Sleep Apnea is Associated With Accelerated Vascular Aging: Results From 2 European Community-Based Cohort Studies

Vascular senescence and aging: mechanisms, clinical implications, and therapeutic prospects

The aging vasculature is characterized by endothelial dysfunction, arterial stiffness, and increased susceptibility to vascular pathologies. Central to these changes is the process of cellular senescence, where endothelial and vascular smooth muscle cells lose their replicative and functional capacity and adopt a pro-inflammatory secretory phenotype. This review provides an overview of the key mechanisms underlying vascular senescence, including the p53/p21 and p16/Rb pathways, the senescence-associated secretory phenotype (SASP), and oxidative stress, examines its contribution to cardiovascular diseases in older adults, and highlights emerging therapeutic strategies aimed at delaying or reversing these age-related vascular changes. In vascular cells, DNA damage, oxidative stress, and chronic inflammation associated with aging converge to amplify senescence. Clinically, vascular senescence is linked with hypertension, atherosclerosis, and increased overall cardiovascular risk. Several interventions, ranging from senolytics to lifestyle factors, show promise in mitigating these changes; however, long-term studies are needed. Given that vascular senescence is a pivotal driver of cardiovascular pathology in aging, targeting senescent cells or their secretory phenotype may potentially offer new avenues for preventing or attenuating age-related vascular diseases. This review presents an updated and integrative overview of vascular senescence, connecting fundamental cellular mechanisms with their clinical manifestations and highlighting the most promising therapeutic interventions.

Accelerated Vascular Aging as a Possible Mechanism of Troponin I Release in the Absence of Clinically Manifested Myocardial Injury

BACKGROUND

We examined the association between clusters of vascular aging manifestations and ultrasensitivity cardiac troponin I in individuals without cardiovascular disease.

METHODS AND RESULTS

A cross-sectional analysis was conducted using baseline data from PPS-3 (Paris Prospective Study III), a French cohort of 10 157 participants. Cardiac troponin I was measured with an ultrasensitive immunoassay with a limit of detection of 0.013 pg/mL. Vascular aging manifestations were assessed via echotracking of the right common carotid artery to measure structural and functional parameters. Hierarchical clustering was used to identify clusters of vascular aging. Multinomial regression assessed the association between vascular aging clusters and cardiac troponin I quintiles. The study included 8722 cardiovascular disease-free participants (mean±SD age, 59.5±6.3 years; 39% women). Three vascular aging clusters were identified. Cluster 1 (n=4158; 47.4%) was characterized as healthy vascular aging with the lowest arteriosclerosis and atherosclerosis indices; cluster 2 (n=2237; 25.5%) was characterized by the highest arteriosclerosis indices, including increased pulse wave velocity, β index, and Young elastic modulus and lowest distensibility coefficient; and cluster 3 (n=2377; 27.0%) was characterized by the highest atherosclerosis indices, including more frequent plaque prevalence and greater intima-media thickness. Compared with healthy vascular aging, arteriosclerosis and atherosclerosis clusters showed a graded positive association with cardiac troponin I quintiles, independent of traditional risk factors. The adjusted odds ratio for belonging to the highest quintile (quintile 5 versus quintile 1) was 1.55 (95% CI, 1.31-1.92) for arteriosclerosis and 2.66 (95% CI, 2.18-3.23) for atherosclerosis clusters.

CONCLUSIONS

Vascular aging manifestations of arteriosclerosis and atherosclerosis may partly explain the release of troponin I into the bloodstream in adults without clinical cardiovascular disease.

REGISTRATION

URL: https://clinicaltrials.gov; Unique identifier: NCT00741728.

Association of Vascular Aging Phenotypes with Adverse Clinical Outcomes in the Chinese Population: A Multicentre Study

Purpose

This study aimed to investigate the clinical implications of vascular aging (VAg) phenotypes based on the difference between chronological age (CA) and vascular age (VA).

