Continuous positive airway pressure treatment reduces mortality in patients with ischemic stroke and obstructive sleep apnea: a 5-year follow-up study

Genetic Overlap Between Obstructive Sleep Apnea and Ischemic Stroke: A Large-Scale Genome-Wide Cross-Trait Analysis

Background

To further understand the complex relationship between Obstructive Sleep Apnea (OSA) and ischemic stroke, this study explores the role of genetic factors in the comorbidity of these two conditions.

Methods

Based on large-scale available Genome-Wide Association Studies (GWAS) for OSA and ischemic stroke, we conducted a multi-level cross-trait analysis. First, we utilized Linkage Disequilibrium Score Regression (LDSC) to analyze the genetic correlation between the two diseases. Subsequently, we performed cross-trait analysis to identify pleiotropic Single Nucleotide Polymorphisms (SNPs) associated with both OSA and ischemic stroke. On this basis, we applied annotation and Multi-marker Analysis of GenoMic Annotation (MAGMA) analysis to examine results at the gene level. Finally, we conducted Transcriptome-Wide Association Studies (TWAS) to analyze gene expressions significantly related to both traits.

Results

The LDSC analysis revealed a significant positive genetic correlation between OSA and ischemic stroke. Cross-trait analysis identified a total of 90 pleiotropic SNPs, with rs78581380 being the most significant. Combining Functional Mapping and Annotation (FUMA) annotation and MAGMA analysis, we identified 83 genes in total. TWAS analysis discovered 23 gene expressions that were significantly associated with both OSA and ischemic stroke traits.

Conclusion

This study elucidates the shared genetic architecture between OSA and ischemic stroke, emphasizing the crucial role of genetic factors in the comorbidity of these two conditions.

Stroke recurrence and all-cause mortality in CPAP-treated sleep-disordered-breathing patients

BACKGROUND

Obstructive sleep apnea (OSA) affects about 70 % of stroke patients and is closely linked to stroke development. It is unclear whether treatment with continuous positive airway pressure (CPAP) reduces the risk of stroke recurrence or mortality in post-stroke patients, partly due to limited follow-up time and small sample sizes of previous studies. To close this knowledge gap, this study investigated changes in stroke recurrence and mortality among CPAP-treated post-stroke patients with sleep-disordered breathing.

METHODS

We conducted a retrospective cohort study using data from the Danish National Patient Registry covering the period from 2003 to 2016, involving 1821 patients diagnosed with sleep-disordered breathing and a prior ischemic stroke or transient ischemic attack (TIA). Patients were categorized into three groups: CPAP users, CPAP-non-users, and no CPAP treatment. We used Cox hazard regression to assess the risk of recurrent stroke or TIA over a 5-year follow-up period, and all-cause mortality over a 14-year follow-up period.

RESULTS

CPAP treatment improved survival rate in CPAP users compared to patients categorized as no CPAP treatment (hazard ratio 0.75, 95 % CI [0.60;0.92], p = 0.007). This effect persisted after adjusting for age, sex, and pre-existing comorbidities within three years (the Quan-updated Charlson Comorbidity Index). There was no difference in recurrence of stroke/TIA among the three CPAP groups.

CONCLUSIONS

In this registry-based study, we found that CPAP was associated with a reduction in all-cause mortality in post-stroke/TIA patients with sleep-disordered breathing. CPAP treatment did not seem to affect the risk of re-stroke/TIA during the five years of follow-up.

Strengthening oropharyngeal muscles as an approach to treat post-stroke obstructive sleep apnea: A feasibility randomised controlled trial

This study aimed to determine the feasibility of a randomised controlled trial (RCT) evaluating oropharyngeal exercise (OPE) intervention as an alternative therapy for obstructive sleep apnea (OSA) in patients with stroke or transient ischaemic attack (TIA). Despite the high prevalence of OSA in this population, the standard therapy, continuous positive airway pressure (CPAP), is often poorly tolerated. Thirty stroke/TIA patients with OSA unable to tolerate CPAP were randomly assigned to an oropharyngeal exercise or sham exercise protocol. They performed exercises for 6 weeks, 5 days per week, 30 minutes twice per day. Feasibility was ascertained by the proportion of enrolled patients who completed more than 80% of the OPE regimen. Isometric tongue pressures, apnea-hypopnea index (AHI), oxygen desaturation index (ODI), daytime sleepiness, and quality of life (QOL) outcomes were collected at baseline, post-training (6-week follow-up), and retention (10-week follow-up) to document preliminary efficacy. Adherence to study exercises was excellent, with 83% of participants completing more than 80% of the exercises. The isometric tongue pressures were observed to improve in the oropharyngeal exercise group (compared with the sham group), along with a decrease in OSA severity (measured by the AHI and ODI), reduced daytime sleepiness, and enhanced quality of life outcomes following the exercise programme. Only the effects on posterior isometric tongue pressure and daytime sleepiness remained significantly different between groups at the retention session. In conclusion, an RCT evaluating the efficacy of oropharyngeal exercises on post-stroke/TIA OSA is feasible and our preliminary results suggest a clinically meaningful effect.

Changes in plasma concentrations of novel vascular and inflammatory biomarkers in obstructive sleep apnea patients pre- and post-stroke

BACKGROUND

Obstructive sleep apnea (OSA) is increasingly recognized as a common condition in the general population and causes significant OSA-associated morbidities including cardiovascular and cerebrovascular events such as cerebral small vessel disease (CSVD) and stroke.

METHODS

In this study, using sensitive ELISA immunoassays, we measured subset of endothelial/vascular and inflammatory biomarkers as well as neurofilament light chain (NfL), a sensitive marker for neuroaxonal injury, using plasma from OSA patients post-stroke (Acute Cerebral Infarction (ACI), N = 26) to determine their usefulness as potential prognostic markers in disease progression.

RESULTS

Our results showed significantly increased plasma TNFα and NfL concentrations and decreased concentrations of platelet derived growth factor (PDGF-AA) in post-stroke OSA patients with more severe white matter hyperintensities (WMHs). And after separating the patients based on sex, compared to females, male post-stroke OSA patients with severe WMHs have increased circulating levels of inflammatory chemokine CXCL10 and cytokine Interleukin-10 (IL-10) and significantly decreased levels of Angiopoietin-1 (Ang-1) an important protein responsible for endothelial/vascular integrity functions. Importantly, in a subset of newly diagnosed OSA patients (without prior history of stroke), significantly increased plasma CXCL10 levels and decreased plasma Ang-1 levels were also readily observed when compared to healthy controls, indicating possible altered endothelial integrity and ongoing vascular inflammation in these newly diagnosed OSA patients.

CONCLUSIONS

In summary, our study has identified a novel set of plasma biomarkers including PDGF-AA, CXCL10 and Ang-1 for their potential prognostic value for disease outcomes pre- and post-stroke in OSA patients and use as surrogate markers to measure efficacy of treatment modalities.

Pulmonology: What You May Have Missed in 2023

The field of pulmonology saw significant advances in 2023. The publications highlighted in this article address advances and changes in practice related to asthma, chronic obstructive pulmonary disease (COPD), interstitial lung disease, pleural disorders, and sleep-disordered breathing. One article reviews data examining the efficacy of vaccination against respiratory syncytial virus, a respiratory viral illness that has had devastating effects globally. Four studies evaluate the role of various therapies in COPD, including dupilumab, ensifentrine, pulmonary rehabilitation programs, and lung volume reduction versus endobronchial valves. Another study explores the effect on vascular events of positive-pressure ventilation in patients with sleep-disordered breathing and recent stroke. The use of combination therapy with rituximab and mycophenolate mofetil on progression-free survival in patients with nonspecific interstitial pneumonia is the topic of another study. We also highlight an update of clinical recommendations for the evaluation of patients with pleural disorders and a systematic review analyzing the effectiveness of inhaled corticosteroids as a supplement to dual therapy for COPD.

