Department of Neurology, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Institute of Neuroimmunology, Jinan, People's Republic of China
| | - Jiyou Tang
- Department of Neurology, Shandong Provincial Qianfoshan Hospital, Cheeloo College of Medicine, Shandong University, NO. 16766 Jingshi Road, Jinan, Shandong, 250012, People's Republic of China.
- Department of Neurology, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Institute of Neuroimmunology, Jinan, People's Republic of China.
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Torres G, Sánchez de la Torre M, Pinilla L, Barbé F. Obstructive sleep apnea and cardiovascular risk. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ARTERIOSCLEROSIS 2024:S0214-9168(24)00016-0. [PMID: 38413245 DOI: 10.1016/j.arteri.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 01/17/2024] [Indexed: 02/29/2024]
Abstract
Patients with obstructive sleep apnea (OSA) experience repetitive episodes of upper airway obstruction due to recurrent collapse during sleep. This leads to intermittent hypoxia episodes, which, through complex pathophysiological mechanisms, trigger sympathetic overactivation, endothelial dysfunction, hypercoagulation, and metabolic dysregulation. Consequently, other cardiovascular risk factors such as hypertension, metabolic syndrome, and diabetes are induced. Furthermore, this enhances target organ damage, affecting the heart, arteries, and kidneys, leading to an increased risk of cardiovascular morbidity and mortality. Among the various treatments for OSA, Continuous Positive Airway Pressure (CPAP) has been extensively studied. To date, this treatment has shown mild benefits in reducing blood pressure, particularly noticeable in patients with resistant hypertension. Furthermore, CPAP treatment appears to reduce cardiovascular events, both in primary and secondary prevention, though this benefit is limited to individuals with good compliance (CPAP use ≥4h/night). Future research perspectives in OSA seem to focus on identifying patients in whom the condition significantly influences cardiovascular risk, thus determining those who would benefit the most from treatment in the reduction of cardiovascular risk.
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Affiliation(s)
- Gerard Torres
- Translational Research in Respiratory Medicine, University Hospital Arnau de Vilanova and Santa Maria, IRBLleida, Lleida, España; CIBER of Respiratory Diseases (CIBERES), Instituto de Salud Carlos III, Madrid, España.
| | - Manuel Sánchez de la Torre
- CIBER of Respiratory Diseases (CIBERES), Instituto de Salud Carlos III, Madrid, España; Precision Medicine in Chronic Diseases, Hospital Universitari de Santa Maria, IRBLleida, Lleida, España; Department of Nursing and Physiotherapy, Faculty of Nursing and Physiotherapy, University of Lleida, Lleida, España
| | - Lucia Pinilla
- CIBER of Respiratory Diseases (CIBERES), Instituto de Salud Carlos III, Madrid, España; Precision Medicine in Chronic Diseases, Hospital Universitari de Santa Maria, IRBLleida, Lleida, España; Department of Nursing and Physiotherapy, Faculty of Nursing and Physiotherapy, University of Lleida, Lleida, España
| | - Ferran Barbé
- Translational Research in Respiratory Medicine, University Hospital Arnau de Vilanova and Santa Maria, IRBLleida, Lleida, España; CIBER of Respiratory Diseases (CIBERES), Instituto de Salud Carlos III, Madrid, España
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11
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Khan MTF, Smith DF, Schuler CL, Witter AM, DiFrancesco MW, Armoni Domany K, Amin RS, Hossain MM. Circadian blood pressure dysregulation in children with obstructive sleep apnea. Sleep 2024; 47:zsad254. [PMID: 38092705 PMCID: PMC10851857 DOI: 10.1093/sleep/zsad254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 09/14/2023] [Indexed: 02/09/2024] Open
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) adversely affects normal blood pressure (BP) and may disrupt circadian BP patterns. We sought to examine 24-hour circadian BP rhythms in children with OSA and healthy controls. METHODS Children 5-14 years with OSA and healthy controls underwent 24-hour BP monitoring and actigraphy to quantify sleep. Shape invariant statistical models compared circadian BP patterns (e.g. times of BP peaks, time arrived at peak BP velocity [TAPV]) in the OSA and control groups. RESULTS The analytic sample included 219 children (mild OSA: n = 52; moderate-to-severe OSA (MS-OSA): n = 50; controls: n = 117). In the morning, the MS-OSA group had earlier TAPV for DBP than controls (51 minutes, p < 0.001). TAPV in the evening was earlier for the MS-OSA group than controls (SBP: 95 minutes, p < 0.001; DBP: 28 minutes, p = 0.028). At mid-day, SBP and DBP velocity nadirs were earlier for the MS-OSA group than controls (SBP: 57 minutes, p < 0.001; DBP: 38 minutes, p < 0.01). The MS-OSA group reached most BP values significantly earlier than controls; the largest differences were 118 minutes (SBP) and 43 minutes (DBP) (p < 0.001). SBP and DBP were elevated in the MS-OSA group (hours 18-21 and 7--12, respectively, p < 0.01) compared to controls. The MS-OSA group was prone to "non-dipping" compared to controls (SBP: odds ratio [OR] = 2.16, 95% CI: 1.09, 4.29; DBP: OR = 3.45, 95% CI: 1.21, 10.23). CONCLUSIONS Children with MS-OSA had changes in circadian BP patterns, namely earlier TAPV and BP peaks and nadirs than controls. Circadian disturbances in BP rhythms may be key to mapping the natural history of BP dysregulation in children with OSA.
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Affiliation(s)
- Md Tareq Ferdous Khan
- Division of Biostatistics and Bioinformatics, Department of Environmental and Public Health Sciences, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Department of Mathematics and Statistics, Cleveland State University, Cleveland, OH, USA
| | - David F Smith
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Division of Pulmonary Medicine and the Sleep Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- The Center for Circadian Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Otolaryngology–Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Christine L Schuler
- Division of Pulmonary Medicine and the Sleep Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Abigail M Witter
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Mark W DiFrancesco
- The Imaging Research Center, Department of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Keren Armoni Domany
- Pediatric Pulmonology Unit, Wolfson Medical Center, Holon, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Raouf S Amin
- Division of Pulmonary Medicine and the Sleep Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Md Monir Hossain
- Division of Biostatistics and Bioinformatics, Department of Environmental and Public Health Sciences, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Pulmonary Medicine and the Sleep Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
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12
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Chou TTC, Hsu HC, Twu CW, Huang WK, Huang HM, Weng SH, Chen MC. Prevalence of Obstructive Sleep Apnea Using Home Sleep Test in Taiwan During the Coronavirus Disease Pandemic. Nat Sci Sleep 2023; 15:1107-1116. [PMID: 38149042 PMCID: PMC10750777 DOI: 10.2147/nss.s434278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 12/12/2023] [Indexed: 12/28/2023] Open
Abstract
Background Obstructive sleep apnea syndrome (OSAS) is a common disorder associated with serious sequelae. The current gold standard diagnostic method, polysomnography, is costly and time consuming and requires patients to stay overnight at a facility. Aim This study aimed to reveal the prevalence of OSAS in general adult population using a home sleep test (HST) during the coronavirus disease 2019 (COVID-19) pandemic. Methods This prospective cohort study was conducted by the Department of Otolaryngology, Taipei City Hospital, Taipei, Taiwan, between January 2020 and December 2021. A total of 1372 patients aged 30-70 years completed an HST using a Type 3 portable sleep monitor (PM). The apnea-hypopnea index (AHI) was analyzed to assess the association of OSAS with age, body mass index (BMI), sex, Epworth Sleepiness Scale (ESS) and the Sleep Apnea Risk Assessment questionnaire (STOP-Bang questionnaire) rating. Results The mean age of the patients (782 men, 57%; 590 women, 43%) was 49.24 ± 11.04 years. OSAS was detected in 954 (69.5%) patients with 399 (29.1%) mild OSAS; 246 (17.9%) moderate OSAS; and 309 (22.5%) severe OSAS. Among these, the prevalence of moderate-to-severe OSAS was 143 (10.4%) in women and 412 (30.0%) in men. The mean age was the highest (51.29 ± 11.29) in the mild OSAS group and lowest (47.08 ± 10.87) in the healthy group. OSAS severity was greater with increasing BMI, 23.39 ± 3.44 in the healthy group and 29.29 ± 5.01 in the severe OSAS group. A positive correlation was also noted between the ESS/STOP-Bang questionnaire rating and OSAS severity. Conclusion The prevalence of OSAS in Taiwan was 69.5% in our study. It showed strong evidence that OSAS has important public health consequences and PMs are simple, fast, feasible, and cost-effective tools for OSAS screening in the home environment, especially during the COVID-19 pandemic.
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Affiliation(s)
| | - Hsin-Chien Hsu
- Department of Otolaryngology, Taipei City Hospital, Taipei City, Taiwan
- Graduate Institute of Business Administration, College of Management, Fu Jen Catholic University, New Taipei City, Taiwan
- General Education Center, University of Taipei, Taipei City, Taiwan
| | - Chih-Wen Twu
- Department of Otorhinolaryngology, Head and Neck Surgery, Changhua Christian Hospital, Changhua County, Taiwan
- Department of Post-Baccalaureate Medicine, National Chung Hsing University, Taichung City, Taiwan
| | - Wen-Kuan Huang
- Division of Hematology/Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan City, Taiwan
| | - Hung-Meng Huang
- Department of Otolaryngology, Taipei City Hospital, Taipei City, Taiwan
- Department of Otolaryngology, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan
| | - Shih-Han Weng
- Department of Education and Research, Taipei City Hospital, Taipei City, Taiwan
| | - Ming-Chih Chen
- Graduate Institute of Business Administration, College of Management, Fu Jen Catholic University, New Taipei City, Taiwan
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Chen A, Ju C, Mackenzie IS, MacDonald TM, Struthers AD, Wei L, Man KK. Impact of beta-blockers on mortality and cardiovascular disease outcomes in patients with obstructive sleep apnoea: a population-based cohort study in target trial emulation framework. THE LANCET REGIONAL HEALTH. EUROPE 2023; 33:100715. [PMID: 37601338 PMCID: PMC10432194 DOI: 10.1016/j.lanepe.2023.100715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 07/19/2023] [Accepted: 07/26/2023] [Indexed: 08/22/2023]
Abstract
Background There is no real-world evidence regarding the association between beta-blocker use and mortality or cardiovascular outcomes in patients with obstructive sleep apnoea (OSA). We aimed to investigate the impact of beta-blocker use on all-cause mortality and cardiovascular diseases (CVDs) in patients with OSA. Methods We conducted a target trial emulation study of 37,581 patients with newly diagnosed OSA from 1st January 2000 to 30th November 2021 using the IMRD-UK database (formerly known as the THIN database). We compared the treatment strategies of initiating beta-blocker treatment within one year versus non-beta-blocker treatment through the method of clone-censor-weight. Covariates, including patients' demographics, lifestyle, comorbidities, and recent medications, were measured and controlled. Patients were followed up for all-cause mortality or composite CVD outcomes (angina, myocardial infarction, stroke/transient ischaemic attack, heart failure, or atrial fibrillation). We estimated the five-year absolute risks, risk differences and risk ratio with 95% confidence intervals (CIs) with standardised, weighted pooled logistic regression, which is a discrete-time hazard model for survival analysis. Several sensitivity analyses were performed, including multiple imputation addressing the missing data. Findings The median follow-up time was 4.1 (interquartile range, 1.9-7.8) years. The five-year absolute risk of all-cause mortality and CVD outcomes were 4.9% (95% CI, 3.8-6.0) and 13.0% (95% CI, 11.4-15.0) among beta-blocker users, and 4.0% (95% CI, 3.8-4.2) and 9.4% (95% CI, 9.1-9.7) among non-beta-blocker users, respectively. The five-year absolute risk difference and risk ratio between the two groups for all-cause mortality and CVD outcomes were 0.9% (95% CI, -0.2 to 2.1) and 1.22 (95% CI, 0.96-1.54), and 3.5% (95% CI, 2.1-5.5) and 1.37 (95% CI, 1.22-1.62), respectively. Findings were consistent across the sensitivity analyses. Interpretation Beta-blocker treatment was associated with an increased risk of CVD and a trend for an increased risk of mortality among patients with OSA. Further studies are needed to confirm our findings. Funding Innovation and Technology Commission of the Hong Kong Special Administration Region Government.
