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Harańczyk M, Konieczyńska M, Płazak W. Endothelial dysfunction in obstructive sleep apnea patients. Sleep Breath 2021. [PMID: 33961199 DOI: 10.1007/s11325-021-02382-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 03/05/2021] [Accepted: 04/15/2021] [Indexed: 11/10/2022]
Abstract
Purpose Obstructive sleep apnea syndrome (OSAS) is an independent risk factor for cardiovascular diseases. The aim of the study was to assess the influence of OSAS on endothelial dysfunction and thrombosis biomarkers and to evaluate the effect of treatment with continuous positive airway pressure (CPAP) on biomarker levels. Methods NT-proBNP, sICAM-1, endothelin-1, von Willebrand factor, D-dimers, and thrombin-antithrombin complex (TAT) were measured in 50 patients diagnosed with moderate-to-severe OSAS. All patients underwent transthoracic echocardiography, and 38 months after the inclusion, 16 CPAP users and 22 non-CPAP users were reassessed. Results Sleep-related indices of apnea-hypopnea index (AHI) and mean SpO2 were associated with higher sICAM-1 levels (AHI < 30: 7.3 ± 4.7 vs. AHI ≥ 30: 19.5 ± 19.4 mg/ml, p = 0.04; SpO2 ≥ 90%: 11.9 ± 9.3 vs. SpO2 < 90%: 23.6 ± 25.8, p = 0.04). sICAM-1 levels were significantly higher in obese patients, particularly with BMI ≥ 40. Plasma levels of TAT were significantly correlated with the increased right ventricular size (right ventricular diameter ≤ 37 mm: 0.86 ± 0.70 vs. > 37 mm: 1.96 ± 1.20 ng/ml, p = 0.04). Endothelin-1 levels were higher in patients with decreased right ventricular function (right ventricle TDI-derived S′ ≥ 12 cm/s: 11.5 ± 10.9 vs. < 12 cm/s: 26.0 ± 13.2 pg/ml, p = 0.04). An increase in NT-proBNP was related to impaired parameters of the right ventricular contractile function. There were no correlations between long-term CPAP therapy and the levels of biomarkers. Conclusion Severe OSAS influences endothelial damage as manifested by an increase in sICAM-1 levels. Changes in right ventricular structure and function, observed mainly in patients with higher TAT and endothelin-1 levels, are also manifested by an increase in NT-proBNP levels. Long-term CPAP treatment does not seem to influence biomarkers in patients with moderate-to-severe OSAS, which may help to explain the lack of influence of CPAP on cardiovascular risk reduction.
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Fernández-Bello I, Monzón Manzano E, García Río F, Justo Sanz R, Cubillos-Zapata C, Casitas R, Sánchez B, Jaureguizar A, Acuña P, Alonso-Fernández A, Álvarez Román MT, Jiménez Yuste V, Butta NV. Procoagulant State of Sleep Apnea Depends on Systemic Inflammation and Endothelial Damage. Arch Bronconeumol 2020; 58:117-124. [PMID: 33461785 DOI: 10.1016/j.arbres.2020.11.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/08/2020] [Accepted: 11/25/2020] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Growing evidence shows a hypercoagulable state in obstructive sleep apnea (OSA) that could be a risk factor for thromboembolic disease. OBJECTIVES We aimed to elucidate mechanisms involved in the procoagulant profile observed in patients with OSA and to investigate the potential utility of global tests in its characterization. METHODS Thirty-eight patients with severe OSA without previous history of thrombosis and nineteen healthy age- and sex-matched controls were included. Kinetic of clot formation was determined using rotational thromboelastometry. Haemostatic capacity of plasma and microparticles was determined by Calibrated Automated Thrombinography. Platelet surface receptors, activation markers and formation of platelet/leukocytes aggregates were analyzed by flow cytometry. RESULTS Thromboelastometry showed a procoagulant state in patients with OSA that did not seem to be related to a basal activation of platelets but by the increased existence of platelet/leukocyte aggregates. Patients with OSA presented many signs of endothelial damage such as increased plasma levels of E-selectin and cfDNA and enhanced thrombin generation due to the presence of microparticles rich in tissue-factor, which is related to OSA severity. CONCLUSIONS OSA induces an enhancement in the dynamics of clot formation which appears to be caused by at least two pathological mechanisms. First, a greater formation of platelet-leukocyte aggregates; secondly, endothelial damage which provokes a greater procoagulant potential due to the increase in tissue factor-rich microparticles. Moreover, this study has identified thromboelastometry and thrombin generation assay as useful tools to evaluate the prothrombotic state in these patients.