Obstructive Sleep Apnea and Stroke: Determining the Mechanisms Behind their Association and Treatment Options

Sleep-disordered breathing (SDB) can be a sequela of stroke caused by vascular injury to vital respiratory centers, cerebral edema, and increased intracranial pressure of space-occupying lesions. Likewise, obstructive sleep apnea (OSA) contributes to increased stroke risk through local mechanisms such as impaired ischemic cerebrovascular response and systemic effects such as promoting atherosclerosis, hypercoagulability, cardiac arrhythmias, vascular-endothelial dysfunction, and metabolic syndrome. The impact of OSA on stroke outcomes has been established, yet it receives less attention in national guidelines on stroke management than hyperglycemia and blood pressure dysregulation. Furthermore, whether untreated OSA worsens stroke outcomes is not well-described in the literature. This scoping review provides an updated investigation of the correlation between OSA and stroke, including inter-relational pathophysiology. This review also highlights the importance of OSA treatment and its role in stroke outcomes. Knowledge of pathophysiology, the inter-relationship between these common disorders, and the impact of OSA therapy on outcomes affect the clinical management of patients with acute ischemic stroke. In addition, understanding the relationship between stroke outcomes and pre-existing OSA will allow clinicians to predict outcomes while treating acute stroke.

Impact of Comorbid Sleep-Disordered Breathing and Atrial Fibrillation on the Long-Term Outcome After Ischemic Stroke

BACKGROUND

Sleep-disordered breathing (SDB) and atrial fibrillation (AF) are highly prevalent in patients with stroke and are recognized as independent risk factors for stroke. Little is known about the impact of comorbid SDB and AF on long-term outcomes after stroke.

METHODS

In this prospective cohort study, 353 patients with acute ischemic stroke or transient ischemic attacks were analyzed. Patients were screened for SDB by respiratory polygraphy during acute hospitalization. Screening for AF was performed using a 7-day ECG up to 3× in the first 6 months. Follow-up visits were scheduled at 1, 3, 12, 24, and 36 months poststroke. Cox regression models adjusted for various factors (age, sex, body mass index, hypertension, diabetes, dyslipidemia, and heart failure) were used to assess the impact of comorbid SDB and AF on subsequent death or cerebro-cardiovascular events.

RESULTS

Among 353 patients (299 ischemic stroke and 54 transient ischemic attacks), median age, 67 (interquartile range, 57-74) years with 63% males. Moderate-to-severe SDB (apnea-hypopnea index score, ≥15/h) was present in 118 (33.4%) patients. Among the 56 (15.9%) patients with AF, 28 had comorbid moderate-to-severe SDB and AF. Over 36 months, there were 12 deaths and 67 recurrent cerebro-cardiovascular events. Patients with comorbid moderate-to-severe SDB and AF had a higher risk of subsequent death or cerebro-cardiovascular events compared with those with only moderate-to-severe SDB without AF (hazard ratio, 2.49 [95% CI, 1.18-5.24]) and to those without moderate-to-severe SDB or AF (hazard ratio, 2.25 [95% CI, 1.12-4.50]). However, no significant difference was found between the comorbid moderate-to-severe SDB and AF group and the group with only AF without moderate-to-severe SDB (hazard ratio, 1.64 [95% CI, 0.62-4.36]).

CONCLUSIONS

Comorbid moderate-to-severe SDB and AF significantly increase the risk of long-term mortality or recurrent cerebro-cardiovascular events after acute ischemic stroke. Considering both conditions as cumulative and modifiable cerebro-cardiovascular risk factors is of interest for the management of acute stroke.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02559739.

Cardiovascular diseases across OSA phenotypes: A retrospective cohort study

Background

Despite the considerable knowledge of Obstructive Sleep Apnea (OSA) implications for cardiac diseases, the evidence regarding cardiovascular complications across OSA phenotypes including Rapid Eye Movement OSA (REM-OSA) and Positional OSA (POSA) is limited. In this study, we aimed to evaluate the risk of cardiovascular diseases development and progression among patients with REM-OSA and POSA.

Methods

Based on a retrospective cohort analysis, we included polysomnography studies done in the sleep lab at the Jordan University Hospital. Regarding cardiovascular diseases, primary outcomes were Heart Failure, and 1-years Major Adverse Cardiac Events while secondary outcomes were atrial fibrillation, pulmonary hypertension, other arrhythmia, metabolic profile, and echocardiographic measurements of the heart.

Results

The total number of the included patients was 1,026 patients. POSA group had significantly lower percentage of patients with hypertension (P-value = 0.004). Additionally, systolic blood pressure and HbA1c were significantly lower among patients with POSA compared to the NPOSA group (P-value<0.050). Left ventricular end diastolic dimension was significantly higher among patients with POSA while ejection fraction was significantly lower (P-value<0.050). Patients with diabetes and mean HbA1c were significantly lower among patients with REM-OSA compared to patients with NREM-OSA (P-value = 0.015, P-value = 0.046). Multivariate regression analysis revealed that after adjusting for age, gender and preexisting comorbidities, POSA was significantly associated with lower ejection fraction and higher left ventricular diastolic diameter.

Conclusion

In conclusion, our findings indicate that POSA might be associated with huge and clinically significant heart strain and poor cardiac functions, yet it might not have a clinically significant atherogenic effect. This study should guide clinicians to identify OSA phenotypes to imply the best treatment plan to reduce its detrimental impact on cardiac muscle.

Objective Sleep Duration and All-Cause Mortality Among People With Obstructive Sleep Apnea

Importance

The association between sleep duration and all-cause mortality remains unclear among people with obstructive sleep apnea (OSA).

Objective

To explore whether there is an association between sleep duration and all-cause mortality among people with OSA.

Design, Setting, and Participants

This cohort study investigated participants with OSA from the Sleep Heart Health Study (SHHS) in which participants were enrolled between 1995 and 1998 with questionnaires and polysomnography (PSG) assessment and followed up for a median of 11.8 years. SHHS was a multicenter community-based study; 2574 participants with OSA defined by apnea-hypopnea index (AHI) greater than or equal to 15 from SHHS were found; all of them had all-cause mortality data and were included in the study. Data were analyzed from November 2022 to October 2023.

Exposures

Participants were divided into 4 groups with objective sleep duration of (1) at least 7 hours, (2) 6 to less than 7 hours, (3) 5 to less than 6 hours, and (4) less than 5 hours, which was determined by total sleep time on PSG at baseline.

Main Outcomes and Measures

All-cause mortality was defined as deaths from any cause and its risk was compared among 4 OSA groups using Cox regression models.

Results

A total of 2574 participants with OSA were included (1628 [63.2%] men and 946 [36.8%] women; mean [SD] age, 65.4 [10.7] years; 211 [8.2%] Black, 2230 [86.6%] White, 133 [5.2%] other race). Overall, 688 all-cause deaths were observed in participants. Compared with the group sleeping at least 7 hours, the groups sleeping 6 to less than 7 hours (hazard ratio [HR], 1.53 [95% CI, 1.13-2.07]), 5 to less than 6 hours (HR, 1.40 [95% CI, 1.03-1.90]), and less than 5 hours (HR, 1.64 [95% CI, 1.20-2.24]) had significantly higher risks of all-cause mortality independent of AHI. Sensitivity analyses were performed among participants with available data of positive airway pressure treatment during follow-up and the finding was mostly consistent, albeit the HR for the group of 5 to less than 6 hours was not statistically significant.

Conclusions and Relevance

In this cohort study of 2574 participants with OSA, those with shorter objective sleep duration had higher risk of all-cause mortality independent of AHI compared with those sleeping at least 7 hours. Further studies would be needed to investigate health benefits of extending sleep length among people with OSA with short sleep duration.