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Affiliation(s)
- Anthony Chen
- Research Department of Practice and Policy, UCL School of Pharmacy, Mezzanine Floor, BMA House, Tavistock Square, London, WC1H 9JP, England
- Faculty of Medicine & Health Sciences, University of Nottingham, Clinical Sciences Building, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, England
| | - Chengsheng Ju
- Research Department of Practice and Policy, UCL School of Pharmacy, Mezzanine Floor, BMA House, Tavistock Square, London, WC1H 9JP, England
| | - Isla S. Mackenzie
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, Scotland
| | - Thomas M. MacDonald
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, Scotland
| | - Allan D. Struthers
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, Scotland
| | - Li Wei
- Research Department of Practice and Policy, UCL School of Pharmacy, Mezzanine Floor, BMA House, Tavistock Square, London, WC1H 9JP, England
- Laboratory of Data Discovery for Health (D4H), Hong Kong Science Park, Hong Kong, China
- Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, England
| | - Kenneth K.C. Man
- Research Department of Practice and Policy, UCL School of Pharmacy, Mezzanine Floor, BMA House, Tavistock Square, London, WC1H 9JP, England
- Laboratory of Data Discovery for Health (D4H), Hong Kong Science Park, Hong Kong, China
- Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, England
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China
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Huang W, Zhang X, Wang X, Zhou T, Zhao X, Xu H, Li X, Guan J, Yi H, Yin S. Effects of obstructive sleep apnea during rapid eye movement sleep on cardiac autonomic dysfunction: Results from the Shanghai sleep health study cohort. J Sleep Res 2023; 32:e13904. [PMID: 37042020 DOI: 10.1111/jsr.13904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/11/2023] [Accepted: 03/29/2023] [Indexed: 04/13/2023]
Abstract
In our large-scale study, the correlation between obstructive sleep apnea (OSA) related to rapid eye movement (REM) sleep and cardiac autonomic dysfunction was assessed by standard polysomnography (PSG). Cardiac autonomic dysfunction was evaluated by the measurement of heart rate variability (HRV). The cardiovascular disease (CVD) risk was determined using the cross-sectional prevalence of CVD and its overall 10 year risk according to the Framingham risk score (FRS). 4152 individuals were included in the study. A higher apnea-hypopnea index during REM sleep (AHIREM ) was correlated with increased CVD risk. The adjusted odds ratios (95% CIs) for CVD prevalence and its high 10 year risk in participants having severe OSA during REM sleep (AHIREM ≥30 events/h) were 1.452 (1.012-2.084) and 1.904 (1.470-2.466) in the demographic adjusted model and 1.175 (0.810-1.704) and 1.716 (1.213-2.427) in the multivariate adjusted model, respectively, compared with the group with a AHIREM of <5 events/h. Fully adjusted multivariate linear regression models showed the independent association between AHIREM and a more elevated ratio of low-frequency and high-frequency (LF/HF) and LF in normalised units [LF (n.u.)] (P = 0.042, P = 0.027 in all participants and P = 0.033, P = 0.029 in participants with AHI during non-REM sleep <5 events/h, respectively). Mediation analysis demonstrated that OSA during REM sleep and CVD risk was significantly mediated by LF/HF and LF (n.u.). OSA during REM sleep may be a marker behind CVD risk because it promotes cardiac autonomic dysfunction.
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Affiliation(s)
- Weijun Huang
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
- Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
| | - Xiaoman Zhang
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
- Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
| | - Xiaoting Wang
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
- Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
| | - Tianjiao Zhou
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
- Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
| | - Xiaolong Zhao
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
- Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
| | - Huajun Xu
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
- Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
| | - Xinyi Li
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
- Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
| | - Jian Guan
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
- Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
| | - Hongliang Yi
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
- Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
| | - Shankai Yin
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
- Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
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15
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Ravichandran R, Gupta L, Singh M, Nag A, Thomas J, Panjiyar BK. The Interplay Between Sleep Disorders and Cardiovascular Diseases: A Systematic Review. Cureus 2023; 15:e45898. [PMID: 37885512 PMCID: PMC10598613 DOI: 10.7759/cureus.45898] [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] [Accepted: 09/25/2023] [Indexed: 10/28/2023] Open
Abstract
Non-communicable diseases (NCDs) have emerged as the predominant cause of global mortality, resulting in a substantial annual loss of human lives. Among these conditions, cardiovascular diseases (CVD) stand out as the primary cause of death. The majority of CVD cases can be attributed to certain factors that, upon modification, have the potential to significantly decrease both the incidence and severity of the disease. For numerous years, the impact of sleep disorders on cardiovascular health has been a prominent subject of extensive discussion. Chronic sleep disturbances are known to have a range of negative health consequences, with the relationship between sleep apnea and hypertension being well-established through numerous studies. However, further exploration is needed to understand other disease associations with sleep apnea and to examine the impact of various sleep disorders, aside from sleep apnea, on cardiovascular health. This systematic review assesses the available evidence on the association between various sleep disorders and cardiovascular diseases by addressing the question: Do sleep disorders contribute to or exacerbate cardiovascular diseases? After a comprehensive review, we identified 122 articles. Following this initial review, seven papers directly aligned with our research topic. Subsequently, we meticulously assessed the remaining seven papers, all meeting our predetermined criteria. Our analysis showed a strong correlation between sleep disruptions and cardiovascular health. Numerous sleep disorders, such as narcolepsy, central sleep apnea, obstructive sleep apnea, and insomnia, have shown different effects on cardiovascular outcomes. Increased risks of illnesses such as acute coronary syndrome (ACS), hypertension, cardiovascular mortality, and coronary artery calcification were included in these consequences. This systematic review underscores the need for early identification and comprehensive management of sleep disturbances to mitigate their potential adverse effects on cardiovascular well-being. Integrating strategies that address sleep disorders and cardiovascular health is imperative in enhancing overall health outcomes. This study paves the way for more effective preventive and therapeutic approaches by focusing on the relationship between sleep disorders and cardiovascular diseases.
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Affiliation(s)
- Rakshana Ravichandran
- Department of Internal Medicine, Rajarajeswari Medical College and Hospital, Bangalore, IND
| | - Lovish Gupta
- Department of Internal Medicine, Maulana Azad Medical College, New Delhi, IND
| | - Mansi Singh
- Department of Medicine, O. O. Bogomolets National Medical University, Kyiv, UKR
| | - Aiswarya Nag
- Department of Internal Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - Jingle Thomas
- Department of Internal Medicine, Al-Ameen Medical College, Vijayapura, IND
| | - Binay K Panjiyar
- Global Clinical Scholars Research Training (GCSRT) and Postgraduate Medical Education (PGME), Harvard Medical School, Boston, USA
- Department of Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
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16
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Perger E, Bertoli S, Lombardi C. Pharmacotherapy for obstructive sleep apnea: targeting specific pathophysiological traits. Expert Rev Respir Med 2023; 17:663-673. [PMID: 37646222 DOI: 10.1080/17476348.2023.2241353] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 07/24/2023] [Indexed: 09/01/2023]
Abstract
INTRODUCTION The pathophysiology of obstructive sleep apnea (OSA) is multi-factorial and complex. Varying OSA's pathophysiological traits have been identified, including pharyngeal collapsibility, upper airway muscle reactivity, arousal threshold, and regulation of the ventilatory drive. Being CPAP of difficult tolerance and other interventions reserved to specific subpopulations new pharmacological treatments for OSA might be resolutive. AREAS COVERED Several existing and newly developed pharmacological drugs can impact one or more endotypes and could therefore be proposed as treatment options for sleep disordered breathing. With this review we will explore different pathophysiological traits as new targets for OSA therapy. This review will summarize the most promising pharmacological treatment for OSA accordingly with their mechanisms of action on upper airway collapsibility, muscle responsiveness, arousal threshold, and loop gain. EXPERT OPINION Only understanding the pathophysiological traits causing OSA in each patient and placing the disease in the framework of patient comorbidities, we will be able to evolve interventions toward OSA. The development of new drug's combinations will permit different approaches and different choices beside conventional treatments. In the next future, we hope that sleep specialists will select the treatment for a specific patient on the base of its pathophysiology, defining a precision medicine for OSA.
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Affiliation(s)
- Elisa Perger
- Sleep Disorders Center & Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Simona Bertoli
- Sleep Disorders Center & Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, Milan, Italy
- Department of Food, Environmental and Nutritional Sciences (DeFENS), University of Milan, Milan, Italy
- Lab of Nutrition and Obesity Research, Istituto Auxologico Italiano, IRCCS, Milan, Carolina
| | - Carolina Lombardi
- Sleep Disorders Center & Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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17
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Mathew D, Kosuru B, Agarwal S, Shrestha U, Sherif A. Impact of sleep apnoea on 30 day hospital readmission rate and cost in heart failure with reduced ejection fraction. ESC Heart Fail 2023. [PMID: 37295960 PMCID: PMC10375077 DOI: 10.1002/ehf2.14430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 05/08/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
AIMS In this study, we estimated the 30 day all-cause and heart failure-specific readmission rates, predictors, mortality, and hospitalization costs in patients with obstructive sleep apnoea admitted with acute decompensated heart failure with reduced ejection fraction. METHODS AND RESULTS This is a retrospective cohort study using the Agency of Healthcare Research and Quality's National Readmission Database for the year 2019. The primary outcome was the 30 day all-cause hospital readmission rate. The secondary outcomes were (i) in-hospital mortality rate for index admissions; (ii) 30 day mortality rate for index hospitalizations; (iii) the five most common principal diagnosis for readmission; (iv) readmission in-hospital mortality rate; (v) length of hospital stay; (vi) independent risk factors for readmission; and (vii) hospitalization costs. We identified 6908 hospitalizations that met our study definition. The mean patient age was 62.8 years, and women comprised only 27.6% of patients. The 30 day all-cause readmission rate was 23.4%. 48.9% of readmissions were due to decompensated heart failure. The in-hospital mortality rate during readmissions was significantly higher than that of the index admission (5.6% vs. 2.4%; P < 0.05). The mean length of stay for patients during index admissions was 6.5 days (6.06-7.02), while during readmissions, it was 8.5 days (7.4-9.6; P < 0.05). The mean total hospitalization charges at index admissions were $78 438 (68 053-88 824), while during readmissions, they were higher at $124 282 (90 906-157 659; P < 0.05). The mean total cost of hospitalization during index admissions was $20 535 (18 311-22 758), while at readmissions, it was higher at $29 954 (24 041-35 867; P < 0.05). The total hospital charges for all 30 day readmissions were $195 million, and total hospital costs was $46.9 million. The variables found to be associated with increased rate of readmissions were patients with Medicaid insurance, higher Charlson co-morbidity Index, and longer length of stay. The variables associated with lower rate of readmissions were prior percutaneous coronary intervention and patients with private insurance. CONCLUSIONS In patients with obstructive sleep apnoea admitted with heart failure with reduced ejection fraction, we found a substantial all-cause readmission rate of 23.4% with heart failure readmission constituting about 48.9% of readmissions. Readmissions were associated with higher mortality and resource use.