Patients and Methods

We defined VA as the predicted age in a multivariable linear regression model including structural and functional parameters of arteries and conventional risk factors, in a multicentric, cross-sectional cohort (n=15580). According to the 10th and 90th percentiles of Δ-age (CA minus VA), we then classified the status of VAg into 3 phenotypes: the early VAg (EVA), the Normal VAg and the supernormal VAg (SUPERNOVA). We used Cox survival analysis to investigate the association between VAg phenotypes and the risk for adverse clinical outcomes (including all-cause death and cardiovascular disease) in an independent, prospective cohort (n=5316).

Results

In the prospective cohort (11.07 years, 927 events), when compared to the Normal VAg phenotype, EVA had an increased risk (HR: 2.43; 95% CI: 1.80-3.27) and SUPERNOVA had a decrease risk (HR: 0.75; 95% CI: 0.64-0.90) of adverse clinical outcomes, in particular stroke events. EVA also showed a higher risk of myocardial infarction (HR: 3.21, 95% CI: 1.56-6.62) and all-cause death (HR: 1.79, 95% CI: 1.12-2.85). The associations were independent of the atherosclerotic cardiovascular disease risk score. Further, the C-statistics increased 0.010 (P < 0.001), 0.013 (P < 0.001) and 0.016 (P < 0.001) separately when adding baPWV, adding the combination of baPWV and CIMT, and adding the VAg phenotypes to a model of conventional risk factors in predicting cardiovascular events.

Conclusion

This is the first study to evaluate the clinical implications of VAg phenotypes using multicentric data and undergone external validation in China. Our results emphasized that the classification of VAg phenotypes may be a potential tool to identify individuals who were susceptible to or resilient to VAg.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Senolytic-facilitated Reversal of End-Organ Dysfunction in a Murine Model of Obstructive Sleep Apnea

Rationale: Obstructive sleep apnea (OSA) is a highly prevalent condition that is associated with accelerated biological aging and multiple end-organ morbidities. Current treatments, such as continuous positive airway pressure (CPAP), have shown limited cognitive, metabolic, and cardiovascular beneficial outcomes despite adherence. Thus, adjunct therapies aiming to reduce OSA burden, such as senolytics, could improve OSA outcomes.Objectives: To assess if targeting senescence in addition to partial normoxia mimicking "good" CPAP adherence can improve physiological outcomes in mice exposed to chronic intermittent hypoxia.Methods: We compared the effects of 6 weeks of therapy with either partial normoxic recovery alone or combined with the senolytic navitoclax after 16 weeks of intermittent hypoxia exposures, a hallmark of OSA, on multiphenotypic cardiometabolic and neurocognitive parameters.Measurements and Main Results: Our findings indicate that only when combined with navitoclax, partial normoxic recovery significantly improved sleepiness (sleep in the dark phase: 34% ± 4% vs. 26% ± 3%; P < 0.01), cognition (preference score: 51% ± 19% vs. 70% ± 11%; P = 0.048), coronary artery function (response to acetylcholine [vasodilation]: 56% ± 13% vs. 72% ± 10%; P < 0.001), glucose, and lipid metabolism and reduced intestinal permeability and senescence in multiple organs.Conclusions: These findings indicate that the reversibility of end-organ morbidities induced by OSA is not only contingent on restoration of normal oxygenation patterns but can be further enhanced by targeting other OSA-mediated detrimental cellular processes, such as accelerated senescence.

Healthy sleep score changes and incident cardiovascular disease in European prospective community-based cohorts

BACKGROUND AND AIMS

Evidence on the link between sleep patterns and cardiovascular diseases (CVDs) in the community essentially relies on studies that investigated one single sleep pattern at one point in time. This study examined the joint effect of five sleep patterns at two time points with incident CVD events.