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Affiliation(s)
- Ihosvany Fernández-Bello
- Hematology Unit, Hospital Universitario La Paz-IdiPAZ, Paseo de la Castellana 261, Madrid 28046, Spain
| | - Elena Monzón Manzano
- Hematology Unit, Hospital Universitario La Paz-IdiPAZ, Paseo de la Castellana 261, Madrid 28046, Spain
| | - Francisco García Río
- Respiratory Diseases Research Group, Servicio de Neumología, Hospital Universitario La Paz-IdiPAZ, Madrid, Spain; Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Madrid, Spain; Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, Spain
| | - Raul Justo Sanz
- Hematology Unit, Hospital Universitario La Paz-IdiPAZ, Paseo de la Castellana 261, Madrid 28046, Spain
| | - Carolina Cubillos-Zapata
- Respiratory Diseases Research Group, Servicio de Neumología, Hospital Universitario La Paz-IdiPAZ, Madrid, Spain; Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Raquel Casitas
- Respiratory Diseases Research Group, Servicio de Neumología, Hospital Universitario La Paz-IdiPAZ, Madrid, Spain; Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Begoña Sánchez
- Respiratory Diseases Research Group, Servicio de Neumología, Hospital Universitario La Paz-IdiPAZ, Madrid, Spain
| | - Ana Jaureguizar
- Respiratory Diseases Research Group, Servicio de Neumología, Hospital Universitario La Paz-IdiPAZ, Madrid, Spain
| | - Paula Acuña
- Hematology Unit, Hospital Universitario La Paz-IdiPAZ, Paseo de la Castellana 261, Madrid 28046, Spain
| | - Alberto Alonso-Fernández
- Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Madrid, Spain; Servicio de Neumología, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | | | - Víctor Jiménez Yuste
- Hematology Unit, Hospital Universitario La Paz-IdiPAZ, Paseo de la Castellana 261, Madrid 28046, Spain; Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, Spain
| | - Nora V Butta
- Hematology Unit, Hospital Universitario La Paz-IdiPAZ, Paseo de la Castellana 261, Madrid 28046, Spain.
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Vizzardi E, Sciatti E, Bonadei I, D'Aloia A, Curnis A, Metra M. Obstructive sleep apnoea-hypopnoea and arrhythmias: new updates. J Cardiovasc Med (Hagerstown) 2018; 18:490-500. [PMID: 25000252 DOI: 10.2459/jcm.0000000000000043] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AIMS Obstructive sleep apnoea-hypopnoea (OSAH) is a prevalent condition characterized by repetitive pharyngeal collapse during sleep, leading to hypoxemia, hypercapnia, and persistent inspiratory efforts against an occluded airway until arousal. Several studies demonstrated that OSAH exerts acute and chronic effects on the cardiovascular system. Thus, although being a respiratory problem, the most important consequences of OSAH are cardiovascular, among which there are arrhythmias. The purpose of this review is to systematically analyse what has been recently published about the relationship between OSAH and every cardiac arrhythmia separately. METHODS We searched Pubmed, Scopus, Web of Science and Cochrane Collaboration databases for 'OSAHS arrhythmias', 'OSAH arrhythmias' and 'OSA arrhythmias'. We analyse 1298 articles and meta-analyses, excluding already edited reviews. RESULTS Arrhythmias, especially of ventricular origin, are frequent in OSAH. Ventricular premature beats, couplets and ventricular tachycardia runs are even more frequent in patients suffering from heart failure. They may be due to left heart remodelling, overwork and ischaemia and can explain at least some sudden deaths occurring between midnight and 6 a.m. Sinus pauses and atrioventricular blocks are increased according to the severity of the disturbance and may be reduced by continuous positive airway pressure therapy, preventing pace-maker implantation. Finally, atrial fibrillation, resistance against antiarrhythmic drugs and recurrences after surgical procedures are strongly related to OSAH. CONCLUSION Arrhythmias are frequent in OSAH. Treatment of OSAH may reduce some of them. An implantable cardioverter-defibrillator and continuous positive airway pressure should be considered in some patients.
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Affiliation(s)
- Enrico Vizzardi
- Section of Cardiovascular Diseases, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Study of Brescia, Brescia, Italy
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Barón A, Paez-Moya S. Repercusiones cardiovasculares del síndrome de apnea-hipopnea obstructiva del sueño (SAHOS). Rev Fac Med 2017. [DOI: 10.15446/revfacmed.v65n1sup.59666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
En la población de sujetos con síndrome de apnea-hipopnea obstructiva del sueño se describen entidades clínicas cardiovasculares asociadas con esta entidad y que afectan su curso y pronóstico. Dentro de estas se encuentran hipertensión arterial, arritmias, enfermedad coronaria, insuficiencia cardíaca, hipertensión pulmonar y tromboembolismo venoso. Del mismo modo, se describen los mecanismos fisiopatológicos de estas asociaciones, su prevalencia e impacto. Dado que afectan el curso de la enfermedad y, por tanto, la severidad de la misma, estas entidades juegan un papel muy importante en la toma de decisiones al momento de ofrecer el mejor manejo en cada caso, el cual debe ser abordado de forma multidisciplinaria.