Sex Differences in 90-Day Functional Outcomes for Acute Ischemic Stroke Patients With Obstructive Sleep Apnea

Background Obstructive sleep apnea (OSA) is characterized by repeated episodes of either full or partial obstruction of the upper airway. OSA is an independent risk factor for acute ischemic stroke (AIS) and a contributor to other key risk factors. OSA may damage endothelial and brain tissues and worsen outcomes following AIS. We aimed to evaluate the impact of sex differences on 90-day functional outcomes following AIS in an OSA population, as measured by the modified Rankin Scale (mRS) score. Methodology We performed a retrospective study of patients with OSA and AIS from the Houston Methodist Hospital Outcomes-Based Prospective Endpoints in Stroke (HOPES) Registry from 2016 to 2022. Patients with charts that noted a diagnosis of OSA before AIS or within the 90 days following AIS were included. A multivariable logistic regression model was constructed adjusting for demographics, first admit National Institutes of Health Stroke Scale (NIHSS), and comorbidities on the binary outcome. The odds ratios (ORs) and 95% confidence intervals (CIs) were reported, providing likelihood estimates of a shift to higher mRS for a given comparison between females (reference category) and males. Statistical significance was defined as two-tailed p-values <0.05 for all tests. Results From the HOPES registry, 291 females and 449 males were found to have OSA. Males had a higher proportion of comorbid conditions such as atrial fibrillation (15% vs. 9%, p = 0.014) and intracranial hemorrhage compared to females (6% vs. 2%, p = 0.020). The multivariate logistic regression model showed that males were at two times higher risk for developing poor functional outcomes at 90 days (OR = 2.35, 95% CI = 1.06-5.19), p < 0.001). Conclusions Males were found to have two times higher risk for developing poor functional outcomes at 90 days. This may be due to more severe oxygen desaturation, increased susceptibility to oxidative stress, and greater frequency of full airway obstruction in males. Greater emphasis on early diagnosis and treatment of OSA may be necessary to reduce the disproportionate incidence of poor functional outcomes, particularly among apneic male stroke survivors.

Post-stroke sleep disturbance and recurrent cardiovascular and cerebrovascular events: A systematic review and meta-analysis

Despite improvements in survival rates, risk of recurrent events following stroke remains high. Identifying intervention targets to reduce secondary cardiovascular risk in stroke survivors is a priority. The relationship between sleep and stroke is complex: sleep disturbances are likely both a contributor to, and consequence of, stroke. The current aim was to examine the association between sleep disturbance and recurrent major acute coronary events or all-cause mortality in the post-stroke population. Thirty-two studies were identified, including 22 observational studies and 10 randomized clinical trials (RCTs). Identified studies included the following as predictors of post-stroke recurrent events: obstructive sleep apnea (OSA, n = 15 studies), treatment of OSA with positive airway pressure (PAP, n = 13 studies), sleep quality and/or insomnia (n = 3 studies), sleep duration (n = 1 study), polysomnographic sleep/sleep architecture metrics (n = 1 study), and restless legs syndrome (n = 1 study). A positive relationship of OSA and/or OSA severity with recurrent events/mortality was seen. Findings on PAP treatment for OSA were mixed. Positive findings indicating a benefit of PAP for post-stroke risk came largely from observational studies (pooled RR [95% CI] for association between PAP and recurrent cardiovascular event: 0.37 [0.17-0.79], I2 = 0%). Negative findings came largely from RCTs (RR [95% CI] for association between PAP and recurrent cardiovascular event + death: 0.70 [0.43-1.13], I2 = 30%). From the limited number of studies conducted to date, insomnia symptoms/poor sleep quality and long sleep duration were associated with increased risk. Sleep, a modifiable behavior, may be a secondary prevention target to reduce the risk of recurrent event and death following stroke. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42021266558.

Positive airway pressure therapy for post-stroke sleep disordered breathing: a systematic review, meta-analysis and meta-regression

BACKGROUND

Sleep disordered breathing (SDB) is an under-recognised independent risk factor and a potential consequence of stroke. We systematically reviewed and meta-analysed the effectiveness of positive airway pressure (PAP) therapy in improving post-stroke outcomes.

METHODS

We searched CENTRAL, Embase, PubMed, CINAHL, PsycINFO, Scopus, ProQuest, Web of Science and CNKI (China National Knowledge Infrastructure) for randomised controlled trials comparing PAP therapy against a control or placebo group. We evaluated the pooled effects of PAP therapy on recurrent vascular events, neurological deficit, cognition, functional independence, daytime sleepiness and depression using random effects meta-analyses.

RESULTS

We identified 24 studies. Our meta-analyses showed that PAP therapy reduced recurrent vascular events (risk ratio 0.47, 95% CI 0.28-0.78), and showed significant beneficial effects on neurological deficit (Hedges' g= -0.79, 95% CI -1.19- -0.39), cognition (g=0.85, 95% CI 0.04-1.65), functional independence (g=0.45, 95% CI 0.01-0.88) and daytime sleepiness (g= -0.96, 95% CI -1.56- -0.37). However, there was insignificant reduction in depression (g= -0.56, 95% CI -2.15-1.02). No publication bias was detected.

CONCLUSIONS

Post-stroke patients with SDB benefited from PAP therapy. Prospective trials are needed to determine the ideal initiation period and the minimum effective therapeutic dose.

Adherence to CPAP Treatment: Can Mindfulness Play a Role?

Obstructive sleep apnea (OSA) is considered a chronic disease that requires long-term multidisciplinary management for effective treatment. Continuous Positive Airway Pressure (CPAP) is still considered the gold standard of therapy. However, CPAP effectiveness is limited due to poor patients' adherence, as almost 50% of patients discontinue treatment after a year. Several interventions have been used in order to increase CPAP adherence. Mindfulness-based therapies have been applied in other sleep disorders such as insomnia but little evidence exists for their application on OSA patients. This review aims to focus on the current data on whether mindfulness interventions may be used in order to increase CPAP adherence and improve the sleep quality of OSA patients. Even though controlled trials of mindfulness and CPAP compliance remain to be performed, this review supports the hypothesis that mindfulness may be used as an adjunct method in order to increase CPAP adherence in OSA patients.

Brain tissue integrity mapping in adults with obstructive sleep apnea using T1-weighted and T2-weighted images

Background

Obstructive sleep apnea (OSA) is accompanied by both gray and white matter differences in brain areas that regulate autonomic, cognitive, and mood functions, which are deficient in the condition. Such tissue changes have been examined through diffusion tensor and diffusion kurtosis imaging-based procedures. However, poor in-plane spatial resolution of these techniques precludes precise determination of the extent of tissue injury. Tissue texture maps derived from the ratio of T1-weighted and T2-weighted images can provide more adequate in-plane assessment of brain tissue differences.

Objectives

To examine brain tissue integrity in recently diagnosed, treatment-naïve OSA subjects, relative to age- and sex-comparable control subjects using T1-weighted and T2-weighted images.

Design

A cross-sectional study.

Methods

We examined the extent of tissue changes in 106 OSA over 115 control subjects using high-resolution T1- and T2-weighted images collected from a 3.0-Tesla scanner (analysis of covariance; covariates: age, sex, body-mass-index, Pittsburgh sleep quality index, Epworth sleepiness scale, Beck Anxiety Inventory, and Beck Depression Inventory II; false discovery rate corrected; p < 0.01).

Results

OSA subjects showed significantly lowered tissue integrity in several brain regions, including the frontal, cingulate and insular cortices, cingulum bundle, thalamus, corpus callosum, caudate and putamen, pons, temporal, occipital, and parietal sites, cerebellar peduncles, and medial medullary sites, compared with controls.

Conclusion

OSA subjects show widespread lowered tissue integrity in autonomic, mood, and cognitive control sites over healthy controls. The pathological processes contributing to the alterations may include repetitive hypoxic and hypercarbic processes and excitotoxic injury, leading to altered brain tissue integrity in OSA.