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Affiliation(s)
- Don Mathew
- Department of Internal Medicine, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Bhanu Kosuru
- Department of Internal Medicine, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Siddharth Agarwal
- Department of Internal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Utsav Shrestha
- Department of Pulmonary and Critical Care Medicine, West Virginia University, Morgantown, WV, USA
| | - Akil Sherif
- Department of Cardiology, St Vincent Hospital, Worcester, MA, USA
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18
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Schwartz AR, Jacobowitz O, Eisele DW, Mickelson SA, Miller MB, Oliven A, Certal V, Hopp ML, Winslow DH, Huntley TC, Nachlas NE, Pham LV, Gillespie MB, Weeks BH, Lovett EG, Shen J, Malhotra A, Maurer JT. Targeted Hypoglossal Nerve Stimulation for Patients With Obstructive Sleep Apnea: A Randomized Clinical Trial. JAMA Otolaryngol Head Neck Surg 2023; 149:512-520. [PMID: 37022679 PMCID: PMC10080405 DOI: 10.1001/jamaoto.2023.0161] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 02/03/2023] [Indexed: 04/07/2023]
Abstract
Importance Evidence is lacking from randomized clinical trials of hypoglossal nerve stimulation in obstructive sleep apnea (OSA). Objective To evaluate the safety and effectiveness of targeted hypoglossal nerve stimulation (THN) of the proximal hypoglossal nerve in patients with OSA. Design, Setting, and Participants This randomized clinical trial (THN3) was conducted at 20 centers and included 138 patients with moderate to severe OSA with an apnea-hypopnea index (AHI) of 20 to 65 events per hour and body mass index (calculated as weight in kilograms divided by height in meters squared) of 35 or less. The trial was conducted from May 2015 through June 2018. Data were analyzed from January 2022 through January 2023. Intervention Implant with THN system; randomized 2:1 to activation at month 1 (treatment) or month 4 (control). All received 11 months of THN with follow-up at months 12 and 15, respectively. Main Outcomes and Measures Primary effectiveness end points comprised AHI and oxygen desaturation index (ODI) responder rates (RRs). Treatment responses at months 4 and 12/15 were defined as a 50% or greater reduction in AHI to 20 or less per hour and an ODI decrease of 25% or greater. Coprimary end points comprised (1) month 4 AHI and ODI RR in the treatment greater than the control group and (2) month 12/15 AHI and ODI RR in the entire cohort exceeding 50%. Secondary end points included sleep apnea severity (AHI and ODI) and patient-reported outcomes (Epworth Sleepiness Scale, Functional Outcomes of Sleep Questionnaire, and EQ-5D visual analog scale). Results Among 138 participants, the mean (SD) age was 56 (9) years, and 19 (13.8%) were women. Month 4 THN RRs were substantially greater in those in the treatment vs control group (AHI, 52.3% vs 19.6%; ODI, 62.5% vs 41.3%, respectively) with treatment-control standardized mean differences of 0.725 (95% CI, 0.360-1.163) and 0.434 (95% CI, 0.070-0.843) for AHI and ODI RRs, respectively. Months 12/15 RRs were 42.5% and 60.4% for AHI and ODI, respectively. Improvements in AHI, ODI, Epworth Sleepiness Scale, Functional Outcomes of Sleep Questionnaire, and EQ-5D visual analog scale scores were all clinically meaningful (medium to large effect size). Two serious adverse events and 100 nonserious related adverse events were observed from the implant procedure or study protocol. Conclusions and Relevance This randomized clinical trial found that THN demonstrated improvements in sleep apnea, sleepiness, and quality of life in patients with OSAs over an extended AHI and body mass index range without prior knowledge of pharyngeal collapse pattern. Clinically meaningful improvements in AHI and patient-reported responses compared favorably with those of distal hypoglossal nerve stimulation trials, although clinically meaningful differences were not definitive for ODI. Trial Registration ClinicalTrials.gov Identifier: NCT02263859.
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Affiliation(s)
- Alan R Schwartz
- Department of Otorhinolaryngology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Otolaryngology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Ofer Jacobowitz
- Sleep Department, ENT and Allergy Associates, New York, New York
| | - David W Eisele
- Department of Otolaryngology, Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Samuel A Mickelson
- Advanced Ear Nose & Throat Associates, The Atlanta Snoring & Sleep Disorders Institute, Atlanta, Georgia
| | | | - Arie Oliven
- Department of Medicine, Bnai-Zion Medical Centre, Haifa, Israel
- Rappaport School of Medicine, Technion Institute of Technology, Haifa, Israel
| | - Victor Certal
- Department of Otorhinolaryngology/Sleep Medicine Centre, Hospital CUF Porto & CHEDV, Porto, Portugal
- Center for Research in Health Technologies and Information Systems, University of Porto, Porto, Portugal
| | - Martin L Hopp
- Department of Otolaryngology-Head and Neck Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | | | - Tod C Huntley
- Center for Ear, Nose, Throat and Allergy, Carmel, Indiana
| | - Nathan E Nachlas
- Ear, Nose, Throat, and Allergy Associates of Florida, Boca Raton, Florida
| | - Luu V Pham
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - M Boyd Gillespie
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis
| | - Brian H Weeks
- Department of Otolaryngology SENTA Clinic, San Diego, California
| | - Eric G Lovett
- Clinical and Medical Affairs, LivaNova PLC, Minneapolis, Minnesota
| | - John Shen
- OcTech Consulting, St Paul, Minnesota
| | - Atul Malhotra
- Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California San Diego, La Jolla
| | - Joachim T Maurer
- Division of Sleep Medicine, Department of Otorhinolaryngology, University Hospital Mannheim, Mannheim, Germany
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19
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Grzęda-Hałon M, Poręba M, Gut G, Czerwińska K, Gać P, Martynowicz H, Mazur G, Poręba R. The effect of CPAP therapy on heart rate variability in patients with obstructive sleep apnea. Sleep Biol Rhythms 2023; 21:143-154. [PMID: 38469284 PMCID: PMC10899982 DOI: 10.1007/s41105-022-00424-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 08/30/2022] [Indexed: 10/14/2022]
Abstract
The aim of this study was to analyze the relationship between the initiation of CPAP therapy and HRV in patients with OSA. The study group consisted of 37 patients, aged 34-79 (mean 54.95 years) with OSA treated with CPAP. Two subgroups of patients were distinguished: less than severe (AHI < 30, n = 16) and severe OSA (AHI ≥ 30, n = 21). The second study was carried out around a month after the initiation of therapy. CPAP therapy caused the improvement in polysomnographic parameters, however, in most parameters in time and frequency analysis, there were no significant positive changes in parasympathetic tone. Moreover, in HRV time analysis, the reduced rMSSD and pNN50 parameters in the hours of night rest and rMSSD and SDSD during the 15-min N3 sleep period were noted. Especially, in the group with AHI ≥ 30, we observed significant decreases in rMSSD and pNN50 for the entire time. The changes were mainly for the night periods including the N3 sleep period, which is especially connected with sleep apnea (parameters: rMSSD, SDSD, and pNN50). In spectral analysis, the decrease in HF from the 15-min daily activity period and the N3 sleep period was observed. Inverse correlations were seen between the maximum, median, and mean positive airway pressure (PAP) and the change in rMSSD, SDNN, and SDSD, mainly during night hours and the N3 sleep period. Only in patients with AHI < 30 the increase in SDNN was observed in 15-min N3 sleep period. The beneficial increase in SDNN parameter from time analysis was observed only in one sleep period in less ill patients with OSA. The lack of significant changes was observed in the majority of the parameters of heart rate variability after initiation of CPAP therapy in a short observational time; however, the shift towards reduced HRV was observed in patients with AHI > 30, so the response to CPAP therapy may depends on the severity of the apnea. The results may suggest that a longer observational period is needed in such studies, and the problem is still not fully elucidated.
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Affiliation(s)
- Magda Grzęda-Hałon
- Department of Internal Medicine, Occupational Diseases and Hypertension, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, PL Poland
| | - Małgorzata Poręba
- Department of Paralympic Sports, Wroclaw University of Health and Sport Sciences, Witelona 25a, 51-617 Wroclaw, PL Poland
| | - Gabriela Gut
- Department of Internal Medicine, Occupational Diseases and Hypertension, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, PL Poland
| | - Karolina Czerwińska
- Department of Population Health, Division of Environmental Health and Occupational Medicine, Wroclaw Medical University, Mikulicza-Radeckiego 7, 50-368 Wroclaw, PL Poland
| | - Paweł Gać
- Department of Population Health, Division of Environmental Health and Occupational Medicine, Wroclaw Medical University, Mikulicza-Radeckiego 7, 50-368 Wroclaw, PL Poland
| | - Helena Martynowicz
- Department of Internal Medicine, Occupational Diseases and Hypertension, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, PL Poland
| | - Grzegorz Mazur
- Department of Internal Medicine, Occupational Diseases and Hypertension, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, PL Poland
| | - Rafał Poręba
- Department of Internal Medicine, Occupational Diseases and Hypertension, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, PL Poland
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20
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Li Y, Miao Y, Zhang Q. Causal associations of obstructive sleep apnea with cardiovascular disease: a Mendelian randomization study. Sleep 2023; 46:zsac298. [PMID: 36480010 DOI: 10.1093/sleep/zsac298] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 11/14/2022] [Indexed: 12/13/2022] Open
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) had been associated with various cardiovascular diseases (CVDs) in observational studies, but causal inferences have not been confirmed. We used the Mendelian randomization (MR) study to explore the potential causal association between OSA with CVDs in the general population. METHODS We performed a two-sample MR analysis using five gene-wide significant single-nucleotide polymorphisms associated with OSA at genome-wide significance from the FinnGen study (N = 217 955) and 12 cardiovascular diseases from the UK Biobank and the genetic consortia. The inverse-variance weight was chosen as the primary analysis and was complemented by various sensitivity analyses. The study design applied univariable MR, multivariable MR, and mediation analysis. RESULTS MR analyses provide evidence of genetically predicted OSA on the risk of heart failure (odds ratio [OR],1.26; 95% confidence interval [CI],1.08 to 1.47), hypertension (OR,1.24; 95%CI, 1.11 to 1.39) and atrial fibrillation (OR,1.21; 95%CI,1.12 to 1.31). Multivariable MR indicated the adverse effect of OSA on heart failure persisted after adjusting BMI, smoking, drinking, and education (IVW OR,1.13; 95%CI, 1.01 to 1.27). However, the significance of hypertension and atrial fibrillation was dampened. Mediation analyses suggest that the causal association between OSA and heart failure is mediated in part by Apolipoprotein B, with a mediated portion of 9%. CONCLUSIONS This study suggested that genetically predicted OSA is a potential causal risk factor for heart failure based on a large-scale population. Nevertheless, further studies regarding ancestral diversity are needed to confirm the causal association between OSA and CVDs.