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Abstract
BACKGROUND The current literature suggests a relationship between obstructive sleep apnea (OSA) severity and hematocrit. However, the degree that OSA contributes to clinically significant erythrocytosis is uncertain. The aim of this study is to evaluate this association in a large study sample controlling for multiple confounders. METHODS We evaluated consecutive subjects with suspected untreated OSA using multivariate analysis to test the associations between apnea-hypopnea index (AHI) and hematocrit. Subjects were evaluated with sleep studies, comprehensive sleep questionnaires, and detailed electronic medical record reviews to document their medical comorbidities, and demographic and laboratory information. RESULTS 1604 consecutive veterans (age 57.6 ± 13.4 years, 92% male) were included in the analysis with 77.4% diagnosed with OSA. However, few included subjects (1.6%) had clinical erythrocytosis. OSA severity defined by AHI was not associated with hematocrit or clinically significant erythrocytosis. Rather, awake oxygen saturation (-0.17 points, p < 0.001) and mean nocturnal oxygen saturation (-0.08 points, p = 0.04) were inversely proportional to hematocrit (per standardized Z-score). Other factors including active tobacco, increased alcohol ingestion and exogenous testosterone therapy were associated with higher hematocrit. Although AHI was not predictive of erythrocytosis, having severe OSA was predictive of nocturnal hypoxemia (adjusted OR 7.4, p < 0.001). CONCLUSIONS Hematocrit levels and presence of erythrocytosis appear not associated with OSA severity, but rather with hypoxemia as measured by awake and to a lesser extent mean nocturnal oxygen saturation. Nocturnal oximetry may provide diagnostic utility in the evaluation of unexplained secondary polycythemia and polysomongraphy may be warranted in those with unexplained nocturnal hypoxemia and erythrocytosis.
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Affiliation(s)
- Christopher D Nguyen
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University, Palo Alto, CA, USA; Stanford Sleep Medicine Center, Department of Psychiatry, Stanford University, Palo Alto, CA, USA
| | - Jon-Erik C Holty
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University, Palo Alto, CA, USA; Pulmonary, Critical Care and Sleep Medicine Section, VA Palo Alto Health Care System, Palo Alto, CA, USA; Center for Health Policy (CHP/PCOR), Stanford University, Palo Alto, CA, USA.
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Jóźwik-plebanek K, Prejbisz A, Wypasek E, Pręgowska-chwała B, Hanus K, Kaszuba AM, Januszewicz M, Bieleń P, Kabat M, Kruk M, Dobrowolski P, Klisiewicz A, Śliwiński P, Januszewicz A, Undas A. Altered plasma fibrin clot properties in hypertensive patients with obstructive sleep apnoea are improved by continuous positive airway pressure treatment. J Hypertens 2017; 35:1035-43. [DOI: 10.1097/hjh.0000000000001269] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Doumas M, Stavropoulos K, Imprialos K. Obstructive sleep apnea, hypertension, and fibrin clot properties. J Hypertens 2017; 35:950-952. [DOI: 10.1097/hjh.0000000000001316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Alkhiary W, Morsy NE, Yousef AM, El-Saddik AM, Arram EO. Adenosine Diphosphate-Induced Platelets Aggregability in Polysomnographically Verified Obstructive Sleep Apnea. Clin Appl Thromb Hemost 2015; 23:360-366. [PMID: 26276686 DOI: 10.1177/1076029615600790] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Obstructive sleep apnea syndrome (OSAS) is a risk factor for arterial thrombosis and cardiovascular morbidity. Activated platelets play key roles in the development of atherothrombosis, thus may be involved in these complications of OSAS. Herein, we evaluated the relationship between severity of OSAS and the degree of platelet aggregates as a marker of activated platelets in 64 patients with OSAS. Platelet aggregations were determined by means of optical aggregometry, using adenosine diphosphate (ADP) as an agonist. Compared with the control group, ADP-induced platelet aggregability was increased in patients with total OSAS, severe OSAS, and in mild to moderate OSAS. Moreover, ADP-induced platelet aggregation was correlated with the Epworth sleepiness scale (ESS) in patients with severe OSAS. Obstructive sleep apnea syndrome is associated with enhanced platelets aggregations, which may predispose the cardiovascular sequels. The ESS may be important in predicting platelet activation and thus atherothrombotic complications in those with OSAS.