The mobile sleep medicine model in neurologic practice: Rationale and application

Background

Undiagnosed obstructive sleep apnea (OSA) is prevalent in neurological practice and significantly contributes to morbidity and mortality. OSA is prevalent in US adults and causes poor quality sleep and significant neurocognitive, cardiovascular, and cerebrovascular impairments. Timely treatment of OSA reduces cardio-cerebrovascular risks and improves quality of life. However, most of the US population has limited systematic access to sleep medicine care despite its clinical significance.

Focus

We discuss the importance of systematic screening, testing, and best-practice management of OSA and hypoventilation/hypoxemia syndromes (HHS) in patients with stroke, neurocognitive impairment, and neuromuscular conditions. This review aims to introduce and describe a novel integrated Mobile Sleep Medicine (iMSM) care model and provide the rationale for using an iMSM in general neurological practice to assist with systematic screening, testing and best-practice management of OSA, HHS, and potentially other sleep conditions.

Key points

The iMSM is an innovative, patient-centered, clinical outcome-based program that uses a Mobile Sleep Medicine Unit—a “sleep lab on wheels”—designed to improve access to OSA management and sleep care at all levels of health care system. The protocol for the iMSM care model includes three levels of operations to provide effective and efficient OSA screening, timely testing/treatment plans, and coordination of further sleep medicine care follow-up. The iMSM care model prioritizes effective, efficient, and patient-centered sleep medicine care; therefore, all parties and segments of care that receive and provide clinical sleep medicine services may benefit from adopting this innovative approach.

Adherence to Positive Airway Pressure Therapy in Patients With Obstructive Sleep Apnea

Adherence to either continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) therapy in patients with obstructive sleep apnea syndrome (OSAS) represents a real challenge to sleep medicine physicians. Many risk factors/predictors for nonadherence exist, and usually, it is multifactorial. Long-term nonadherence with CPAP therapy has been associated with the use of CPAP for <4 hours/night during early treatment, moderate to severe obstructive sleep apnea (OSA), poor self-efficacy, and unsupportive bed partner. The American Academy of Sleep Medicine (AASM) recommends follow-up of patients with OSA within the first two weeks of CPAP use to optimize adherence. Measures to improve adherence to positive airway pressure (PAP) therapy go through an integrated approach that involves behavioral therapy and prompt management of side effects. Pharmacologic therapy in the form of a sedative-hypnotic sleep aid has a minor role in managing nonadherence to CPAP based on the greater risk of side effects. This article will briefly discuss the risk factors and management of nonadherence to PAP therapy in patients with OSAS.

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Obstructive Sleep apnea and cardiovascular events in Elderly Patients

INTRODUCTION

In recent decades, life expectancy has increased considerably. The cardiovascular effects of Obstructive Sleep Apnea (OSA) in the elderly lead to patient disability and high resource consumption. Intermittent nocturnal hypoxia leads to hemodynamic stress and adrenergic activation, which promotes cardiovascular disease. However, chronic intermittent hypoxia may protect elderly patients from cardiovascular events (CVE) due to biological adaptation.

AREAS COVERED

OSA patients are at increased risk of cardiovascular events. The severity of OSA increases cardiovascular risk, and this association also exists in the elderly. This article reviews the association between OSA, CPAP treatment, and CVE, particularly stroke and coronary heart disease (CHD), in the elderly. MEDLINE and the Cochrane Collaboration databases were searched from inception to July 2021.

EXPERT COMMENTARY

Although a positive association between OSA and the incidence of cardiovascular disease in the elderly has been established, the role of sleep apnea in certain cardiovascular events remains controversial. Most authors agree that untreated OSA is a risk factor for stroke or worse stroke prognosis. However, the association between OSA and CHD is usually less pronounced than between OSA and stroke, especially in the elderly.

Racial Disparities in Surgical Treatment of Obstructive Sleep Apnea

Objective

Determine risk factors for failure to receive surgical treatment among patients with obstructive sleep apnea.

Study Design

Population-based observational longitudinal cohort study.

Setting

Population-based database.

Methods

Multivariate analysis of 500,792 individuals with obstructive sleep apnea from Optum's deidentified Clinformatics Data Mart database (2004-2018).

Results

Black race, increased age, diabetes, atrial fibrillation, obesity, and congestive heart failure were independently associated with a decreased rate of surgery for obstructive sleep apnea. Asian race, hypertension, arrhythmias other than atrial fibrillation, pulmonary disease, and liver disease were independently associated with an increased rate of surgery for obstructive sleep apnea.

Conclusion

Racial disparities in health outcomes related to health care access and in economic resources have an enormous impact on public health and social equity. We found differences in rates of surgery for obstructive sleep apnea based on race. These data are consistent with others demonstrating disparities in medical treatment of sleep apnea with positive pressure and underline a need for a change in awareness and treatment in these populations.

The effect of obstructive sleep apnea on the increased risk of cardiovascular disease: a systematic review and meta-analysis

BACKGROUND

Obstructive sleep apnea (OSA) is a disorder characterized by intermittent airway obstruction during sleep. The association between OSA and the incidence of cardiovascular disease (CVD) has been investigated in many studies; however, the results are not entirely consistent between studies. The aim of this study was to investigate the relationship between OSA and the risk of CVD through a meta-analysis of cohort studies.

METHODS

A systematic review and meta-analysis of literature was conducted using the PubMed, WoS, Embase, ScienceDirect, Scopus, and Web of Science databases up to the year 2020. In order to analyze the eligible studies, the stochastic effects model was used and the heterogeneity of the studies with the I² index was investigated. Data analysis was performed with Comprehensive Meta-Analysis software (Version 2).

RESULTS

A total of 24 studies were included in the meta-analysis according to the inclusion criteria. Twelve studies reported CVD results, 11 studies reported stroke results, 9 studies reported mortality results, and 8 studies reported CVD results. The odds ratio of CVD in patients with OSA 1.71 (1.17-2.27: 95% confidence interval) stroke in patients with OSA, 1.86 (1.28-2.69: 95% confidence interval), mortality in patients with OSA, 1.77 (1.37-2.29: 95% confidence interval) and CHD in patients with OSA, and 1.48 (1.06-2.28: 95% confidence interval) was obtained.

CONCLUSION

OSA is considered a cardiovascular risk factor. There is a relationship between the severity of OSA and the risk of cardiovascular disease. OSA increases the risk of heart attack, CHD, and death from cardiovascular disease.

A Prospective Study of CPAP Therapy in Relation to Cardiovascular Outcome in a Cohort of Romanian Obstructive Sleep Apnea Patients

Background: Despite efforts at treatment, obstructive sleep apnea (OSA) remains a major health problem, especially with increasing evidence showing an association with cardiovascular morbidity and mortality. The treatment of choice for OSA patients is Continuous Positive Airway Pressure (CPAP), which has been proven in randomized controlled trials to be an effective therapy for this condition. The impact of CPAP on the cardiovascular pathology associated with OSA remains, however, unclear. Although the effect of CPAP has been previously studied in relation to cardiovascular outcome, follow-up of the treatment impact on cardiovascular risk factors at one year of therapy is lacking in a Romanian population. Thus, we aimed to evaluate the one-year effect of CPAP therapy on lipid profile, inflammatory state, blood pressure and cardiac function, assessed by echocardiography, on a cohort of Romanian OSA patients. Methods: We enrolled 163 participants and recorded their baseline demographic and clinical characteristics with a follow-up after 12 months. Inflammatory and cardiovascular risk factors were assessed at baseline and follow up. Results: Our results show that CPAP therapy leads to attenuation of cardiovascular risk factors including echocardiographic parameters, while having no effect on inflammatory markers. Conclusion: Treatment of OSA with CPAP proved to have beneficial effects on some of the cardiovascular risk factors while others remained unchanged, raising new questions for research into the treatment and management of OSA patients.