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Affiliation(s)
- Ye Li
- Department of Geriatrics, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Geriatrics Institute, Tianjin, China
| | - Yuyang Miao
- Department of Geriatrics, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Geriatrics Institute, Tianjin, China
| | - Qiang Zhang
- Department of Geriatrics, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Geriatrics Institute, Tianjin, China
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21
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Patel SI, Zareba W, Wendel C, Perez K, Patel I, Quan SF, Youngstedt SD, Parthasarathy S, Woosley RL. A QTc risk score in patients with obstructive sleep apnea. Sleep Med 2023; 103:159-164. [PMID: 36805915 DOI: 10.1016/j.sleep.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 02/03/2023] [Accepted: 02/06/2023] [Indexed: 02/10/2023]
Abstract
INTRODUCTION Patients with obstructive sleep apnea (OSA) are at risk for QTc prolongation, a known risk factor for increased mortality. The pro-QTc score can help identify individuals at increased risk for mortality associated with increased QTc however, it has not been evaluated in patients with OSA. The goal of this study was to evaluate the pro-QTc score in patients with OSA. METHODS Medical records of patients undergoing a sleep study at our sleep center from February 2012 to August 2020 were analyzed. Presence or absence of OSA was determined by polysomnography. The pro-QTc score was calculated with 1 point assigned for each of the following: female sex, QT-prolonging diagnoses and conditions, QT-prolonging electrolyte abnormalities, and medications with known risk for QT-prolongation. Mortality was determined from the electronic medical record of an integrated healthcare system. RESULTS There were 2246 patients (age 58 ± 15 years, 54% male, 82 dead) with OSA and 421 patients (age 54 ± 18 years, 43% male, 18 dead) without OSA. Of those with OSA, 1628 (72.5%) had at least one risk factor for QTc prolongation. A higher pro-QTc score was associated with greater mortality in patients with OSA (HR 1.48 per pro-QTc score, p < 0.001, 95% CI 1.3-1.7) but not in patients without OSA (HR 1.25 per pro-QTc score, p = 0.30, 95% CI 0.82-1.9), after adjusting for age, body mass index (BMI), and smoking status. CONCLUSION In patients with OSA, a higher pro-QTc score was associated with greater mortality.
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Affiliation(s)
- Salma I Patel
- UAHS Center for Sleep and Circadian Sciences, University of Arizona, USA; Division of Pulmonary, Allergy, Critical Care Medicine and Sleep Medicine, University of Arizona College of Medicine, Tucson, USA.
| | - Wojciech Zareba
- Division of Cardiology and Heart Research, University of Rochester Medical Center, USA
| | - Christopher Wendel
- UAHS Center for Sleep and Circadian Sciences, University of Arizona, USA
| | - Karolina Perez
- UAHS Center for Sleep and Circadian Sciences, University of Arizona, USA
| | - Imran Patel
- UAHS Center for Sleep and Circadian Sciences, University of Arizona, USA; Division of Pulmonary, Allergy, Critical Care Medicine and Sleep Medicine, University of Arizona College of Medicine, Tucson, USA
| | - Stuart F Quan
- UAHS Center for Sleep and Circadian Sciences, University of Arizona, USA; Division of Pulmonary, Allergy, Critical Care Medicine and Sleep Medicine, University of Arizona College of Medicine, Tucson, USA; Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Shawn D Youngstedt
- UAHS Center for Sleep and Circadian Sciences, University of Arizona, USA; Edson College of Nursing and Health Innovation, Arizona State University, USA
| | - Sairam Parthasarathy
- UAHS Center for Sleep and Circadian Sciences, University of Arizona, USA; Division of Pulmonary, Allergy, Critical Care Medicine and Sleep Medicine, University of Arizona College of Medicine, Tucson, USA
| | - Raymond L Woosley
- Department of Medicine, Division of Clinical Data Analytics and Decision Support, University of Arizona College of Medicine, Phoenix, USA
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22
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A Concise Review of Polysomnography and Obstructive Sleep Apnea for the Neurophysiologist. J Clin Neurophysiol 2023; 40:191-197. [PMID: 36872497 DOI: 10.1097/wnp.0000000000000935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023] Open
Abstract
SUMMARY Sleep as an electrical phenomenon in the brain was first recorded in 1875. Over the next 100 years, recordings of sleep evolved into modern-day polysomnography, which includes not only electroencephalography but also combinations of electro-oculography, electromyography, nasal pressure transducers, oronasal airflow monitors, thermistors, respiratory inductance plethysmography, and oximetry. The most common usage of polysomnography is to identify obstructive sleep apnea (OSA). Research has demonstrated that subjects with OSA have distinctive patterns detected by EEG. The evidence indicates that increased slow activity is seen in both sleep and wake for subjects with OSA and that these changes are reversible with treatment. This article reviews normal sleep, changes in sleep that result from OSA, and the effect that treatment of OSA via continuous positive airway pressure therapy has on normalizing the EEG. A review of alternative OSA treatment options is included, although their effects on EEG in OSA patients have not been studied.
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23
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Wang Z, Jiang F, Xiao J, Chen L, Zhang Y, Li J, Yi Y, Min W, Su L, Liu X, Zou Z. Heart rate variability changes in patients with obstructive sleep apnea: A systematic review and meta-analysis. J Sleep Res 2023; 32:e13708. [PMID: 36070876 DOI: 10.1111/jsr.13708] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 06/25/2022] [Accepted: 07/07/2022] [Indexed: 02/03/2023]
Abstract
Obstructive sleep apnea is a common sleep breathing disorder related to autonomic nervous function disturbances. Heart rate variability is an important non-invasive indicator of autonomic nervous system function. The PubMed, Embase, Medline and Web of Science databases were systematically searched for English literature comparing patients with obstructive sleep apnea with controls up to May 2021. Heart rate variability outcomes, including integrated indices (parasympathetic function and total variability), time domain indices (the standard deviation of NN intervals and the root mean square of the successive differences between normal heartbeats) and frequency domain indices (high-frequency, low-frequency, very-low-frequency and the ratio of low-frequency to high-frequency) were derived from the studies. Twenty-two studies that included 2565 patients with obstructive sleep apnea and 1089 healthy controls were included. Compared with controls, patients with obstructive sleep apnea exhibited significantly reduced parasympathetic function. For the obstructive sleep apnea severity subgroup meta-analysis, patients with severe obstructive sleep apnea had significantly lower parasympathetic function, high-frequency, root mean square of the successive differences between normal heartbeats and standard deviation of NN intervals, and higher low-frequency and ratios of low-frequency to high-frequency. However, only the ratio of low-frequency to high-frequency was significantly higher in patients with moderate obstructive sleep apnea than in controls. Finally, for the collection time analysis, patients with obstructive sleep apnea had significantly higher low-frequency and ratio of low-frequency to high-frequency at night, significantly lower parasympathetic function, high-frequency, root mean square of the successive differences between normal heartbeats and standard deviation of NN intervals, and a higher ratio of low-frequency to high-frequency during the day than controls. Autonomic function impairment was more serious in patients with severe obstructive sleep apnea. During sleep, low-frequency can well reflect the impairment of autonomic function in obstructive sleep apnea, and the ratio of low-frequency to high-frequency may play an important role in obstructive sleep apnea diagnosis.
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Affiliation(s)
- Zuxing Wang
- Sichuan Provincial Center for Mental Health, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China.,Key Laboratory of Psychosomatic Medicine, Chinese Academy of Medical Sciences, Chengdu, China
| | - Fugui Jiang
- Sichuan Provincial Center for Mental Health, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China.,Key Laboratory of Psychosomatic Medicine, Chinese Academy of Medical Sciences, Chengdu, China
| | - Jun Xiao
- Sichuan Provincial Center for Mental Health, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China.,Key Laboratory of Psychosomatic Medicine, Chinese Academy of Medical Sciences, Chengdu, China
| | - Lili Chen
- Sichuan Provincial Center for Mental Health, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China.,Key Laboratory of Psychosomatic Medicine, Chinese Academy of Medical Sciences, Chengdu, China
| | - Yuan Zhang
- Personalized Drug Therapy Key Laboratory of Sichuan Province, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China
| | - Jieying Li
- Sichuan Provincial Center for Mental Health, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China.,Key Laboratory of Psychosomatic Medicine, Chinese Academy of Medical Sciences, Chengdu, China
| | - Yang Yi
- Sichuan Provincial Center for Mental Health, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China.,Key Laboratory of Psychosomatic Medicine, Chinese Academy of Medical Sciences, Chengdu, China
| | - Wenjiao Min
- Sichuan Provincial Center for Mental Health, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China.,Key Laboratory of Psychosomatic Medicine, Chinese Academy of Medical Sciences, Chengdu, China
| | - Liuhui Su
- Sichuan Provincial Center for Mental Health, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China.,Key Laboratory of Psychosomatic Medicine, Chinese Academy of Medical Sciences, Chengdu, China
| | - Xuemei Liu
- Sichuan Provincial Center for Mental Health, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China.,Key Laboratory of Psychosomatic Medicine, Chinese Academy of Medical Sciences, Chengdu, China
| | - Zhili Zou
- Sichuan Provincial Center for Mental Health, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China.,Key Laboratory of Psychosomatic Medicine, Chinese Academy of Medical Sciences, Chengdu, China
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24
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Rodriguez-Quintana J, Bueno-Florez S, Mora-Muñoz L, Orrego-González E, Barragan AM, Suárez-Burgos F, Velez-Van-Meerbeke A, Cendes F. Dysautonomia in people with epilepsy: A scoping review. Seizure 2023; 105:43-51. [PMID: 36702019 DOI: 10.1016/j.seizure.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Epilepsy is one of the most common neurological diseases and has high morbidity and mortality. Multiple methods for assessing dysautonomia have been reported; however, the patient characteristics and epilepsy features that drive any method selection are unclear. People with epilepsy (PWE) can experience sudden unexpected death in epilepsy (SUDEP) and one reason can be dysautonomia. If dysautonomia can be detected in PWE before a severe event, then it could complement and redirect patient treatment and monitoring. OBJECTIVE To map the available literature on dysautonomia in PWE and describe patients' characteristics and methods used to evaluate dysautonomia. METHODS We performed a scoping literature review. We searched PubMed, Scopus, Embase, and hand searched starting from the first registry in the literature until August 2019. Studies were independently assessed by three authors and two epileptologists. We present data in tables and summarize information according to the following structure: population, concepts, and context. RESULTS Thirty-five studies were included in the analysis with epidemiological designs including case reports (23), cross-sectional studies (4), case‒controls (7), and cohort studies (1). A total of 618 patients were enrolled. Heart rate variability, arrhythmia, blood pressure, the tilt-table test, polysomnography, respiratory function, and magnetic resonance imaging were the methods most commonly used to assess dysautonomia in PWE. A detailed description of the heart rate variability assessment is presented. CONCLUSIONS This review provides a broad description of the available literature identifying clinical findings, the most frequently reported assessment measurements of dysautonomia, in temporal lobe epilepsy and extratemporal epilepsies.