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Affiliation(s)
- Wael Alkhiary
- 1 Department of Clinical Pathology, Mansoura Faculty of Medicine, Mansoura University, Egypt
| | - Nesreen E Morsy
- 2 Department of Chest Medicine, Mansoura Faculty of Medicine, Mansoura University, Egypt
| | - Aida M Yousef
- 2 Department of Chest Medicine, Mansoura Faculty of Medicine, Mansoura University, Egypt
| | - Amr Mohamed El-Saddik
- 1 Department of Clinical Pathology, Mansoura Faculty of Medicine, Mansoura University, Egypt
| | - Eman O Arram
- 2 Department of Chest Medicine, Mansoura Faculty of Medicine, Mansoura University, Egypt
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Hoareau G, Mellema M. Pro-coagulant thromboelastographic features in the bulldog. J Small Anim Pract 2014; 56:103-7. [DOI: 10.1111/jsap.12299] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 05/09/2014] [Accepted: 09/25/2014] [Indexed: 11/27/2022]
Affiliation(s)
- G. Hoareau
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine; University of California Davis; Davis CA 95616-8747 USA
| | - M. Mellema
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine; University of California Davis; Davis CA 95616-8747 USA
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Tosur Z, Green D, De Chavez PJ, Knutson KL, Goldberger JJ, Zee P, Liu K, Kim KY, Carnethon MR. The association between sleep characteristics and prothrombotic markers in a population-based sample: Chicago Area Sleep Study. Sleep Med 2014; 15:973-8. [PMID: 24924657 DOI: 10.1016/j.sleep.2014.04.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Revised: 03/21/2014] [Accepted: 04/14/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIM Short sleep duration and poor quality sleep are associated with coronary heart disease (CHD) mortality; however, the underlying pathophysiologic process remains unclear. Sleep apnea may confound the association because of its relationship with formation of thrombi, the vascular occlusive process in CHD. We tested whether sleep duration and quality were associated with prothrombotic biomarkers in adults with a low probability of apnea. METHODS We included adults aged 35-64 years recruited from the community and who had an apnea hypopnea index <15 after one night of screening (n=506). Sleep duration and maintenance were determined from 7 days of wrist actigraphy; daytime sleepiness was estimated using the Epworth Sleepiness Scale. Factor VIII (FVIII), von Willebrand factor (vWF), thrombin antithrombin (TAT) complexes, and plasminogen activator inhibitor-1 (PAI-1) were measured in fasting blood. RESULTS Sleep duration, maintenance, and daytime sleepiness were not associated with FVIII, vWf, or TAT. Sleep maintenance was modestly inversely associated with higher levels of log-transformed PAI-1 (β = -0.07, standard error (SE)=0.03 per 4.8%, p=0.04) following adjustment for demographic characteristics, cardiovascular risk factors, and body mass index (BMI). CONCLUSIONS Mild impairment in sleep was modestly associated with activation of coagulation; further study is needed to evaluate the role of fibrinolytic factors in sleep-mediated coronary thrombosis.
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Affiliation(s)
- Zehra Tosur
- Division of Hematology/Oncology, Department of Medicine, Chicago, IL, USA
| | - David Green
- Division of Hematology/Oncology, Department of Medicine, Chicago, IL, USA
| | - Peter John De Chavez
- Department of Preventive Medicine, Feinberg School of Medicine of Northwestern University, Chicago, IL, USA
| | | | - Jeffrey J Goldberger
- Department of Preventive Medicine, Feinberg School of Medicine of Northwestern University, Chicago, IL, USA
| | - Phyllis Zee
- Department of Preventive Medicine, Feinberg School of Medicine of Northwestern University, Chicago, IL, USA
| | - Kiang Liu
- Department of Preventive Medicine, Feinberg School of Medicine of Northwestern University, Chicago, IL, USA
| | - Kwang-Youn Kim
- Department of Preventive Medicine, Feinberg School of Medicine of Northwestern University, Chicago, IL, USA
| | - Mercedes R Carnethon
- Department of Preventive Medicine, Feinberg School of Medicine of Northwestern University, Chicago, IL, USA.
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Shamsuzzaman A, Amin RS, Calvin AD, Davison D, Somers VK. Severity of obstructive sleep apnea is associated with elevated plasma fibrinogen in otherwise healthy patients. Sleep Breath 2014; 18:761-6. [PMID: 24510497 DOI: 10.1007/s11325-014-0938-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 12/09/2013] [Accepted: 01/09/2014] [Indexed: 02/07/2023]
Abstract
PURPOSE Obstructive sleep apnea (OSA) has been implicated in both cardiovascular and cerebrovascular diseases. Systemic inflammation and coagulation may be related to cardiovascular pathophysiology in patients with OSA. Fibrinogen is a major coagulation protein associated with inflammation, and long-term elevated plasma fibrinogen is associated with an increased risk of major cardiovascular diseases. We assessed whether severity of OSA is associated with levels of fibrinogen in newly diagnosed, untreated, and otherwise healthy OSA patients. METHODS We studied 36 men with OSA and 18 male control subjects (apnea-hypopnea index [AHI]<5 events/h). OSA patients were divided into mild (AHI≥5<15 events/h) and severe (AHI≥15 events/h) OSA groups. Morning fibrinogen levels in OSA patients were compared to those in control subjects of similar age, body mass index, blood pressure, smoking habits, and alcohol consumption. RESULTS Fibrinogen levels were significantly elevated in patients with severe OSA compared to both control (P=0.003) and mild OSA (P=0.02) subjects after adjustment for covariates. However, there were no significant differences in fibrinogen levels between mild OSA and control subjects. Fibrinogen levels were directly related to AHI and arousal index and inversely related to mean and lowest oxygen saturation during sleep. CONCLUSIONS Severity of OSA was associated with increased fibrinogen level independent of other factors, suggesting that apneic events and oxygen desaturation during sleep are mechanisms for increased fibrinogen levels in patients with OSA.