Acute lacunar infarct in an obese adolescent with obstructive sleep apnea

Obstructive sleep apnea is associated with an increased risk of acute ischemic cerebrovascular accidents in adults. However, this association has not been well established in the pediatric population. We report a case of acute right internal capsule lacunar infarct manifesting as left-sided hemiplegia in an adolescent with severe obesity. Severe untreated obstructive sleep apnea was identified during the hospital stay. Positive airway pressure therapy, weight loss, and tonsillectomy eventually normalized sleep-disordered breathing. The patient recovered completely without any residual neurological deficits with multidisciplinary care. Lacunar infarcts due to hypertension-related cerebral vasculopathy are a well-known cause of stroke in adults. Untreated obstructive sleep apnea may cause hypertension and potentially predispose even the pediatric population to develop lacunar infarcts. Polysomnography needs to be considered as a part of the diagnostic algorithm in pediatric patients with stroke.

CITATION

Chen B, Gorantla S, Shah V. Acute lacunar infarct in an obese adolescent with obstructive sleep apnea. J Clin Sleep Med. 2021;17(8):1743-1747.

The impact of continuous positive airway pressure treatment on retinal vascular changes in obstructive sleep apnea

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) was recently shown to be associated with quantifiable retinal vascular changes, which correlate with disease severity. This follow-up study examines the response of retinal vascular changes in patients with OSA receiving continuous positive airway pressure (CPAP) treatment.

METHODS

This prospective cohort study recruited adult patients undergoing diagnostic polysomnography at a tertiary sleep clinic in Sydney, Australia, stratified into 4 groups by the apnea-hypopnea index; control patients and patients with mild, moderate, and severe OSA. At baseline and follow-up approximately 24 months later, static retinal vascular calibers were derived from fundus photographs, and dynamic vascular pulsation amplitudes were measured on video fundoscopy. A proportion of patients started CPAP therapy after baseline assessment.

RESULTS

Seventy-nine patients participated in this follow-up study: 9 control patients and 18 patients with mild OSA, 21 patients with moderate OSA, and 31 patients with severe OSA. Twenty-five patients started CPAP after baseline. In the severe group, patients not on treatment showed progressive narrowing of retinal arteries from baseline, whereas those on CPAP showed a slight improvement (mean, 171.3-165.1 and 171.2-174.0 μm, respectively; P = .012). Arterio-venous ratio was also significantly reduced in the nontreatment group compared to the treatment group in those with severe OSA (0.836-0.821 and 0.837-0.855, respectively; P = .031). CPAP did not seem to have a significant impact on venous caliber or vascular pulsatility.

CONCLUSIONS

This study shows that patients with severe untreated OSA demonstrate progressive retinal arterial narrowing, whereas CPAP treatment may be protective.

Autotitrating Bilevel Positive Airway Pressure in Large Vessel Steno-Occlusive Stroke Patients With Suspected Sleep Apnea: A Multicenter Randomized Controlled Study

Background: We hypothesized that autotitrating bilevel positive airway pressure (auto-BPAP) favorably affects short-term clinical outcomes in hyperacute ischemic stroke.

Methods: In a multicenter, randomized, controlled trial patients with large vessel steno-occlusive stroke and clinically suspected sleep apnea were allocated to auto-BPAP or standard stroke care alone. Auto-BPAP was initiated within 24 h from stroke onset and performed over 48 h during diurnal and nocturnal sleep. Sleep apnea was assessed using cardiorespiratory polygraphy. Primary endpoint was early neurological improvement on National Institutes of Health Stroke Scale (NIHSS) score at 72 h. Safety and tolerability of BPAP, functional independence [modified Rankin Scale (mRS) 0–2], stroke recurrence, and mortality at 90 days were assessed.

Results: Due to low recruitment, the trial was prematurely stopped after 24 patients had been randomized (auto-BPAP, n = 14; control, n = 10): median baseline NIHSS 13 (5.5–18), 88% large vessel occlusion, and 12% large vessel stenosis. Polygraphy confirmed sleep apnea in 64% of auto-BPAP and 88% of control patients (p = 0.34). Adherence to auto-BPAP was achieved by 9 of the 14 (64%) patients. Between auto-BPAP and control patients, no differences were observed in early neurological improvement (median NIHSS change: −2.0, IQR = 7 points vs. −0.5, IQR = 3 points), 90 days functional independence (21 vs. 30%, p = 0.67), stroke recurrence (0 vs. 20%, p = 0.16), and death (14 vs. 20%, p = 1.0). No safety concerns were identified.

Conclusions: In this prematurely terminated trial, auto-BPAP was safe but did not show an effect on short-term clinical outcomes in selected ischemic stroke patients. Its tolerability, however, may be limited in hyperacute stroke care and needs to be improved before larger trials are conducted.

Clinical Trial Registration:ClinicalTrials.gov, identifier: NCT01812993.

CPAP Therapy Termination Rates by OSA Phenotype: A French Nationwide Database Analysis

The nationwide claims data lake for sleep apnoea (ALASKA)—real-life data for understanding and increasing obstructive sleep apnea (OSA) quality of care study—investigated long-term continuous positive airway pressure (CPAP) termination rates, focusing on the contribution of comorbidities. The French national health insurance reimbursement system data for new CPAP users aged ≥18 years were analyzed. Innovative algorithms were used to determine the presence of specific comorbidities (hypertension, diabetes and chronic obstructive pulmonary disease (COPD)). Therapy termination was defined as cessation of CPAP reimbursements. A total of 480,000 patients were included (mean age 59.3 ± 13.6 years, 65.4% male). An amount of 50.7, 24.4 and 4.3% of patients, respectively, had hypertension, diabetes and COPD. Overall CPAP termination rates after 1, 2 and 3 years were 23.1, 37.1 and 47.7%, respectively. On multivariable analysis, age categories, female sex (1.09 (1.08–1.10) and COPD (1.12 (1.10–1.13)) and diabetes (1.18 (1.16–1.19)) were significantly associated with higher CPAP termination risk; patients with hypertension were more likely to continue using CPAP (hazard ratio 0.96 (95% confidence interval 0.95–0.97)). Therapy termination rates were highest in younger or older patients with ≥1 comorbidity. Comorbidities have an important influence on long-term CPAP continuation in patients with OSA.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.

RESULTS

Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Trials in Sleep Apnea and Stroke: Learning From the Past to Direct Future Approaches

Few randomized controlled trials have evaluated the effectiveness of continuous positive airway pressure (CPAP) in reducing recurrent vascular events and mortality in poststroke obstructive sleep apnea (OSA). To date, results have been mixed, most studies were underpowered and definitive conclusions are not available. Using lessons learned from prior negative trials in stroke, we reappraise prior randomized controlled trials that examined the use of CPAP in treating poststroke OSA and propose the following considerations: (1) Intervention-based changes, such as ensuring that patients are using CPAP for at least 4 hours per night (eg, through use of improvements in CPAP technology that make it easier for patients to use), as well as considering alternative treatment strategies for poststroke OSA; (2) Population-based changes (ie, including stroke patients with severe and symptomatic OSA and CPAP noncompliers); and (3) Changes to timing of intervention and follow-up (ie, early initiation of CPAP therapy within the first 48 hours of stroke and long-term follow-up calculated in accordance with sample size to ensure adequate power). Given the burden of vascular morbidity and mortality in stroke patients with OSA, there is a strong need to learn from past negative trials and explore innovative stroke prevention strategies to improve stroke-free survival.

Impact of sleep apnoea-hypopnoea syndrome on diabetic neuropathy. A systematic review

INTRODUCTION

Diabetes mellitus and sleep apnoea-hypopnoea syndrome appear to be related, but it is not well defined whether there is an increased risk of peripheral neuropathy in patients with both diseases. For this reason, we conducted a systematic review.

METHODS

Bibliographic search in 3 electronic databases using a predefined strategy and the PRISMA methodology. Only original studies (any type of design) published from 2000 onwards in English, French, Portuguese or Spanish were included. A study quality scale was established.