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Affiliation(s)
- Jesús Rodriguez-Quintana
- Neuroscience Research Group NEUROS, School of Medicine and Health Sciences, Universidad del Rosario, Adress: Carrera 24 N° 63C-69, Bogota. Colombia; Fundación Cardioinfantil, Adress: Calle 163A # 13B - 60, Bogota. Colombia; Colombia Hospital Universitario Mayor (MEDERI), Adress: Cl 24 # 29 45, Bogota. Colombia
| | | | - Laura Mora-Muñoz
- Neuroscience Research Group NEUROS, School of Medicine and Health Sciences, Universidad del Rosario, Adress: Carrera 24 N° 63C-69, Bogota. Colombia
| | - Eduardo Orrego-González
- Neuroscience Research Group NEUROS, School of Medicine and Health Sciences, Universidad del Rosario, Adress: Carrera 24 N° 63C-69, Bogota. Colombia
| | - Ana M Barragan
- School of Medicine and Health Sciences, Public Health Research Group, Universidad del Rosario, Bogotá, Adress: Carrera 24 N° 63C-69, Bogotá, Colombia
| | | | - Alberto Velez-Van-Meerbeke
- Neuroscience Research Group NEUROS, School of Medicine and Health Sciences, Universidad del Rosario, Adress: Carrera 24 N° 63C-69, Bogota. Colombia
| | - Fernando Cendes
- Department of Neurology, School of Medical Sciences, University of Campinas (UNICAMP), Cidade Universitária Zeferino Vaz, Rua Tessália Vieira de Camargo, 126, 13083-888, Campinas, SP, Brazil
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25
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Huang W, Li C, Zou J, Wang X, Zhang J, Guan J, Yi H, Yin S. Effects of the combination of novel eye mask sleep position therapy device and oral appliance on positional OSA: A multi-arm, parallel-group randomized controlled trial. Sleep Med 2023; 102:52-63. [PMID: 36599196 DOI: 10.1016/j.sleep.2022.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/28/2022] [Accepted: 12/20/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVES We explored whether a new combination of eye mask sleep position therapy (SPT) and oral appliance therapy (OAT) was more effective at treating positional obstructive sleep apnea (POSA) than was the use of either device alone. METHODS In this randomized controlled trial, 60 POSA subjects diagnosed by standard polysomnography (PSG) were divided into three groups (ratio 1:1:1): SPT, OAT, and SPT combined with OAT (SOT). Participants underwent hospital-based follow-ups during months 1 and 6 after beginning treatment. The primary outcome was the decline in the apnea hypopnea index (AHI) at month 6. The secondary outcomes were changes in oxygen-derived parameters and the curative effect at month 6. RESULTS After 6 months of treatment, PSG showed that SPT, OAT, and SOT all improved the AHI and oxygen-derived parameters. The AHI decline was significantly better in the SOT group than in the OAT or SPT group (71.58% [50.56-84.84%] for SOT, 44.42% [21.23-67.52%] for OAT, and 33.24% [19.03-54.62%] for SPT at 6 months) (P = 0.018 and P < 0.001 for the comparisons of SOT with OAT and SOT with SPT, respectively). In terms of oxygen-derived parameters, only the sleep apnea-specific hypoxic burden (SASHB) improved more in the SOT group (76.89% [57.43-85.91%]) than in the other groups (44.73% [32.38-72.69%] for OAT and 41.82% [15.40-65.24%] for SPT, P = 0.002 and P < 0.001 for the comparisons of SOT with OAT and SOT with SPT, respectively). The efficacies of SPT, OAT, and SOT were 36.84%, 50%, and 80% at 6 months; the SOT group evidenced the highest value (rate ratio [95% confidence interval] 1.78 (1.05-3.03), P = 0.048 and 2.17 (1.16-4.07), P = 0.010, for the comparisons of SOT with OAT and SOT with SPT, respectively). CONCLUSION The combination of SPT and OAT was better than either treatment alone and may represent a good option for the treatment of POSA. TRIAL REGISTRATION Chinese Clinical Trial Registry; URL: http://www.chictr.org.cn/showproj.aspx?proj=42,852; No. ChiCTR1900025584.
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Affiliation(s)
- Weijun Huang
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China; Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
| | - Chenyang Li
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China; Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
| | - Jianyin Zou
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China; Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
| | - Xiaoting Wang
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China; Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
| | - Jingyu Zhang
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China; Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
| | - Jian Guan
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China; Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
| | - Hongliang Yi
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China; Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China.
| | - Shankai Yin
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China; Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
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Impact of the 3% Oxygen Desaturation Index via Overnight Pulse Oximetry on Cardiovascular Events and Death in Patients Undergoing Hemodialysis: A Retrospective Cohort Study. J Clin Med 2023; 12:jcm12030858. [PMID: 36769506 PMCID: PMC9917943 DOI: 10.3390/jcm12030858] [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: 12/18/2022] [Revised: 01/12/2023] [Accepted: 01/19/2023] [Indexed: 01/24/2023] Open
Abstract
It is unclear whether the severity of sleep-disordered breathing (SDB) affects the risk of cardiovascular events and mortality in patients undergoing hemodialysis (HD). We determined the severity of SDB with the 3% oxygen desaturation index (ODI) via overnight pulse oximetry. This study was a retrospective cohort, observational study of 134 patients on maintenance HD at a single center. They were divided into four groups according to SDB severity (normal, mild, moderate, and severe), and were followed. The baseline characteristics of all patients were as follows: the median age was 67 (interquartile range, 59-75) years, 64.2% were men, 37.3% were diabetic, and the median duration of HD was 69 (29-132) months. During follow-up, major adverse cardiovascular events (MACEs) occurred in 71 patients and deaths in 60 (including 32 cardiovascular deaths). Severe SDB was an independent risk factor for MACEs (hazard ratio [HR] = 4.66, 95% confidence interval [CI] = 1.87-11.61, p = 0.001) and all-cause death (HR = 5.74, 95% CI = 1.92-16.70, p = 0.001). Severe SDB had a statistically significant impact on the risk of MACEs and mortality in patients undergoing HD. The severity of the 3% ODI via overnight pulse oximetry may be a useful marker as a risk factor for cardiovascular outcomes and mortality in these patients.
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Smoking-Induced Disturbed Sleep. A Distinct Sleep-Related Disorder Pattern? Healthcare (Basel) 2023; 11:healthcare11020205. [PMID: 36673573 PMCID: PMC9858764 DOI: 10.3390/healthcare11020205] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/27/2022] [Accepted: 01/03/2023] [Indexed: 01/12/2023] Open
Abstract
The relationship between smoking and sleep disorders has not been investigated sufficiently yet. Many aspects, especially regarding non-obstructive sleep apnea−hypopnea (OSA)-related disorders, are still to be addressed. All adult patients who visited a tertiary sleep clinic and provided information about their smoking history were included in this cross-sectional study. In total, 4347 patients were divided into current, former and never smokers, while current and former smokers were also grouped, forming a group of ever smokers. Sleep-related characteristics, derived from questionnaires and sleep studies, were compared between those groups. Ever smokers presented with significantly greater body mass index (BMI), neck and waist circumference and with increased frequency of metabolic and cardiovascular co-morbidities compared to never smokers. They also presented significantly higher apnea−hypopnea index (AHI) compared to never smokers (34.4 ± 24.6 events/h vs. 31.7 ± 23.6 events/h, p < 0.001) and were diagnosed more frequently with severe and moderate OSA (50.3% vs. 46.9% and 26.2% vs. 24.8% respectively). Epworth sleepiness scale (ESS) (p = 0.13) did not differ between groups. Ever smokers, compared to never smokers, presented more frequent episodes of sleep talking (30.8% vs. 26.6%, p = 0.004), abnormal movements (31.1% vs. 27.7%, p = 0.021), restless sleep (59.1% vs. 51.6%, p < 0.001) and leg movements (p = 0.002) during sleep. Those were more evident in current smokers and correlated significantly with increasing AHI. These significant findings suggest the existence of a smoking-induced disturbed sleep pattern.
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Yu Y, Li W, Xu L, Wang Y. Circadian rhythm of plasminogen activator inhibitor-1 and cardiovascular complications in type 2 diabetes. Front Endocrinol (Lausanne) 2023; 14:1124353. [PMID: 37020596 PMCID: PMC10067678 DOI: 10.3389/fendo.2023.1124353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/27/2023] [Indexed: 03/22/2023] Open
Abstract
Cardiovascular complications are a common death cause in type 2 diabetes patients, as they are often combined. Plasminogen-activator Inhibitor 1 (PAI-1) participates in the development and progression of cardiovascular complications in diabetes. Insulin resistance increases PAI-1 production, and high PAI-1 levels lead to an environment conducive to thrombosis and earlier and more severe vascular disease. Current evidence also suggests that PAI-1 has a rhythmic profile of circadian fluctuations and acrophase in the morning within a single day, which might explain the high morning incidence of cardiovascular events. Thus, PAI-1 is a possible drug target. Although several PAI-1 inhibitors have been developed, none have yet been allowed for clinical use. Research on rhythm has also led to the concept of "chronotherapy", a rhythm-based drug regimen expected to improve the treatment of cardiovascular complications in diabetic patients. Herein, we searched several databases and reviewed relevant articles to describe the circadian rhythm characteristics and endogenous molecular mechanisms of PAI-1, its relationship with insulin resistance, the causes of cardiovascular complications caused by PAI-1, and the current development of PAI-1 inhibitors. We also summarized the possibility of using the circadian rhythm of PAI-1 to treat cardiovascular complications in diabetic patients.
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Sleep-related breathing disorders in young orthodontic patients. Am J Orthod Dentofacial Orthop 2023; 163:95-101. [PMID: 36184392 DOI: 10.1016/j.ajodo.2021.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 09/01/2021] [Accepted: 09/01/2021] [Indexed: 12/27/2022]
Abstract
INTRODUCTION This study aimed to find out the frequency of sleep-related breathing disorders (SRBD) in young orthodontic patients in Israel. SRBD is characterized by prolonged upper airway obstruction during sleep. METHODS The study group consisted of 309 children aged 6-17 years who attended the Orthodontic Clinic at Hadassah Medical Center. Parents were asked to complete a translated validated Pediatric Sleep Questionnaire. RESULTS Of the examined children, 10% were at high risk for SRBD. Boys were at higher risk for SRBD and were at high risk at a younger age than girls. Girls had a low risk of SRBD after adenotonsillectomy, whereas 50% of the boys that underwent adenotonsillectomy were at high risk for SRBD. CONCLUSIONS Our findings propose that 10% of the children aged 6-17 years, who were seeking orthodontic consultation at our medical center, were at high risk for SRBD. Boys were significantly at a higher risk for SRBD than girls and were at high risk at a younger age. It is important to screen young orthodontic patients for SRBD and to refer high-risk patients to their physicians for further evaluation and treatment.
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Yao Y, Xue J, Li B. Obesity and sudden cardiac death: Prevalence, pathogenesis, prevention and intervention. Front Cell Dev Biol 2022; 10:1044923. [PMID: 36531958 PMCID: PMC9757164 DOI: 10.3389/fcell.2022.1044923] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/24/2022] [Indexed: 02/04/2024] Open
Abstract
Obesity and sudden cardiac death (SCD) share common risk factors. Obesity, in and of itself, can result in the development of SCD. Numerous epidemiologic and clinical studies have demonstrated the close relationships between obesity and SCD, however, the underlying mechanisms remain incompletely understood. Various evidences support the significance of excess adiposity in determining the risk of SCD, including anatomical remodeling, electrical remodeling, metabolic dysfunction, autonomic imbalance. Weight reduction has improved obesity related comorbidities, and reversed abnormal cardiac remodeling. Indeed, it is still unknown whether weight loss contributes to decreased risk of SCD. Further high-quality, prospective trials are needed to strengthen our understanding on weight management and SCD.