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von Känel R, Natarajan L, Ancoli-Israel S, Mills PJ, Wolfson T, Gamst AC, Loredo JS, Dimsdale JE. Effect of continuous positive airway pressure on day/night rhythm of prothrombotic markers in obstructive sleep apnea. Sleep Med 2013; 14:58-65. [PMID: 23036264 PMCID: PMC3540139 DOI: 10.1016/j.sleep.2012.07.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 06/02/2012] [Accepted: 07/26/2012] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Obstructive sleep apnea (OSA) has been associated with an increased risk of atherothrombotic events. A prothrombotic state might partially explain this link. This study investigated OSA patients' day/night rhythm of several prothrombotic markers and their potential changes with therapeutic continuous positive airway pressure (CPAP). METHODS The study included 51 OSA patients [apnea hypopnea index (AHI) ⩾10] and 24 non-OSA controls (AHI<10). Of the 51 OSA patients, 25 were randomized to CPAP and 26 to placebo-CPAP. Twelve blood samples were collected over a 24h period to measure prothrombotic markers. For the apneic patients these samples were collected before treatment and after 3weeks of treatment with either CPAP or placebo-CPAP. Day/night variation in prothrombotic markers was examined using a cosinor analysis. RESULTS Compared with controls, OSA patients showed lower mesor (mean) and amplitude (difference between maximum and minimum activity) of D-dimer. In unadjusted (but not in adjusted) analysis, patients showed higher mesor of plasminogen activator inhibitor-1 (p<0.05 in all cases). No significant group differences were seen in mesor and amplitude for either soluble tissue factor or von Willebrand factor, or the acrophase (time of the peak) and periodic pattern for any prothrombotic markers. There were no significant differences in changes of periodic pattern and in day/night rhythm parameters of prothrombotic markers pre- to post-treatment between the CPAP and placebo condition. CONCLUSIONS There may be altered day/night rhythm of some prothrombotic markers in OSA patients compared with controls. CPAP treatment for 3weeks did not affect day/night rhythm of prothrombotic markers in OSA patients differently from placebo-CPAP.
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Affiliation(s)
- Roland von Känel
- Department of General Internal Medicine, Inselspital, Bern University Hospital, and University of Bern, Switzerland
- Department of Psychiatry, University of California, San Diego, USA
| | - Loki Natarajan
- Department of Family and Preventive Medicine, University of California, San Diego, USA
| | - Sonia Ancoli-Israel
- Department of Psychiatry, University of California, San Diego, USA
- Department of Medicine, University of California, San Diego, USA
| | - Paul J. Mills
- Department of Psychiatry, University of California, San Diego, USA
| | - Tanya Wolfson
- Computational and Applied Statistics Laboratory, San Diego, Supercomputer Center University of California, San Diego, USA
| | - Anthony C. Gamst
- Computational and Applied Statistics Laboratory, San Diego, Supercomputer Center University of California, San Diego, USA
| | - José S. Loredo
- Department of Medicine, University of California, San Diego, USA
| | - Joel E. Dimsdale
- Department of Psychiatry, University of California, San Diego, USA
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Abstract
BACKGROUND Obstructive sleep apnea (OSA) is a common disorder that affects both quality of life and cardiovascular health. The causal link between OSA and cardiovascular morbidity⁄mortality remains elusive. One possible explanation is that repeated episodes of nocturnal hypoxia lead to a hypercoagulable state that predisposes patients to thrombotic events. There is evidence supporting a wide array of hematological changes that affect hemostasis (eg, increased hematocrit, blood viscosity, platelet activation, clotting factors and decreased fibrinolytic activity). OBJECTIVE To provide a comprehensive review of the current evidence associating OSA with increased coagulability, and to highlight areas for future research. METHODS Keyword searches in Ovid Medline were used to identify relevant articles; all references in the articles were searched for relevant titles. The Web of Science was used to identify articles citing the relevant articles found using the Ovid Medline search. All original peer-reviewed articles, meta-analyses and systematic reviews regarding the pertinent topics between 1990 and present were selected for review. RESULTS Hematocrit, blood viscosity, certain clotting factors, tissue factor, platelet activity and whole blood coagulability are increased in patients with OSA, while fibrinolysis is impaired. CONCLUSION There is considerable evidence that OSA is associated with a procoagulant state. Several factors are involved in the procoagulant state associated with OSA. There is a need for adequately powered clinical studies involving well-matched control groups to address potential confounding variables, and to accurately delineate the individual factors involved in the procoagulant state associated with OSA and their response to treatment.
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Abstract
STUDY OBJECTIVES In order to provide a comprehensive estimate of the health risks for OSA patients, we analyzed multiple outcomes and independent predictors of these outcomes in an OSA population evaluated and followed at one sleep center. METHODS Cox proportional hazard regression analyses were used in an 8-year follow-up analysis of consecutive OSA patients (N = 1025) and non-apneic snorers (apnea-hypopnea index < 5, N = 494). RESULTS In our fully adjusted model, independent variables predictive of all-cause mortality, myocardial infarction, cerebral vascular accident, and pulmonary embolus were: older age, male gender, and history of cardiovascular diseases or procedures. In examining subgroups based on age and gender, severe OSA (AHI ≥ 30) was one of the independent predictors of mortality in males and in patients < 50 years old. Severe OSA interacted with maleness, age, and hypertension to predict mortality and myocardial infarction. CPAP use ≥ 4 h/night was associated with lower mortality rates in males and those ≥ 50 years old with severe OSA. CONCLUSIONS Mortality and cardiovascular event outcomes were predicted by demographics and cardiovascular disease history more commonly than by OSA severity. OSA severity was an important predictor of mortality in male and young OSA patients. CPAP use appeared protective in older and male severe OSA patients.
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Affiliation(s)
- David W Hudgel
- Sleep Disorders Centre, Section of Respirology, University of Manitoba, Winnipeg.