RESULTS

Twelve articles were selected, of which six studied type 2 diabetic patients. The overall prevalence of sleep apnoea-hypopnoea syndrome was 43.7% (1,559/3,564 patients). Diabetic neuropathy was more frequent in patients with sleep apnoea-hypopnoea syndrome in nine studies, although significantly only in four (60% vs 27%, P<.001; 64.5% vs 36%, P=.03; 37% vs 23.4%, P<.02; 66.6% vs 0%, P=.007). In one study, diabetic neuropathy was more frequent in patients without sleep apnoea-hypopnoea syndrome (although not statistically significant) and in 2 no comparison was made between patients with/without sleep apnoea/hypopnoea syndrome.

CONCLUSIONS

The observed results suggest a relationship between diabetes mellitus and sleep apnoea-hypopnoea syndrome in the occurrence of diabetic neuropathy.

Effect of High-Flow Nasal Cannula on Sleep-disordered Breathing and Sleep Quality in Patients With Acute Stroke

Introduction Sleep-disordered breathing (SDB) is common after stroke. Although the standard treatment of SDB is continuous positive airway pressure (CPAP) ventilation, the patient's intolerance and discomfort result in low adherence rates. Alternatively, high-flow nasal cannula (HFNC) may be useful as it reduces upper airway collapse with low level of positive pressure and well tolerability. The aim of this study was to investigate whether HFNC therapy reduces SDB and improves sleep quality with higher compliance rate. Methods We included acute stroke patients with SDB for the assessment of apnea-hypopnea index (AHI) >5/h using WatchPAT 200 (Itamar Medical Ltd, Caesarea, Israel). Patients who met inclusion criteria received HFNC therapy (40 L/min) with monitoring by WatchPAT. AHI, oxygen desaturation index (ODI), sleep efficiency, and rapid eye movement (REM) sleep were compared in patients with and without HFNC therapy. We also evaluated the patient's comfort of HFNC therapy (discomfort or not). Results Among 17 patients assessed for AHI, 12 received HFNC therapy. HFNC therapy was not adhered in two patients due to intolerance. Eight patients remained for final analysis. There were no differences in SDB and sleep quality with and without HFNC therapy as follows: HFNC therapy vs control; AHI 24.9 ± 20.1 vs 21.3 ± 15.0/h (p = 0.63), ODI 16.2 ± 16.5 vs 12.9 ± 12.3/h (p = 0.54), sleep efficiency 80.4 ± 12.9 vs 87.1 ± 6.2 (p = 0.28), percentage of REM sleep 19.4% ± 9.6% vs 27.6% ± 8.9% (p = 0.07). Two patients (17%) complained of discomfort among eight patients. Conclusion HFNC therapy did not improve SDB and sleep quality. Nonadherence and discomfort were observed in HFNC therapy. We need a large trial to confirm this result.

SAS Care 1: sleep-disordered breathing in acute stroke an transient ischaemic attack - prevalence, evolution and association with functional outcome at 3 months, a prospective observational polysomnography study

Sleep-disordered breathing (SDB) is frequent in patients with acute stroke. Little is known, however about the evolution of SDB after stroke. Most of our knowledge stems from smaller cohort studies applying limited cardiopulmonary sleep recordings or from cross-sectional data collected in different populations.

This study aims to determine prevalence, type and intra-individual evolution of SDB based on full-night polysomnography (PSG) in acute stroke and 3 months thereafter. Furthermore, we aimed to identify predictors of SDB in the acute and chronic phase and to evaluate associations between SDB and functional outcome at 3 months (M3).

A total of 166 patients with acute cerebrovascular events were evaluated by full PSG at baseline and 105 again at M3. The baseline prevalence of SDB (apnoea–hypopnoea index (AHI)>5·h⁻¹) was 80.5% and 25.4% of the patients had severe SDB (AHI>30·h⁻¹). Obstructive sleep apnoea was more prevalent than central sleep apnoea (83.8% versus 13%). Mean±SD AHI was 21.4±17.6·h⁻¹and decreased significantly at M3 (18±16.4·h⁻¹; p=0.018). At M3, 91% of all patients with baseline SDB still had an AHI>5·h⁻¹ and in 68.1% the predominant type of SDB remained unchanged (78.9% in obstructive sleep apnoea and 44.4% in central sleep apnoea). The only predictors of SDB at baseline were higher age and body mass index and in the chronic phase additionally baseline AHI. Baseline AHI was associated with functional outcome (modified Rankin score >3) at M3.

The high prevalence of SDB in acute stroke, its persistence after 3 months, and the association with functional outcome supports the recommendation for a rapid SDB screening in stroke patients.

The high prevalence of SDB in acute stroke, its persistence after 3 months and its association with functional outcome support the recommendation for rapid SDB screening in stroke patientshttps://bit.ly/3bFWqV7

Impact of Sleep-Disordered Breathing on Functional Outcomes in Ischemic Stroke: A Cardiopulmonary Coupling Analysis

BACKGROUND AND PURPOSE

Cardiopulmonary coupling (CPC) analysis is an easily assessable method to evaluate sleep-disordered breathing (SDB); however, its prognostic impact in patients with acute ischemic stroke needs to be investigated. We performed a CPC analysis using Holter monitoring at the early stage of noncardioembolic ischemic stroke to investigate the prognostic effect of SDB on functional impairment at the 3-month follow-up.

METHODS

A total 615 patients with acute noncardioembolic ischemic stroke who underwent Holter monitoring within 30 days of stroke onset were enrolled from a multicenter, prospective, all-comer cohort. CPC analysis was conducted, and SDB was defined by the presence of narrow-band coupling during sleep time. We investigated the association between SDB and functional impairment at 3 months as measured by the modified Rankin Scale.

RESULT

Narrow-band coupling was present in 191 (31.1%) of 615 patients (mean age 64.5±12.6 years). The narrow-band group showed a significantly higher rate of severe functional impairment (modified Rankin Scale score >2; 45.5% versus 12.9%, P<0.001) and persistent disability (Δmodified Rankin Scale score ≤0; 53.9% versus 39.8%, P<0.001) at the 3-month follow-up. In multivariate analysis, narrow-band coupling was an independent predictor of higher risk of severe and persistent functional impairment at 3 months (odds ratio, 3.98 [95% CI, 2.34-6.78]; P<0.001; and odds ratio, 1.81 [95% CI, 1.23-2.66]; P<0.001, respectively). The results remained consistent after propensity-score matched analysis with 157 patient pairs (C-statistic=0.770).

CONCLUSIONS

SDB assessed by CPC analysis at the early stage of ischemic stroke could predict severe and prolonged functional impairment at 3 months. CPC analysis using Holter monitoring can help predicting functional impairment in acute ischemic stroke.

Educational, supportive and behavioural interventions to improve usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea

BACKGROUND

Although highly effective in the treatment of obstructive sleep apnoea (OSA), continuous positive airway pressure (CPAP) is not universally accepted by users. Educational, supportive and behavioural interventions may help people with OSA initiate and maintain regular and continued use of CPAP.

OBJECTIVES

To assess the effectiveness of educational, supportive, behavioural, or mixed (combination of two or more intervention types) strategies that aim to encourage adults who have been prescribed CPAP to use their devices.

SEARCH METHODS

Searches were conducted on the Cochrane Airways Group Specialised Register of trials. Searches are current to 29 April 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that assessed intervention(s) designed to inform participants about CPAP/OSA, to support them in using CPAP, or to modify their behaviour to increase use of CPAP devices.

DATA COLLECTION AND ANALYSIS

We assessed studies to determine their suitability for inclusion in the review. Data were extracted independently and were entered into RevMan for analysis. 'Risk of bias' assessments were performed, using the updated 'Risk of bias 2' tool, for the primary outcome, CPAP usage. Study-level 'Risk of bias' assessments were performed using the original 'Risk of bias' tool. GRADE assessment was performed using GRADEpro.