METHODS

By combining the data from two prospective studies, the Paris Prospective Study III (Paris, France) and the CoLaus|PsyCoLaus study (Lausanne, Switzerland), a healthy sleep score (HSS, range 0-5) combining five sleep patterns (early chronotype, sleep duration of 7-8 h/day, never/rarely insomnia, no sleep apnoea, and no excessive daytime sleepiness) was calculated at baseline and follow-up.

RESULTS

The study sample included 11 347 CVD-free participants aged 53-64 years (44.6% women). During a median follow-up of 8.9 years [interquartile range (IQR): 8.0-10.0], 499 first CVD events occurred (339 coronary heart disease (CHD) and 175 stroke). In multivariate Cox analysis, the risk of CVD decreased by 18% [hazard ratio (HR) 0.82, 95% confidence interval (CI) 0.76-0.89] per one-point increment in the HSS. After a median follow-up of 6.0 years (IQR: 4.0-8.0) after the second follow-up, 262 first CVD events occurred including 194 CHD and 72 stroke. After adjusting for baseline HSS and covariates, the risk of CVD decreased by 16% (HR 0.84, 95% CI 0.73-0.97) per unit higher in the follow-up HSS over 2-5 years.

CONCLUSIONS

Higher HSS and HSS improvement over time are associated with a lower risk of CHD and stroke in the community.

Is Continuous Positive Airway Pressure a Valid Alternative to Sildenafil in Treating Sexual Dysfunction among OSA Patients? A Systematic Review and Meta-Analysis

Background and Objectives: This study aimed to assess the comparative effectiveness of continuous positive airway pressure (CPAP) therapy and sildenafil pharmacological therapy in improving sexual function among patients with obstructive sleep apnea (OSA) and erectile dysfunction (ED). Materials and methods: Population: Patients affected by OSA and ED; Intervention: CPAP therapy vs. Comparison: Sildenafil pharmacological therapy; Outcomes: Improvement in erectile function, as measured by the International Index of Erectile Function 5 (IIEF-5) scoring system; Time: A systematic review of the literature from the past 20 years; Study Design: Observational studies comparing erectile function improvements after OSA treatment. Results: A total of eight papers were included in the qualitative summary, involving four hundred fifty-seven patients with ED and OSA. Erectile function improvements were observed in both treatment groups. After sildenafil and CPAP treatment, the mean IIEF-5 domain scores were 37.7 and 27.3, respectively (p < 0.001). Sildenafil 100 mg demonstrated a higher therapeutic impact compared to CPAP treatment. Conclusions: CPAP therapy significantly improved sexual parameters in most studies for OSA patients with ED. The findings suggest that CPAP therapy effectively alleviates erectile dysfunction symptoms, resulting in improved sexual performance in OSA patients. The comparison of the two treatments indicates that sildenafil has a more substantial therapeutic impact on erectile function than CPAP therapy; however, a combined treatment will provide a cumulative effect.

Childhood Obesity and Cardiovascular Disease Risk

PURPOSE OF REVIEW

The global epidemic of youth-onset obesity is tightly linked to the rising burden of cardiometabolic disease across the lifespan. While the link between childhood obesity and cardiovascular disease is established, this contemporary review summarizes recent and novel advances in this field that elucidate the mechanisms and impact of this public health issue.

RECENT FINDINGS

The review highlights the emerging data supporting the relationship between childhood adverse events, social determinants of health, and systemic and institutional systems as etiological factors. We also provide updates on new screening and treatment approaches including updated nutrition and dietary guidelines and benchmarks for pediatric obesity screening, novel pharmacological agents for pediatric obesity and type 2 diabetes such as glucagon-like 1 peptide receptor agonists, and we discuss the long-term safety and efficacy data on surgical management of pediatric obesity. The global burden of pediatric obesity continues to rise and is associated with accelerated and early vascular aging especially in youth with obesity and type 2 diabetes. Socio-ecological determinants of risk mediate and moderate the relationship of childhood obesity with cardiometabolic disease. Recognizing the importance of neighborhood level influences as etiological factors in the development of cardiovascular disease is critical for designing effective policies and interventions. Novel surgical and pharmacological interventions are effective pediatric weight-loss interventions, but future research is needed to assess whether these agents, within a socio-ecological framework, will be associated with abatement of the pediatric obesity epidemic and related increased cardiovascular disease risk.