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Abstract
Obstructive sleep apnea (OSA) is associated with significant cardiovascular morbidity and excess in mortality. Atherosclerosis has been shown to occur in OSA patients free of any other significant risk factors. In particular, intima media thickness, an early marker of atherosclerosis, may be increased at the carotid level in OSA. Thus, early atherosclerosis could be one of the intermediary mechanisms supporting the link between OSA and cardiovascular morbidity. The current concept is that the development of atherosclerotic lesions results from a dynamic interplay between the native cells of the vasculature and different proinflammatory leukocytes issued from the general circulation. Immunoinflammatory cells dominate early atherosclerotic processes, with the secretion of several proinflammatory molecules aggravating lesion progression. There is now substantial evidence that intermittent hypoxia in rodents, as a partial model of sleep apnea, triggers atherogenesis. Blood pressure alterations and hemodynamic strains on the vascular wall, impairment in vascular reactivity, lipid metabolism dysregulation, and activation of proinflammatory transcription factors at the vascular wall level are among the key factors promoting atherosclerosis. Specifically, increases in leukocyte rolling and adhesion molecule expression at the endothelial cell level have been shown to occur in the first 2 weeks after intermittent hypoxia exposure initiation. Early changes at the vascular wall level have been shown in OSA patients and its reversibility under continuous positive airway pressure has also been suggested. Several biological markers potentially linked with early atherosclerosis development are under study in OSA patients. Further studies are needed to identify at-risk subjects prone to develop vascular changes because OSA treatment may either be initiated earlier or combined with specific drug treatments.
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Abstract
Untreated obstructive sleep apnea (OSA) is an independent risk factor for hypertension, myocardial infarction, and stroke. The repetitive hypoxia/reoxygenation and sleep fragmentation associated with OSA impair endothelial function. Endothelial dysfunction, in turn, may mediate increased risk for cardiovascular diseases. Specifically, in OSA, endothelial nitric oxide availability and repair capacity are reduced, whereas oxidative stress and inflammation are enhanced. Treatment of OSA improves endothelial vasomotor tone and reduces inflammation. We review the evidence and possible mechanisms of endothelial dysfunction as well as the effect of treatment on endothelial function in OSA.
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Affiliation(s)
- Amy Atkeson
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
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18
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Abstract
BACKGROUND Obstructive sleep apnea (OSA) is closely associated with atrial fibrillation, which is provoked by electrical and structural remodeling. However, the association between OSA and atrial remodeling has not been fully elucidated. METHODS AND RESULTS Atrial electromechanical activation time (EMAT) was investigated using tissue Doppler imaging (TDI) in men with severe OSA (n=24) and control subjects (n=24). The EMAT was determined as the time interval from the initiation of P-wave deflection until the peak of local lateral left atrial (LA) TDI signal. The early diastolic velocity of the mitral annulus (E(a)) and the EMAT were significantly lower and longer in OSA cases than in controls (E(a): 6.1+/-0.9 cm/s vs 7.3+/-1.5 cm/s, P=0.001; EMAT: 129.7+/-11.5 ms vs 118.5+/-12.3 ms, P=0.002). Among OSA cases, the apnea - hypopnea index (AHI) was significantly correlated with EMAT (r=0.660, P<0.001), E(a) (r=-0.609, P=0.002), LA dimension (r=0.486, P=0.016), and early diastolic velocity of mitral flow (E)/E(a) ratio (r=0.418, P=0.042). In multivariate stepwise linear regression analysis, EMAT was independently associated with AHI (P=0.025) and E(a) (P=0.028) in OSA cases. CONCLUSION EMAT measured by TDI could be a useful parameter for identifying atrial remodeling in patients with severe OSA.
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Affiliation(s)
- Hong Euy Lim
- Division of Cardiology, Cardiovascular Center, College of Natural Science, Kookmin University, Seoul, Korea
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19
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El Solh AA, Akinnusi ME, Berim IG, Peter AM, Paasch LL, Szarpa KR. Hemostatic implications of endothelial cell apoptosis in obstructive sleep apnea. Sleep Breath. 2008;12:331-337. [PMID: 18398629 DOI: 10.1007/s11325-008-0182-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2007] [Accepted: 02/25/2008] [Indexed: 01/01/2023]
Abstract
Patients with obstructive sleep apnea (OSA) are at increased risk of atherothrombosis independent of the Framingham risk factors. Studies on hemostasis factors in OSA are scarce and inconsistent. We sought to understand the variation in atherothrombotic propensity as a function of apoptotic circulating endothelial cells (CECs) in OSA by investigating the relationship between CEC apoptosis and plasma levels of hemostatic factors tissue factor (TF) and von Willebrand Factor (vWF) in apneic subjects. Apoptotic CECs were detected by flow cytometry in 35 male subjects free of cardiovascular diseases (AHI range 8-43) and 12 healthy male controls (AHI range 2-5) before and after 8 weeks of nasal continuous positive airway pressure (nCPAP). Quantitative determination of TF and vWF was performed using an enzyme-linked immunosorbent assay (ELISA) kit. The mean levels of TF (66.78 +/- 41.59 pg/ml) and vWF (189.70 +/- 69.24 IU/dl) were significantly higher in OSA patients compared with those in healthy subjects (42.83 +/- 14.18 pg/ml; and 124.48 +/- 31.43 IU/dl). Apoptotic CECs were elevated in patients with OSA and correlated strongly with TF and vWF levels (p = 0.02 and p < 0.001; respectively). There were no correlations between TF, vWF and apnea hypopnea index, or arousal index. Only the percentage of time spent <90% oxygen saturation was inversely associated with TF (r = 0.38; p = 0.02). Following nCPAP therapy, there was significant decrease in TF levels that correlated with decrease in apoptotic CECs. In patients with OSA, increased prothrombotic factors are strongly determined by apoptotic CECs. Treatment with nCPAP may alleviate the coagulation propensity.