MAIN RESULTS

Forty-one studies (9005 participants) are included in this review; 16 of these studies are newly identified with updated searches. Baseline Epworth Sleepiness Scale (ESS) scores indicate that most participants suffered from excessive daytime sleepiness. The majority of recruited participants had not used CPAP previously. When examining risk of bias for the primary outcome of hourly machine usage/night, 58.3% studies have high overall risk (24/41 studies), 39.0% have some concerns (16/41 studies), and 2.4% have low overall risk (1/41 studies). We are uncertain whether educational interventions improve device usage, as the certainty of evidence was assessed as very low. We were unable to perform meta-analyses for number of withdrawals and symptom scores due to high study heterogeneity. Supportive interventions probably increase device usage by 0.70 hours/night (95% confidence interval (CI) 0.36 to 1.05, N = 1426, 13 studies, moderate-certainty evidence), and low-certainty evidence indicates that the number of participants who used their devices ≥ 4 hours/night may increase from 601 to 717 per 1000 (odds ratio (OR), 1.68, 95% CI 1.08 to 2.60, N = 376, 2 studies). However, the number of withdrawals may also increase from 136 to 167 per 1000 (OR 1.27, 95% CI 0.97 to 1.66, N = 1702, 11 studies, low-certainty evidence). Participants may experience small improvements in symptoms (ESS score -0.32 points, 95% CI -1.19 to 0.56, N = 470, 5 studies, low-certainty evidence), and we are uncertain whether quality of life improves with supportive interventions, as the certainty of evidence was assessed as very low. When compared with usual care, behavioural interventions produce a clinically-meaningful increase in device usage by 1.31 hours/night (95% CI 0.95 to 1.66, N = 578, 8 studies, high-certainty evidence), probably increase the number of participants who used their machines ≥ 4 hours/night from 371 to 501 per 1000 (OR 1.70, 95% CI 1.20 to 2.41, N = 549, 6 studies, high-certainty evidence), and reduce the number of study withdrawals from 146 to 101 per 1000 (OR 0.66, 95% CI 0.44 to 0.98, N = 939, 10 studies, high-certainty evidence). Behavioural interventions may reduce symptoms (ESS score -2.42 points, 95% CI -4.27 to -0.57, N = 272, 5 studies, low-certainty evidence), but probably have no effect on quality of life (Functional Outcomes of Sleep Questionnaire (FOSQ), standardised mean difference (SMD) 0.00, 0.95% CI -0.26 to 0.26, N = 228, 3 studies, moderate-certainty evidence). We are uncertain whether behavioural interventions improve apnoea hypopnoea index (AHI), as the certainty of evidence was assessed as very low. We are uncertain if mixed interventions improve device usage, increase the number of participants using their machines ≥ 4 hours/night, reduce study withdrawals, improve quality of life, or reduce anxiety symptoms, as the certainty of evidence for these outcomes was assessed to be very low. Symptom scores via the ESS could not be measured due to considerable heterogeneity between studies.

AUTHORS' CONCLUSIONS

In CPAP-naïve people with OSA, high-certainty evidence indicates that behavioural interventions yield a clinically-significant increase in hourly device usage when compared with usual care. Moderate certainty evidence shows that supportive interventions increase usage modestly. Very low-certainty evidence shows that educational and mixed interventions may modestly increase CPAP usage. The impact of improved CPAP usage on daytime sleepiness, quality of life, and mood and anxiety scores remains unclear since these outcomes were not assessed in the majority of included studies. Studies addressing the choice of interventions that best match individual patient needs and therefore result in the most successful and cost-effective therapy are needed.

A Wearable RF Sensor for Monitoring Respiratory Patterns

We present a non-invasive approach for continuous monitoring of respiration dynamics using a wearable radio-frequency (RF) sensor based on near-field coherent sensing. A continuous-wave RF signal at 1.8 GHz is generated by a software-defined radio, with both transmitter (Tx) and receiver (Rx) antennas placed close to the xiphoid process. The experimental prototype of the mobile sensor can modulate the internal organ motion in the near-field region of the Tx antenna and is then received by the nearby Rx antenna to be demodulated and sampled. Through peak detection, we have identified inhalation and exhalation peaks of each breath cycle to estimate the breath rate and the lung volume. The extracted respiratory parameters are compared with the conventional chest belts data for various simulated respiratory conditions including voluntary deep, fast-shallow and slow-shallow breathing. We also characterized simulated central sleep apneas, Cheyne-Stokes, Biot's, ataxic and coughing conditions. To accurately identify obstructive apnea, we presented a two-sensor approach that can capture paradoxical movement of thorax and abdomen. The on-line recognition of these respiratory patterns can be employed not only to continuously monitor patients with chronic respiratory disorders but also to provide real-time feedback for future therapeutic purposes.

Treatment with CPAP in Elderly Patients with Obstructive Sleep Apnoea

The population pyramid is changing as a result of the ever-increasing life expectancy, which makes it crucial to acquire an in-depth understanding of the diseases that most often affect the elderly. Obstructive sleep apnoea (OSA) affects 15%-20% of the population aged over 65 years. Despite this prevalence, there have been very few specific studies on the management of OSA in this age group, even though over 60% of the patients aged over 65-70 years who attend sleep units with suspicion of OSA receive treatment with continuous positive airway pressure (CPAP), on the basis of an extrapolation of the positive results achieved by CPAP in clinical trials involving middle-aged males. However, the latter's form of presentation, evolution and, probably, prognosis comparing with OSA are not the same as those of elderly patients. Recent clinical trials performed on an exclusive series of elderly patients have shed light on the possible role of CPAP treatment in elderly patients with OSA, but there are still many questions that need to be answered. The physiological increase in the number of sleep-related disorders with the passing of years, and the lack of validated diagnostic and therapeutic tools for this age group are probably the greatest obstacles to define, diagnose and treat OSA in the elderly.

Sleep for Stroke Management and Recovery Trial (Sleep SMART): Rationale and methods

RATIONALE

Obstructive sleep apnea is common among patients with acute ischemic stroke and is associated with reduced functional recovery and an increased risk for recurrent vascular events.

AIMS AND/OR HYPOTHESIS

The Sleep for Stroke Management and Recovery Trial (Sleep SMART) aims to determine whether automatically adjusting continuous positive airway pressure (aCPAP) treatment for obstructive sleep apnea improves clinical outcomes after acute ischemic stroke or high-risk transient ischemic attack.

SAMPLE SIZE ESTIMATE

A total of 3062 randomized subjects for the prevention of recurrent serious vascular events, and among these, 1362 stroke survivors for the recovery outcome.

METHODS AND DESIGN

Sleep SMART is a phase III, multicenter, prospective randomized, open, blinded outcome event assessed controlled trial. Adults with recent acute ischemic stroke/transient ischemic attack and no contraindication to aCPAP are screened for obstructive sleep apnea with a portable sleep apnea test. Subjects with confirmed obstructive sleep apnea but without predominant central sleep apnea proceed to a run-in night of aCPAP. Subjects with use (≥4 h) of aCPAP and without development of significant central apneas are randomized to aCPAP plus usual care or care-as-usual for six months. Telemedicine is used to monitor and facilitate aCPAP adherence remotely.

STUDY OUTCOMES

Two separate primary outcomes: (1) the composite of recurrent acute ischemic stroke, acute coronary syndrome, and all-cause mortality (prevention) and (2) the modified Rankin scale scores (recovery) at six- and three-month post-randomization, respectively.

DISCUSSION

Sleep SMART represents the first large trial to test whether aCPAP for obstructive sleep apnea after stroke/transient ischemic attack reduces recurrent vascular events or death, and improves functional recovery.