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Affiliation(s)
- Yan Yao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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31
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Katz D, DeMaria S, Heckman S, Lin F, Kushida C. Use of the Complete Airway Repositioning and Expansion (CARE) approach in 220 patients with Obstructive Sleep Apnea (OSA): A retrospective cohort study. Sleep Med 2022; 99:18-22. [DOI: 10.1016/j.sleep.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 06/30/2022] [Accepted: 07/04/2022] [Indexed: 11/26/2022]
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Siontis KC, Somers VK. Heart Failure, Sleep-Disordered Breathing, and Ventricular Arrhythmias. JACC Clin Electrophysiol 2022; 8:1257-1259. [DOI: 10.1016/j.jacep.2022.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 08/10/2022] [Indexed: 11/06/2022]
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Bhattacharjee R. Early onset hypertension? Implications of childhood obstructive sleep apnea. Sleep Med Rev 2022; 65:101694. [PMID: 36152500 DOI: 10.1016/j.smrv.2022.101694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 09/02/2022] [Accepted: 09/04/2022] [Indexed: 11/17/2022]
Affiliation(s)
- Rakesh Bhattacharjee
- Division of Respiratory Medicine, Department of Pediatrics, University of California, San Diego, 9500, California, United States.
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Sleep and Epilepsy. Neurol Clin 2022; 40:769-783. [DOI: 10.1016/j.ncl.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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35
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Mehra R, Chung MK, Olshansky B, Dobrev D, Jackson CL, Kundel V, Linz D, Redeker NS, Redline S, Sanders P, Somers VK. Sleep-Disordered Breathing and Cardiac Arrhythmias in Adults: Mechanistic Insights and Clinical Implications: A Scientific Statement From the American Heart Association. Circulation 2022; 146:e119-e136. [PMID: 35912643 PMCID: PMC10227720 DOI: 10.1161/cir.0000000000001082] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Sleep-disordered breathing (SDB), characterized by specific underlying physiological mechanisms, comprises obstructive and central pathophysiology, affects nearly 1 billion individuals worldwide, and is associated with excessive cardiopulmonary morbidity. Strong evidence implicates SDB in cardiac arrhythmogenesis. Immediate consequences of SDB include autonomic nervous system fluctuations, recurrent hypoxia, alterations in carbon dioxide/acid-base status, disrupted sleep architecture, and accompanying increases in negative intrathoracic pressures directly affecting cardiac function. Day-night patterning and circadian biology of SDB-induced pathophysiological sequelae collectively influence the structural and electrophysiological cardiac substrate, thereby creating an ideal milieu for arrhythmogenic propensity. Cohort studies support strong associations of SDB and cardiac arrhythmia, with evidence that discrete respiratory events trigger atrial and ventricular arrhythmic events. Observational studies suggest that SDB treatment reduces atrial fibrillation recurrence after rhythm control interventions. However, high-level evidence from clinical trials that supports a role for SDB intervention on rhythm control is not available. The goals of this scientific statement are to increase knowledge and awareness of the existing science relating SDB to cardiac arrhythmias (atrial fibrillation, ventricular tachyarrhythmias, sudden cardiac death, and bradyarrhythmias), synthesizing data relevant for clinical practice and identifying current knowledge gaps, presenting best practice consensus statements, and prioritizing future scientific directions. Key opportunities identified that are specific to cardiac arrhythmia include optimizing SDB screening, characterizing SDB predictive metrics and underlying pathophysiology, elucidating sex-specific and background-related influences in SDB, assessing the role of mobile health innovations, and prioritizing the conduct of rigorous and adequately powered clinical trials.
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Abstract
SUMMARY Ischemic strokes most often occur between 6 am and 12 am after awakening from sleep but up to 30% occur during sleep. Wake-up strokes (WUS) are new focal neurological deficit(s) persisting for ≥ 24 hours attributable to an ischemic event present on patient awakening. Obstructive sleep apnea (OSA) is a major risk factor for WUS because it compounds the instability of the morning environment and increases the likelihood of cardiovascular events, including hypertension, atrial fibrillation, right-to-left shunts, and stroke. Circadian-driven alterations in structural, homeostatic, and serological factors also predispose to WUS. Also, WUS patients are often not considered candidates for time-dependent intravenous thrombolysis therapy because of an uncertain onset time. However, using the tissue clock (positive diffusion weighted imaging-negative fluid-attenuated inversion recovery mismatch) dates the WUS as 3 to 4.5 hours old and permits consideration for intravenous thrombolysis and if needed mechanical thrombectomy. Given the high prevalence of moderate/severe OSA in stroke patients and its impact on stroke outcomes, screening with overnight pulse oximetry and home sleep apnea test is needed. Treating OSA poststroke remains challenging. Polysomnographic changes in sleep architecture following acute/subacute stroke may also impact upon stroke outcome.
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Affiliation(s)
- Atif Zafar
- Department of Neurology, University of Toronto, Toronto, ON, Canada
| | - Parth Dhruv
- Department of Neurology, Kaiser Permanente, Santa Clara, California, U.S.A
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Sillanmäki S, Lipponen JA, Korkalainen H, Kulkas A, Leppänen T, Nikkonen S, Töyräs J, Duce B, Suni A, Kainulainen S. QTc prolongation is associated with severe desaturations in stroke patients with sleep apnea. BMC Pulm Med 2022; 22:204. [PMID: 35610617 PMCID: PMC9128275 DOI: 10.1186/s12890-022-01996-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 05/10/2022] [Indexed: 01/09/2023] Open
Abstract
Background Obstructive sleep apnea (OSA) is associated with vascular diseases from which stroke and sudden cardiac death are the most significant ones. It is known that disturbances of the autonomic nervous system and electrocardiographic changes are seen in patients with a previous cerebrovascular event. However, the pathophysiological cascade between breathing cessations, autonomic regulation, and cardiovascular events is not fully understood. Methods We aimed to investigate the acute effect of desaturation on repolarisation in OSA patients with a previous stroke. We retrospectively analysed heart-rate corrected QT (QTc) intervals before, within, and after 975 desaturations in OSA patients with a stroke history and at least moderate sleep apnea (apnea–hypopnea index ≥ 15 events/h, n = 18). For the control population (n = 18), QTc intervals related to 1070 desaturation were analysed. Desaturations were assigned to groups according to their length and duration. Groupwise comparisons and regression analyses were further executed to investigate the influence of desaturation features on repolarization. Results In the stroke population the QTc prolonged at least 11 ms during 27.1% of desaturations, and over 20 ms during 12.2% of desaturations. QTc was significantly prolonged during longer (> 30 s, p < 0.04) and deeper (> 7%, p < 0.03) desaturations. Less severe desaturations didn't influence QTc. In median, QTc prolonged 7.5 ms during > 45 s desaturations and 7.4 ms during > 9% deep desaturations. In the control population, QTc prolongation was observed but to a significantly lesser extent than in stroke patients. In addition, desaturation duration was found to be an independent predictor of QTc prolongation (β = 0.08, p < 0.001) among all study patients. Conclusions We demonstrated that longer (> 30 s) and deeper (> 7%) desaturations prolong QTc in patients with stroke history. A significant proportion of desaturations produced clinically relevant QTc prolongation. As it is known that a long QTc interval is associated with lethal arrhythmias, this finding might in part explain the pathophysiological sequelae of cardiovascular mortality in OSA patients with a history of stroke.
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Affiliation(s)
- Saara Sillanmäki
- Diagnostic Imaging Center, Kuopio University Hospital (KYS), P.O. Box 100, 70029, Kuopio, Finland.
| | - Jukka A Lipponen
- Department of Applied Physics, University of Eastern Finland, Kuopio, Finland
| | - Henri Korkalainen
- Diagnostic Imaging Center, Kuopio University Hospital (KYS), P.O. Box 100, 70029, Kuopio, Finland.,Department of Applied Physics, University of Eastern Finland, Kuopio, Finland
| | - Antti Kulkas
- Department of Clinical Neurophysiology, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Timo Leppänen
- Diagnostic Imaging Center, Kuopio University Hospital (KYS), P.O. Box 100, 70029, Kuopio, Finland.,Department of Applied Physics, University of Eastern Finland, Kuopio, Finland.,The School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, Australia
| | - Sami Nikkonen
- Diagnostic Imaging Center, Kuopio University Hospital (KYS), P.O. Box 100, 70029, Kuopio, Finland.,Department of Applied Physics, University of Eastern Finland, Kuopio, Finland
| | - Juha Töyräs
- Department of Applied Physics, University of Eastern Finland, Kuopio, Finland.,Science Service Center, Kuopio University Hospital, Kuopio, Finland.,The School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, Australia
| | - Brett Duce
- Department of Respiratory and Sleep Medicine, Sleep Disorders Centre, Princess Alexandra Hospital, Ipswich Rd, Woolloongabba, QLD, Australia.,Institute for Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Aaron Suni
- The School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Samu Kainulainen
- Diagnostic Imaging Center, Kuopio University Hospital (KYS), P.O. Box 100, 70029, Kuopio, Finland.,Department of Applied Physics, University of Eastern Finland, Kuopio, Finland
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Yi-Fong Su V, Chou KT, Tseng CH, Kuo CY, Su KC, Perng DW, Chen YM, Chang SC. Mouth opening/breathing is common in sleep apnea and linked to more nocturnal water loss. Biomed J 2022; 46:100536. [PMID: 35552020 DOI: 10.1016/j.bj.2022.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 04/26/2022] [Accepted: 05/02/2022] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVES Mouth opening/breathing during sleep is common in patients with obstructive sleep apnea (OSA), which is probably associated with more water loss and higher risk for nocturnal ischemic heart attack. This study aimed to evaluate nocturnal changes in hematocrit/hemoglobin levels and estimated plasma volume loss in OSA patients and its relation to their OSA severity and mouth open/breathing. METHODS Sixty OSA patients and fifteen healthy controls were enrolled and underwent overnight polysomnography. Mouth status was evaluated via an infrared camera and nasal/mouth airflow. Hematocrit and hemoglobin levels in peripheral venous blood were measured before and after sleep to estimate the change of plasma volume. RESULTS Compared to controls, OSA patients had a greater nocturnal increase in hematocrit (1.35% vs. 1.0%, p=0.013), hemoglobin (0.50% vs. 0.30%, p=0.002) and more estimated water loss (5.5% vs 3.7% of plasma volume, p<0.013). The extent of increase was correlated to apnea-hypopnea index_the marker of OSA severity (Spearman's ρ=0.332, p=0.004; ρ=0.367, p=0.001 for hematocrit, hemoglobin, respectively), which remained significant after serial multivariate adjustment. OSA patients had more sleep time with mouth open (96.7% vs 26.7% of total sleep time, p<0.001) and time with complete mouth breathing (14.1% vs 2.7%, p<0.001). The extent of mouth breathing was correlated to apnea-hypopnea index (ρ=0.487, p<0.001), nocturnal increase in hematocrit/hemoglobin levels (ρ=0.236, p=0.042; ρ=0.304, p=0.008, respectively) and estimated plasma volume loss (ρ=0.262, p=0.023). CONCLUSIONS OSA patients had a greater increase in hematocrit/hemoglobin levels after sleep, which is probably linked to more water loss and more sleep time with mouth open/breathing.