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Ozkan Y, Fırat H, Şimşek B, Torun M, Yardim-Akaydin S. Circulating nitric oxide (NO), asymmetric dimethylarginine (ADMA), homocysteine, and oxidative status in obstructive sleep apnea–hypopnea syndrome (OSAHS). Sleep Breath 2007; 12:149-54. [DOI: 10.1007/s11325-007-0148-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Krishnan V, Collop NA. Sleep and Pulmonary Hypertension. Sleep Med Clin 2007. [DOI: 10.1016/j.jsmc.2006.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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22
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Abstract
Obstructive sleep apnea (OSA) is a common medical condition that occurs in a considerable percentage of the population. Substantial evidence shows that patients with OSA have an increased incidence of hypertension compared with individuals without OSA, and that OSA is a risk factor for the development of hypertension. It is established that OSA may be implicated in stroke and transient ischemic attacks. OSA is associated with coronary heart disease, heart failure, and cardiac arrhythmias. Pulmonary hypertension may be associated with OSA, especially in patients with pre-existing pulmonary disease. Although the exact cause that links OSA with cardiovascular disease is unknown, there is evidence that OSA is associated with a group of proinflammatory and prothrombotic factors that have been identified as important in the development of atherosclerosis. OSA is associated with increased daytime and nocturnal sympathetic activity. Autonomic abnormalities seen in patients with OSA include increased resting heart rate, decreased R-R interval variability, and increased blood pressure variability. Both atherosclerosis and OSA are associated with endothelial dysfunction, increased C-reactive protein, interleukin 6, fibrinogen, plasminogen activator inhibitor, and reduced fibrinolytic activity. OSA has been associated with enhanced platelet activity and aggregation. Leukocyte adhesion and accumulation on endothelial cells are common in both OSA and atherosclerosis. Clinicians should be aware that OSA may be a risk factor for the development of cardiovascular disease.
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Affiliation(s)
- E Kasasbeh
- Division of Allergy and Immunology, Department of Internal Medicine, Quillen College of Medicine, East Tennessee State University, Johnson City, TN 37614, USA
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Steiner S, Jax T, Evers S, Hennersdorf M, Schwalen A, Strauer BE. Altered Blood Rheology in Obstructive Sleep Apnea as a Mediator of Cardiovascular Risk. Cardiology 2005; 104:92-6. [PMID: 16015032 DOI: 10.1159/000086729] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2004] [Accepted: 11/22/2004] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cardiovascular complications are common in patients with obstructive sleep apnea (OSA). Blood rheology is a major determent of coagulation and an established risk factor for cardiovascular events. Since nocturnal hypoxemia could influence parameters of blood rheology, we hypothesized that OSA alters blood rheology independent of other cardiovascular risk factors. METHODS One hundred and ten consecutive patients admitted to the sleep laboratory were included. The association of plasma fibrinogen and viscosity (as parameters of blood rheology) with OSA was evaluated. RESULTS One hundred and ten patients aged 61.4+/-10.1 years (body mass index 28.4+/-4.1 kg/m2) were included. OSA was confirmed in 63 patients (57.2%) with an apnea-hypopnea index (AHI) of 28.7+/-14.9 events/hour. Patients with OSA showed higher levels of plasma viscosity (1.36+/-0.09 vs. 1.31+/-0.08 mPas, p=0.005). Nevertheless, hypertensive apneics have even higher levels of plasma viscosity than nonapneics (1.38+/-0.091 vs. 1.32+/-0.028 mPas, p=0.018). Similar results were found in patients with coronary artery disease, where OSA was associated with elevated plasma viscosity (1.36+/-0.076 vs. 1.31+/-0.081 mPas, p=0.007). Plasma fibrinogen was correlated with nocturnal minimal oxygen saturation (r=-0275, p=0.0036) and AHI (r=0.297, p=0.001). OSA was associated with higher plasma fibrinogen (353+/-83 vs. 317+/-62 mg/dl, p=0.015). These differences persist with control for cardiovascular risk factors. CONCLUSIONS Patients with OSA have elevated morning fibrinogen levels and a higher plasma viscosity, which correlate positively with indices of sleep apnea severity. These changes in blood rheology are independent of cardiovascular risk factors, and therefore, might be specific mechanisms of OSA. This supports the pathophysiological concept that sleep apnea is a cardiovascular risk factor.