Long-term Effect of CPAP Treatment on Cardiovascular Events in Patients With Resistant Hypertension and Sleep Apnea. Data From the HIPARCO-2 Study

BACKGROUND

There is some controversy about the effect of continuous positive airway pressure (CPAP) on the incidence of cardiovascular events (CVE). However, the incidence of CVE among patients with both obstructive sleep apnea (OSA) ans resistant hypertension (HR) has not been evaluated. Our objective was to analyze the long-term effect of CPAP treatment in patients with RH and OSA on the incidence of CVE.

METHODS

Multi-center, observational and prospective study of patients with moderate-severe OSA and RH. All the patients were followed up every 3-6 months and the CVE incidence was measured. Patients adherent to CPAP (at least 4h/day) were compared with those with not adherent or those who had not been prescribed CPAP.

RESULTS

Valid data were obtained from 163 patients with 64 CVE incidents. Treatment with CPAP was offered to 82%. After 58 months of follow-up, 58.3% of patients were adherent to CPAP. Patients not adherent to CPAP presented a non-significant increase in the total CVE incidence (HR:1.6; 95%CI: 0.96-2.7; p=0.07). A sensitivity analysis showed that patients not adherent to CPAP had a significant increase in the incidence of cerebrovascular events (HR: 3.1; CI95%: 1.07-15.1; p=0.041) and hypertensive crises (HR: 5.1; CI95%: 2.2-11.6; p=0.006), but the trend went in the opposite direction with respect to coronary events (HR: 0.22; CI95%: 0.05-1.02; p=0.053).

CONCLUSIONS

In patients with RH and moderate-severe OSA, an uneffective treatment with CPAP showed a trend toward an increase in the incidence of CVE (particularly neurovascular events and hypertensive crises) without any changes with respect to coronary events.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Preoperative Predictors of Response to Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea

Objective

Hypoglossal nerve stimulation (HGNS) is an effective treatment for patients with obstructive sleep apnea (OSA) who fail continuous positive airway pressure (CPAP). We assessed the relationship between patient characteristics and response to HGNS.

Study Design

Retrospective cohort study.

Setting

Single tertiary care institution.

Subjects and Methods

This study included CPAP-intolerant patients with moderate to severe OSA after HGNS system implantation from November 2015 to December 2017. Patient measures, drug-induced sleep endoscopy (DISE) findings, and apnea-hypopnea indices (AHIs) were recorded.

Results

Forty-eight patients underwent implantation with the following median measures: age, 66 years; body mass index, 28.6; and neck circumference, 41.0 cm. Patients were classified by Friedman tongue position (II, 27%; III, 56%; IV, 17%) and Mallampati grade (I, 25%; II, 50%; III, 23%; IV, 2%). By DISE, 71% had anterior-posterior palatal collapse. Additionally, 38% had lateral oropharynx collapse; 50%, tongue base collapse; and 27%, epiglottis collapse. Following implantation, median AHI improved from 38.5 to 2.7 ( P < .001), and 92% of patients had no worse than mild OSA (8% moderate). Patients with Friedman tongue position grade II/III experienced greater change in AHI as compared with grade IV (94.2% vs 73.8%, P < .001). Patients with Mallampati score I/II experienced greater improvement versus score III/IV (94.7% vs 66.5%, P < .001). No DISE findings, including any obstruction or collapse, were associated with change in AHI.

Conclusion

This study further confirms HGNS as an effective treatment of CPAP-intolerant OSA. Office measures such as Friedman tongue position IV and Mallampati III/IV were associated with mildly decreased response. DISE findings were not associated with patient response.

Obstructive sleep apnea and cardiovascular disease, a story of confounders!

Obstructive sleep apnea (OSA) syndrome is increasingly common among middle aged and older adults and is frequently linked to most cardiovascular diseases (CVD). Sleep-disordered breathing and CVD share a number of common risk factors and comorbid conditions including obesity, male gender, advancing age, metabolic syndrome, and hypertension. OSA appears to be associated with worsened CVD outcomes, sleep-related symptoms, quality of life, and risk of motor vehicle accidents. Demonstrating a cause-and-effect relationship between CVD and OSA has been challenging due to shared comorbidities. Strong evidence demonstrating clinically significant benefit for OSA treatments on OSA-related CVD outcomes are limited. In this review, we evaluate potential pathophysiologic mechanisms that link OSA to CVD and focus on specific treatments for OSA, including positive airway pressure (PAP), dental devices, and surgeries with regard to OSA-related CVD outcomes.

The Relationship Between Obstructive Sleep Apnea and Ruptured Intracranial Aneurysms

STUDY OBJECTIVES

The role of obstructive sleep apnea (OSA) in the overall outcome of ruptured intracranial aneurysms (RIAs) is unknown. We have investigated the role of OSA in overall outcome of RIAs.

METHODS

Data from 159 consecutive patients were retrospectively reviewed. A chi-square test and regression analysis were performed to determine the significant difference. A value of P < .05 was considered significant.

RESULTS

The prevalence of OSA in RIAs was fivefold higher in the nonaneurysm patient group, P = .002. The number of patients with hypertension (P < .0001), body mass index ≥ 30 (P < .0001), hyperlipidemia (P = .018), chronic heart disease (P = .002) or prior ischemic stroke (P = .001) was significantly higher in the OSA group. Similarly, the number of wide-neck aneurysms (P < .0001) and aneurysm > 7 mm (P = .004), poor Hunt and Hess grade IV-V (P = .005), vasospasms, (P = .03), and patients with poor Modified Rankin Scale scores (3-6) was significantly higher in the OSA group (P < .0001). Interestingly, for the first time in univariate (P = .01) and multivariate (P = .003) regression analysis, OSA was identified as an individual predictor of unfavorable outcome of RIAs. In addition, hypertension (P = .04), smoking (P = .049), chronic heart disease (P = .01), and Hunt and Hess grade IV-V (P = .04) were revealed as predictors of poor outcome of RIAs.

CONCLUSIONS

This is a novel study to determine the association between OSA and ruptured cerebral aneurysm in terms of comorbidities, size of aneurysm, severity of symptoms, and outcomes after treatment. In addition, for the first time, OSA is identified as a positive predictor of unfavorable outcome of RIAs.

Sleep-disordered breathing is associated with brain vascular reactivity in spinal cord injury

OBJECTIVE

To determine the population-level odds of individuals with spinal cord injury (SCI) experiencing fatigue and sleep apnea, to elucidate relationships with level and severity of injury, and to examine associations with abnormal cerebrovascular responsiveness.

METHODS

We used population-level data, meta-analyses, and primary physiologic assessments to provide a large-scale integrated assessment of sleep-related complications after SCI. Population-level and meta-analyses included more than 60,000 able-bodied individuals and more than 1,800 individuals with SCI. Physiologic assessments were completed on a homogenous sample of individuals with cervical SCI and matched controls. We examined the prevalence of (1) self-reported chronic fatigue, (2) clinically identified sleep apnea, and 3) cerebrovascular responsiveness to changing CO₂.

RESULTS

Logistic regression revealed a 7-fold elevated odds of chronic fatigue after SCI (odds ratio [OR] 7.9, 95% confidence interval [CI] 3.5-16.2), and that fatigue and trouble sleeping are correlated with the level and severity of injury. We further show that those with SCI experience elevated risk of clinically defined sleep-disordered breathing in more than 600 individuals with SCI (pooled OR 3.1, 95% CI 1.3-7.5). We confirmed that individuals with SCI experience a high rate of clinically defined sleep apnea using primary polysomnography assessments. We then provide evidence using syndromic analysis that sleep-disordered breathing is a factor strongly associated with impaired cerebrovascular responsiveness to CO₂ in patients with SCI.

CONCLUSIONS

Individuals with SCI have an increased prevalence of sleep-disordered breathing, which may partially underpin their increased risk of stroke. There is thus a need to integrate sleep-related breathing examinations into routine care for individuals with SCI.