Associations between abdominal obesity and the risk of stroke in Chinese older patients with obstructive sleep apnea: Is there an obesity paradox?

Background and purpose

Abdominal obesity (AO) is a well-known independent risk factor for stroke in the general population although it remains unclear in the case of the elderly, especially in Chinese older patients with obstructive sleep apnea (OSA), considering the obesity paradox. This study aimed to investigate the association between AO and stroke among Chinese older patients with OSA.

Methods

Data were collected from January 2015 to October 2017, and 1,290 older patients (age 60–96 years) with OSA (apnea–hypopnea index ≥ 5 events/h on polysomnography) were consecutively enrolled from sleep centers at six hospitals, evaluated for AO defined as waist circumference (WC) using the standardized criteria for the Chinese population, and followed up prospectively for a median period of 42 months. Logistic regression and Cox regression analyses were used to determine the cross-sectional and longitudinal associations between AO and stroke risk in these participants and different groups of the severity of OSA.

Results

Participants with AO had a higher prevalence of stroke at baseline. A higher incidence of stroke during a median follow-up period of 42 months in participants with AO than in participants without AO (12.4% vs. 6.8% and 8.3% vs. 2.4%, respectively; both P &lt; 0.05) was predicted. Cross-sectional analysis revealed an association between AO and stroke (odds ratio [OR]1.96, 95% confidence interval [CI] 1.31–2.91), which was stronger among participants with moderate OSA only (OR 2.16, 95%CI 1.05–4.43). Cox regression analysis showed that, compared to participants without AO, participants with AO had a higher cumulative incidence of stroke (hazard ratio [HR] 2.16, 95% CI 1.12–4.04) during a median follow-up of 42 months, and this association was observed in patients with severe OSA only (HR 3.67, 95% CI 1.41–9.87) but not for individuals with mild OSA (HR = 1.84, 95% CI 0.43–6.23) and moderate OSA (HR = 1.98, 95% CI 0.73–6.45).

Conclusion

The risk of stroke is associated with AO among Chinese older patients who have OSA, both at baseline and during follow-up, and the strength of the association varied by OSA severity. Active surveillance for early detection of AO could facilitate the implementation of stroke-preventive interventions in the Chinese older OSA population.

Long-term outcomes regarding arterial stiffness and carotid artery atherosclerosis in female patients with rapid eye movement obstructive sleep apnea

Objective

Rapid eye movement (REM) obstructive sleep apnea (OSA) is associated with the risk of cardiovascular events. Arterial stiffness and carotid artery intima-media thickness (IMT) predict these events, but few relevant studies have been conducted. We compared long-term changes in arterial stiffness and IMT between patients with REM OSA and non-REM (NREM) OSA receiving continuous positive airway pressure (CPAP) or oral appliance (OA) therapy.

Methods

Newly diagnosed female patients with OSA received CPAP (n = 6) or OA (n = 7). Pulse wave velocity (PWV) and carotid artery ultrasound were performed before and 60 months after treatment.

Results

There were no differences in baseline characteristics (mean age: 56.0 vs. 61.3 years; mean body mass index: 22.6 vs. 21.7 kg/m²) between the REM OSA and non-REM OSA groups. The median apnea-hypopnea index was lower in the REM OSA group than in the non-REM OSA group. Increased PWV (12.92 ± 1.64 to 14.56 ± 2.73 m/s) and deteriorated glucose metabolism were observed in the REM OSA group after treatment. PWV, IMT, and cardiovascular risk factors were unaffected in the non-REM OSA group.