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Affiliation(s)
- Stephan Steiner
- Department of Cardiology, Pneumology and Angiology, Division of Internal Medicine, Heinrich Heine University, Dusseldorf, Germany.
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Schadlich S, Arndt T, Blankenburg T, Schutte UW. Effekte der nCPAP-Therapie auf die Prothrombinaktivierung bei Patienten mit obstruktivem Schlafapnoesyndrom. Effects of NCPAP Therapy on Prothrombin Activation in Patients with Obstructive Sleep Apnoea Syndrome. Somnologie 2004. [DOI: 10.1111/j.1439-054x.2004.00033.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Robinson GV, Pepperell JCT, Segal HC, Davies RJO, Stradling JR. Circulating cardiovascular risk factors in obstructive sleep apnoea: data from randomised controlled trials. Thorax 2004; 59:777-82. [PMID: 15333855 PMCID: PMC1747125 DOI: 10.1136/thx.2003.018739] [Citation(s) in RCA: 213] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Obstructive sleep apnoea (OSA) is associated with high cardiovascular morbidity and mortality and is an independent risk factor for hypertension. Novel circulating cardiovascular risk markers enabling a more accurate prediction of cardiovascular risk have been identified. Examination of these markers may clarify the increased risk in OSA and contribute to an analysis of the benefits of treatment. METHODS Plasma levels of total cholesterol and triglyceride and activated coagulation factors XIIa and VIIa, factors VII, VIII, XII, fibrinogen, thrombin-antithrombin (TAT), von Willebrand factor antigen (vWFAg), soluble P-selectin (sP-sel), and homocysteine were measured before and after treatment for 1 month with therapeutic or subtherapeutic (control) continuous positive airways pressure (CPAP) in 220 patients with OSA. RESULTS Levels of activated coagulation factors XIIa, VIIa, TAT and sP-sel were higher in OSA patients at baseline than in unmatched controls, but did not fall with 1 month of therapeutic CPAP treatment. The raised sP-sel levels correlated only with body mass index (p = 0.002). There was a trend towards a significant fall in total cholesterol with therapeutic CPAP (p = 0.06) compared with the control group. In the therapeutic group there was a clinically significant mean fall in total cholesterol of 0.28 mmol/l (95% confidence interval 0.11 to 0.45, p = 0.001) which may reduce cardiovascular risk by about 15%. CONCLUSION A number of activated coagulation factors are increased in untreated OSA patients, potentially contributing to vascular risk, but they do not fall with 1 month of CPAP treatment. Nasal CPAP may produce a clinically relevant fall in total cholesterol level, potentially reducing cardiovascular risk, but this needs to be verified in a larger prospective study.
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Affiliation(s)
- G V Robinson
- Oxford Centre for Respiratory Medicine, Churchill Hospital Site, Oxford Radcliffe Hospitals, Oxford OX3 7LJ, UK.
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Affiliation(s)
- Stuart F Quan
- Arizona Respiratory and Sleep Centers, University of Arizona College of Medicine, Tucson, Ariz, USA.
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Abstract
Arguments over the definition of obstructive sleep apnoea/hypopnoea syndrome (OSAHS) have still not been satisfactorily resolved. As a result, robust estimates of the prevalence of OSAHS are not possible. New approaches are needed to identify those who have "CPAP responsive" disease, enabling more accurate estimates to be made of the prevalence of the sleep apnoea syndrome in the community.
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Affiliation(s)
- J R Stradling
- Oxford Centre for Respiratory Medicine, University of Oxford and Churchill Hospital, Oxford OX3 7LJ, UK.
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28
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Abstract
STUDY OBJECTIVES Patients with obstructive sleep apnea (OSA) are at increased risk for coronary artery and cerebrovascular diseases. Numerous studies suggest that a hypercoagulable state is prospectively related to atherothrombotic events. This review explores whether changes in hemostasis may constitute one biological link between OSA and vascular disease. DESIGN Ten studies on hemostatic variables in OSA were located by electronic library search and descriptively reviewed. Work on hemostatic function with physiologic conditions similar to those found in OSA (hypoxemia and hyperactivity of the sympathetic nervous system) was considered to discuss potential molecular mechanisms of procoagulant disturbances in OSA. MEASUREMENTS AND RESULTS The reviewed data suggest that, as compared to non-OSA control subjects, patients with OSA have elevated plasma fibrinogen levels, exaggerated platelet activity, and reduced fibrinolytic capacity. Although not consistently shown, severity of OSA (ie, apnea-hypopnea index) and plasma epinephrine were independent predictors of platelet activity, and average minimal oxygen saturation was an independent predictor of fibrinogen. In some studies, treatment with continuous positive airway pressure decreased platelet activity, plasma fibrinogen levels, and activity of clotting factor VII. CONCLUSIONS There is some evidence for a hypercoagulable state in OSA, which might help explain the increased prevalence of vascular diseases in this population. To further confirm such a notion, future studies need to be performed on sufficiently large samples to be able to control for confounders of hemostatic activity. Prospective studies are needed to examine the association between hemostasis molecules and strong vascular end points.
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Affiliation(s)
- Roland von Känel
- Institute for Behavioral Sciences, Swiss Federal Institute of Technology, Zurich, Switzerland.
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