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Affiliation(s)
- Vincent Yi-Fong Su
- Department of Internal Medicine, Taipei City Hospital, Taipei, Taiwan; Institute of Clinical Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan; Faculty of Medicine, School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
| | - Kun-Ta Chou
- Institute of Clinical Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan; Faculty of Medicine, School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan; Center of Sleep Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Division of Clinical Respiratory Physiology.
| | - Chun-Hsien Tseng
- Center of Sleep Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chia-Yu Kuo
- Center of Sleep Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Kang-Cheng Su
- Faculty of Medicine, School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan; Center of Sleep Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Diahn-Warng Perng
- Faculty of Medicine, School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan; Center of Sleep Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yuh-Min Chen
- Faculty of Medicine, School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan; Center of Sleep Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shi-Chuan Chang
- Faculty of Medicine, School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan; Center of Sleep Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Division of Clinical Respiratory Physiology
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Comparison of Expiratory Pressures Generated by Four Different EPAP Devices in a Laboratory Bench Setting. Sleep Med 2022; 96:87-92. [DOI: 10.1016/j.sleep.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 04/04/2022] [Accepted: 05/09/2022] [Indexed: 11/30/2022]
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40
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The Tp-e/QT ratio as a predictor of nocturnal premature ventricular contraction events in patients with obstructive sleep apnea. Sleep Breath 2022; 27:469-476. [DOI: 10.1007/s11325-022-02626-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 04/05/2022] [Accepted: 04/22/2022] [Indexed: 10/18/2022]
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da Silva RP, Martinez D, Uribe Ramos JM, Martins EF, Tedesco-Silva LM, Lopez P, Cadore EL. TheHE effectsEFFECTS ofOF resistanceRESISTANCE exerciseEXERCISE onON obstructiveOBSTRUCTIVE sleepSLEEP apneaAPNEA severitySEVERITY andAND bodyBODY waterWATER contentCONTENT inIN olderOLDER adultsADULTS: A randomizedRANDOMIZED controlledCONTROLLED trialTRIAL. Sleep Med 2022; 95:37-46. [DOI: 10.1016/j.sleep.2022.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 04/08/2022] [Accepted: 04/18/2022] [Indexed: 11/15/2022]
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Xu C, Dong M, Sun L, Deng Y, Zhou J, Yuan Z. Sex differences in the impact of day/Night distribution of ST-segment elevation myocardial infarction onset on in-hospital outcomes: Findings from the improving care for cardiovascular disease in China-Acute Coronary Syndrome Project. Sleep Med 2022; 95:112-119. [DOI: 10.1016/j.sleep.2022.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 04/08/2022] [Accepted: 04/18/2022] [Indexed: 11/26/2022]
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Mjelle KES, Lehmann S, Saxvig IW, Gulati S, Bjorvatn B. Association of Excessive Sleepiness, Pathological Fatigue, Depression, and Anxiety With Different Severity Levels of Obstructive Sleep Apnea. Front Psychol 2022; 13:839408. [PMID: 35432136 PMCID: PMC9008507 DOI: 10.3389/fpsyg.2022.839408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThe aim of this study was to investigate possible associations between obstructive sleep apnea and fatigue. This naturally led to considering the association between OSA and excessive sleepiness, depression, and anxiety.BackgroundOSA is a highly prevalent sleep disorder, associated with a risk of hypertension, cardiovascular events, daytime sleepiness, poor cognitive function, and sudden death during sleep. Both excessive sleepiness, fatigue, and symptoms of depression are frequently reported.Method5,464 patients referred to a university hospital for obstructive sleep apnea underwent standard respiratory polygraphy. The severity of OSA was defined as either mild, moderate, or severe, using the apnea–hypopnea index. Validated questionnaires were used to assess excessive sleepiness, pathological fatigue, depression, and anxiety.ResultsNearly 70% of the patients were men, and median age was 50 (range: 16–89) years. One in three had moderate-to-severe OSA (AHI ≥ 15). Excessive sleepiness and pathological fatigue were present in 43 and 39%, respectively. The prevalence of possible depression and anxiety was 19 and 28%, respectively. The proportion of patients with male sex, obesity, and excessive sleepiness increased with the severity of OSA. In contrast, the proportion of patients with pathological fatigue did not increase with OSA severity, and there was a decrease in depression and anxiety with increasing OSA severity.ConclusionOur study reports that pathological fatigue, as well as anxiety and depression, did not increase with OSA severity, whereas excessive sleepiness did. Knowledge concerning conditions related to OSA severity may be indicative of pretest probability of OSA and thus change the priority for polygraphy. Furthermore, the high prevalence rates of fatigue, anxiety, and depression among these patients warrant further investigations.
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Affiliation(s)
- Karin Elisabeth Sundt Mjelle
- Department of Otorhinolaryngology and Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway
- *Correspondence: Karin Elisabeth Sundt Mjelle,
| | - Sverre Lehmann
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Norwegian Competence Center for Sleep Disorders, Haukeland University Hospital, Bergen, Norway
- Department of Thoracic Medicine, Clinical Center for Sleep Medicine, Haukeland University Hospital, Bergen, Norway
| | - Ingvild West Saxvig
- Norwegian Competence Center for Sleep Disorders, Haukeland University Hospital, Bergen, Norway
- Department of Thoracic Medicine, Clinical Center for Sleep Medicine, Haukeland University Hospital, Bergen, Norway
| | - Shashi Gulati
- Department of Otorhinolaryngology and Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway
- Norwegian Competence Center for Sleep Disorders, Haukeland University Hospital, Bergen, Norway
| | - Bjørn Bjorvatn
- Norwegian Competence Center for Sleep Disorders, Haukeland University Hospital, Bergen, Norway
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
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Friend EJ, Leinveber P, Orban M, Hochhold J, Svatikova A, Somers VK, Pressman GS. Obstructive sleep apnea in patients with acute aortic dissection. Clin Cardiol 2022; 45:386-390. [PMID: 35194820 PMCID: PMC9019905 DOI: 10.1002/clc.23790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/16/2022] [Accepted: 01/24/2022] [Indexed: 11/30/2022] Open
Abstract
Background Obstructive sleep apnea (OSA) imposes an afterload burden on the left ventricle and increases the pressure gradient across the aortic wall. Thus, OSA may increase the risk for aortic dissection (AD). Methods This study enrolled 40 subjects with acute AD from four institutions; 37 completed the modified Berlin Questionnaire and 31 underwent attended overnight polysomnography. Aortic diameter was measured on a computed tomography scan at seven locations from the sinotubular junction to the diaphragm. Results Twenty‐seven subjects had type A dissection; 13 had type B. In those who had polysomnography apnea–hypopnea index (AHI) ranged from 0.7 to 89. Prevalence of OSA (AHI ≥ 5) was 61%. Nocturnal presentation (10 p.m.–7 a.m.) did not differ by presence/absence of OSA. The modified Berlin Questionnaire was not predictive of the presence of OSA. Among type A subjects with polysomnography (n = 23), aortic diameters at all locations were greater in the OSA group though differences were not statistically significant. Summating aortic diameters at the seven locations also yielded a numerically larger mean value in the OSA group versus the non‐OSA group. Conclusions In this sample of patients with acute dissection, OSA was prevalent but was not associated with a nocturnal presentation. The presence of underlying OSA may be associated with larger aortic diameters at the time of dissection compared to patients without OSA. Though differences did not meet statistical significance the current series is limited by small numbers.
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Affiliation(s)
- Evan J Friend
- Division of Cardiology, Institute for Heart and Vascular Disease, Einstein Medical Center Philadelphia, Philadelphia, Pennsylvania, USA
| | - Pavel Leinveber
- International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic
| | - Marek Orban
- Comenius University and NUSCH, Bratislava, Slovakia
| | - John Hochhold
- Division of Cardiology, Institute for Heart and Vascular Disease, Einstein Medical Center Philadelphia, Philadelphia, Pennsylvania, USA
| | - Anna Svatikova
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Virend K Somers
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Gregg S Pressman
- Division of Cardiology, Institute for Heart and Vascular Disease, Einstein Medical Center Philadelphia, Philadelphia, Pennsylvania, USA
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45
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Pattullo GG. Clinical implications of opioid-induced ventilatory impairment. Anaesth Intensive Care 2022; 50:52-67. [PMID: 35189729 DOI: 10.1177/0310057x211070292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Opioid-induced ventilatory impairment is the primary mechanism of harm from opioid use. Opioids suppress the activity of the central respiratory centres and are sedating, leading to impairment of alveolar ventilation.Respiratory physiological changes induced with acute opioid use include depression of the hypercapnic ventilatory response and hypoxic ventilatory response. In chronic opioid use a compensatory increase in hypoxic ventilatory response maintains ventilation and contributes to the onset of sleep-disordered breathing patterns of central sleep apnoea and ataxic breathing. Supplemental oxygen use in those at risk of opioid-induced ventilatory impairment requires careful consideration by the clinician to prevent failure to detect hypoventilation, if oximetry is being relied on, and the overriding of hypoxic ventilatory drive. Obstructive sleep apnoea and opioid-induced ventilatory impairment are frequently associated, with this interrelationship being complex and often unpredictable. Monitoring the patient for opioid-induced ventilatory impairment poses challenges in the areas of reliability, avoidance of alarm fatigue, cost, and personnel demands. Many situations remain in which patients cannot be provided effective analgesia without opioids, and for these the clinician requires a comprehensive knowledge of opioid-induced ventilatory impairment.
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Affiliation(s)
- Gavin G Pattullo
- Department of Anaesthesia and Pain Management, Royal North Shore Hospital, St Leonards, Australia
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46
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Gabryelska A, Turkiewicz S, Karuga FF, Sochal M, Strzelecki D, Białasiewicz P. Disruption of Circadian Rhythm Genes in Obstructive Sleep Apnea Patients-Possible Mechanisms Involved and Clinical Implication. Int J Mol Sci 2022; 23:ijms23020709. [PMID: 35054894 PMCID: PMC8775490 DOI: 10.3390/ijms23020709] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/29/2021] [Accepted: 01/05/2022] [Indexed: 02/06/2023] Open
Abstract
Obstructive sleep apnea (OSA) is a chronic condition characterized by recurrent pauses in breathing caused by the collapse of the upper airways, which results in intermittent hypoxia and arousals during the night. The disorder is associated with a vast number of comorbidities affecting different systems, including cardiovascular, metabolic, psychiatric, and neurological complications. Due to abnormal sleep architecture, OSA patients are at high risk of circadian clock disruption, as has been reported in several recent studies. The circadian clock affects almost all daily behavioral patterns, as well as a plethora of physiological processes, and might be one of the key factors contributing to OSA complications. An intricate interaction between the circadian clock and hypoxia may further affect these processes, which has a strong foundation on the molecular level. Recent studies revealed an interaction between hypoxia-inducible factor 1 (HIF-1), a key regulator of oxygen metabolism, and elements of circadian clocks. This relationship has a strong base in the structure of involved elements, as HIF-1 as well as PER, CLOCK, and BMAL, belong to the same Per-Arnt-Sim domain family. Therefore, this review summarizes the available knowledge on the molecular mechanism of circadian clock disruption and its influence on the development and progression of OSA comorbidities.
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Affiliation(s)
- Agata Gabryelska
- Department of Sleep Medicine and Metabolic Disorders, Medical University of Lodz, 92-215 Lodz, Poland; (S.T.); (F.F.K.); (M.S.); (P.B.)
- Correspondence: ; Tel.: +48-660796004
| | - Szymon Turkiewicz
- Department of Sleep Medicine and Metabolic Disorders, Medical University of Lodz, 92-215 Lodz, Poland; (S.T.); (F.F.K.); (M.S.); (P.B.)
| | - Filip Franciszek Karuga
- Department of Sleep Medicine and Metabolic Disorders, Medical University of Lodz, 92-215 Lodz, Poland; (S.T.); (F.F.K.); (M.S.); (P.B.)
| | - Marcin Sochal
- Department of Sleep Medicine and Metabolic Disorders, Medical University of Lodz, 92-215 Lodz, Poland; (S.T.); (F.F.K.); (M.S.); (P.B.)
| | - Dominik Strzelecki
- Department of Affective and Psychotic Disorders, Medical University of Lodz, 92-215 Lodz, Poland;
| | - Piotr Białasiewicz
- Department of Sleep Medicine and Metabolic Disorders, Medical University of Lodz, 92-215 Lodz, Poland; (S.T.); (F.F.K.); (M.S.); (P.B.)