Conclusion

Arterial stiffness and glucose metabolism are deteriorated in patients with REM OSA compared with these parameters in patients with non-REM OSA after CPAP or OA treatment.

Proteomic Biomarkers of the Apnea Hypopnea Index and Obstructive Sleep Apnea: Insights into the Pathophysiology of Presence, Severity, and Treatment Response

Obstructive sleep apnea (OSA), a disease associated with excessive sleepiness and increased cardiovascular risk, affects an estimated 1 billion people worldwide. The present study examined proteomic biomarkers indicative of presence, severity, and treatment response in OSA. Participants (n = 1391) of the Stanford Technology Analytics and Genomics in Sleep study had blood collected and completed an overnight polysomnography for scoring the apnea−hypopnea index (AHI). A highly multiplexed aptamer-based array (SomaScan) was used to quantify 5000 proteins in all plasma samples. Two separate intervention-based cohorts with sleep apnea (n = 41) provided samples pre- and post-continuous/positive airway pressure (CPAP/PAP). Multivariate analyses identified 84 proteins (47 positively, 37 negatively) associated with AHI after correction for multiple testing. Of the top 15 features from a machine learning classifier for AHI ≥ 15 vs. AHI < 15 (Area Under the Curve (AUC) = 0.74), 8 were significant markers of both AHI and OSA from multivariate analyses. Exploration of pre- and post-intervention analysis identified 5 of the 84 proteins to be significantly decreased following CPAP/PAP treatment, with pathways involving endothelial function, blood coagulation, and inflammatory response. The present study identified PAI-1, tPA, and sE-Selectin as key biomarkers and suggests that endothelial dysfunction and increased coagulopathy are important consequences of OSA, which may explain the association with cardiovascular disease and stroke.

Health burden in type 2 diabetes and prediabetes in The Maastricht Study

Mortality in type 2 diabetes, is determined not only by classical complications, but also by comorbidities, and is linked to hyperglycaemia and apparent even in prediabetes. We aimed to comprehensively investigate, in a population-based cohort, health burden defined as the presence of comorbidities in addition to classical complications and cardiometabolic risk factors, in not only type 2 diabetes but also prediabetes. Such population-based study has not been performed previously. Extensive phenotyping was performed in 3,410 participants of the population-based Maastricht Study (15.0% prediabetes and 28.6% type 2 diabetes) to assess presence of 17 comorbidities, six classical complications, and ten cardiometabolic risk factors. These were added up into individual and combined sum scores and categorized. Group differences were studied with multinomial regression analyses adjusted for age and sex. Individuals with type 2 diabetes and prediabetes, as compared to normal glucose metabolism (NGM), had greater comorbidities, classical complications, cardiometabolic risk factors and combined sum scores (comorbidities sum score ≥ 3: frequencies (95% CI) 61.5% (57.6;65.4) and 41.2% (36.5;45.9) vs. 25.4% (23.5;27.4), p-trend < 0.001; classical complications ≥ 2 (26.6% (23.1;30.1; P < 0.001 vs. NGM) and 10.1% (7.8;12.7; P = 0.065 vs NGM) vs. 8.0% (6.9;9.3)); cardiometabolic risk factors ≥ 6 (39.7% (35.9;43.4) and 28.5% (24.5;32.6) vs. 14.0% (12.5;15.6); p-trend < 0.001); combined ≥ 8 (66.6% (62.7;70.5) and 48.4% (43.7;53.1) vs. 26.0%(24.1;28.0), p-trend < 0.001). Type 2 diabetes and prediabetes health burden was comparable to respectively 32 and 14 years of ageing. Our population-based study shows, independently of age and sex, a considerable health burden in both type 2 diabetes and prediabetes, which to a substantial extent can be attributed to comorbidities in addition to classical complications and cardiometabolic risk factors. Our findings emphasize the necessity of comorbidities' awareness in (pre)diabetes and for determining the exact role of hyperglycaemia in the occurrence of comorbidities.