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ECG and Heart Rate Variability in Sleep-Related Breathing Disorders. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1384:159-183. [PMID: 36217084 DOI: 10.1007/978-3-031-06413-5_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Here we discuss the current perspectives of comprehensive heart rate variability (HRV) analysis in electrocardiogram (ECG) signals as a non-invasive and reliable measure to assess autonomic function in sleep-related breathing disorders (SDB). It is a tool of increasing interest as different facets of HRV can be implemented to screen and diagnose SDB, monitor treatment efficacy, and prognose adverse cardiovascular outcomes in patients with sleep apnea. In this context, the technical aspects, pathophysiological features, and clinical applications of HRV are discussed to explore its usefulness in better understanding SDB.
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Trzepizur W, Blanchard M, Ganem T, Balusson F, Feuilloy M, Girault JM, Meslier N, Oger E, Paris A, Pigeanne T, Racineux JL, Sabil A, Gervès-Pinquié C, Gagnadoux F. Sleep Apnea-Specific Hypoxic Burden, Symptom Subtypes, and Risk of Cardiovascular Events and All-Cause Mortality. Am J Respir Crit Care Med 2022; 205:108-117. [PMID: 34648724 DOI: 10.1164/rccm.202105-1274oc] [Citation(s) in RCA: 82] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Data from population-based cohorts suggest that symptom subtypes and obstructive sleep apnea (OSA)-specific hypoxic burden (HB) could help to better identify patients with OSA at high cardiovascular (CV) risk. Objectives: We aimed to evaluate whether those new markers are associated with the risk of major adverse CV events (MACE) in clinical setting. Methods: Data from the Pays de la Loire cohort were linked to health administrative data to identify the occurrence of MACE (a composite outcome including all-cause mortality, acute myocardial infarction, stroke, and unplanned coronary revascularization) in patients with newly diagnosed OSA and no overt CV disease. Latent class analysis was used to identify subtypes based on eight clinically relevant variables. HB was defined as the total area under the respiratory event-related desaturation curve. Cox proportional hazards models were used to evaluate the association of symptom subtypes and HB with MACE. Measurements and Main Results: Four symptom subtypes were identified (minimally symptomatic [22.0%], disturbed sleep [17.5%], excessively sleepy [49.8%], and moderately sleepy [10.6%]). After a median follow-up of 78 months (interquartile range, 52-109), 592 (11.05%) of 5,358 patients experienced MACE. In a fully adjusted model, HB and overall nocturnal hypoxemia assessed by sleep time with oxygen saturation <90% were the only predictors of MACE (hazard ratio, 1.21; 95% confidence interval, 1.07-1.38; and hazard ratio, 1.34; 95% confidence interval, 1.16-1.55, respectively). The association appeared stronger toward younger patients and women. Conclusion: In clinical setting, patients with OSA who demonstrate elevated OSA-specific HB are at higher risk of a CV event and all-cause mortality. Symptom subtypes were not associated with MACE after adjustment for confounders.
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Affiliation(s)
- Wojciech Trzepizur
- Department of Respiratory and Sleep Medicine, Angers University hospital, Angers, France.,INSERM Unit 1063, Angers, France
| | | | - Timothée Ganem
- Department of Respiratory and Sleep Medicine, Angers University hospital, Angers, France
| | - Frédéric Balusson
- Rennes University, Rennes University Hospital, EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Rennes, Rennes, France
| | | | | | - Nicole Meslier
- Department of Respiratory and Sleep Medicine, Angers University hospital, Angers, France.,INSERM Unit 1063, Angers, France
| | - Emmanuel Oger
- Rennes University, Rennes University Hospital, EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Rennes, Rennes, France
| | - Audrey Paris
- Department of Respiratory Diseases, Le Mans General Hospital, Le Mans, France
| | - Thierry Pigeanne
- Respiratory Unit, Pôle santé des Olonnes, Olonne sur Mer, France
| | - Jean-Louis Racineux
- Pays de la Loire Respiratory Health Research Institute, Beaucouzé, France; and
| | | | | | - Frédéric Gagnadoux
- Department of Respiratory and Sleep Medicine, Angers University hospital, Angers, France.,INSERM Unit 1063, Angers, France
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Powell TA, Mysliwiec V, Brock MS, Morris MJ. OSA and cardiorespiratory fitness: a review. J Clin Sleep Med 2022; 18:279-288. [PMID: 34437054 PMCID: PMC8807904 DOI: 10.5664/jcsm.9628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The effects of untreated obstructive sleep apnea (OSA) on cardiopulmonary function remain unclear. Cardiorespiratory fitness (CRF), commonly reflected by VO2 max measured during cardiopulmonary exercise testing, has gained popularity in evaluating numerous cardiopulmonary conditions and may provide a novel means of identifying OSA patients with the most clinically significant disease. This emerging testing modality provides simultaneous assessment of respiratory and cardiovascular function with results helping uncover evidence of evolving pathology in either organ system. In this review, we highlight the current state of the literature in regard to OSA and CRF with a specific focus on changes in cardiovascular function that have been previously noted. While OSA does not appear to limit respiratory function during exercise, studies seem to suggest an abnormal cardiovascular exercise response in this population including decreased cardiac output, a blunted heart rate response (ie, chronotropic incompetence), and exaggerated blood pressure response. Surprisingly, despite these observed changes in the cardiovascular response to exercise, results involving VO2 max in OSA remain inconclusive. This is reflected by VO2 max studies involving middle-aged OSA patients showing both normal and reduced CRF. As prior studies have not extensively characterized oxygen desaturation burden, we propose that reductions in VO2 max may exist in OSA patients with only the most significant disease (as reflected by nocturnal hypoxia). Further characterizing this relationship remains important as some research suggests that positive airway pressure therapy or aerobic exercise may improve CRF in patients with OSA. In conclusion, while it likely that severe OSA, via an abnormal cardiovascular response to exercise, is associated with decreased CRF, further study is clearly warranted to include determining if OSA with decreased CRF is associated with increased morbidity or mortality. CITATION Powell TA, Mysliwiec V, Brock MS, Morris MJ. OSA and cardiorespiratory fitness: a review. J Clin Sleep Med. 2022;18(1):279-288.
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Affiliation(s)
- Tyler A. Powell
- Sleep Medicine Service, Wilford Hall Ambulatory Surgery Center, JBSA Lackland Air Force Base, Texas,Address correspondence to: Tyler A. Powell, MD, Sleep Medicine Service, Wilford Hall Ambulatory Service Center, JBSA Lackland Air Force Base, TX 78234; ,
| | - Vincent Mysliwiec
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Matthew S. Brock
- Sleep Medicine Service, Wilford Hall Ambulatory Surgery Center, JBSA Lackland Air Force Base, Texas
| | - Michael J. Morris
- Graduate Medical Education, Brooke Army Medical Center, JBSA Fort Sam Houston, Texas
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50
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Ng SS, Tam WW, Lee RW, Chan TO, Yiu K, Yuen BT, Wong KT, Woo J, Ma RC, Chan KK, Ko FW, Cistulli PA, Hui DS. Effect of Weight Loss and CPAP on OSA and Metabolic Profile Stratified by Craniofacial Phenotype: A Randomized Clinical Trial. Am J Respir Crit Care Med 2021; 205:711-720. [PMID: 34936531 DOI: 10.1164/rccm.202106-1401oc] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Craniofacial structure is thought to modulate the effect of weight loss on OSA, but whether this affects metabolic profile after weight loss compared with continuous positive airway pressure(CPAP) is unknown among obese Chinese patients with obstructive sleep apnea(OSA). OBJECTIVES To compare the change in metabolic profile between lifestyle modification program(LMP), stratified by craniofacial phenotype, and CPAP therapy for 6 months. METHODS We randomly assigned 194 patients with BMI≥25kg/m2 and moderate-to-severe OSA to receive LMP or CPAP therapy for 6 months in a 2:1 ratio. Assessments included computed tomography for assessing maxillomandibular volume(MMV), high sensitivity C-reactive protein(hsCRP) and insulin sensitivity. Measurements and Main Results(mean±SD or median[interquartile range]): Among 128 and 66 subjects in LMP group and CPAP group, respectively, hsCRP reduced more in LMP group than the CPAP group (-0.7[-1.4 to -0.0]mg/L vs -0.3[-0.9 to 0.4]mg/L, p=0.012). More patients in LMP group achieved low hsCRP(<1mg/L) than the CPAP group(21.1% vs 9.1%, p=0.04). Insulin sensitivity improved only in LMP group with 3.1(95%CI 1.5-6.6) times more patients with normal glucose regulation after intervention. LMP group was stratified into LMP-small MMV(n=64) and LMP-large MMV(n=64) groups according to the median MMV value of 233.2cm3. There was no significant difference in hsCRP(-0.7[-1.3 to 0.1] vs -0.7[-1.5 to -0.2], p=0.884) and insulin sensitivity(0.5[-0.2 to 1.9] vs 0.6[0.1 to 2.0], p=0.4860) between LMP-small and LMP-large MMV groups. CONCLUSION Weight reduction improved subclinical inflammation and insulin sensitivity more than CPAP among obese Chinese patients with moderate to severe OSA, and this effect was not influenced by craniofacial structure. Clinical trial registration available at www.clinicaltrials.gov, ID: NCT03287973.
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Affiliation(s)
- Susanna Ss Ng
- Chinese University of Hong Kong Faculty of Medicine, 71024, Department of Medicine & Therapeutics, Hong Kong, Hong Kong
| | - Wilson Ws Tam
- National University of Singapore, 37580, Alice Lee Centre for Nursing Studies, Singapore, Singapore
| | - Richard Ww Lee
- Gosford Hospital, 90112, Department of Respiratory and Sleep Medicine, Gosford, New South Wales, Australia
| | - Tat-On Chan
- Chinese University of Hong Kong Faculty of Medicine, 71024, Department of Medicine & Therapeutics, Hong Kong, Hong Kong
| | - Karen Yiu
- Chinese University of Hong Kong Faculty of Medicine, 71024, Department of Medicine & Therapeutics, Hong Kong, Hong Kong
| | - Brian Ty Yuen
- Prince of Wales Hospital, 13621, Department of Imaging & Interventional Radiology, Hong Kong, Hong Kong
| | - Ka-Tak Wong
- Prince of Wales Hospital, 13621, Department of Imaging & Interventional Radiology, Hong Kong, Hong Kong
| | - Jean Woo
- Chinese University of Hong Kong Faculty of Medicine, 71024, Department of Medicine & Therapeutics, Hong Kong, Hong Kong
| | - Ronald Cw Ma
- Chinese University of Hong Kong Faculty of Medicine, 71024, Department of Medicine & Therapeutics, Hong Kong, Hong Kong.,The Chinese University of Hong Kong Hong Kong Institute of Diabetes and Obesity, 596882, Hong Kong, Hong Kong
| | - Ken Kp Chan
- The Chinese University of Hong Kong Faculty of Medicine, 71024, Department of Medicine and Therapeutics, Hong Kong, Hong Kong
| | - Fanny Ws Ko
- The Chinese University of Hong Kong Faculty of Medicine, 71024, Department of Medicine and Therapeutics, Hong Kong, Hong Kong
| | - Peter A Cistulli
- The University of Sydney Faculty of Medicine and Health, 522555, Charles Perkins Centre, Sydney, New South Wales, Australia
| | - David S Hui
- The Chinese University of Hong Kong Faculty of Medicine, 71024, Department of Medicine & Therapeutics, Hong Kong, Hong Kong;
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