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Ou YH, Colpani JT, Cheong CS, Loke W, Thant AT, Shih EC, Lee F, Chan SP, Sia CH, Koo CY, Wong S, Chua A, Khoo CM, Kong W, Chin CW, Kojodjojo P, Wong PE, Chan MY, Richards AM, Cistulli PA, Lee CH. Mandibular Advancement vs CPAP for Blood Pressure Reduction in Patients With Obstructive Sleep Apnea. J Am Coll Cardiol 2024; 83:1760-1772. [PMID: 38588926 DOI: 10.1016/j.jacc.2024.03.359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/04/2024] [Accepted: 03/04/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Hypertension guidelines recommend diagnosis and treatment of obstructive sleep apnea (OSA) in patients with hypertension. The mandibular advancement device (MAD) is an oral appliance therapy for patients who decline or cannot tolerate continuous positive airway pressure (CPAP). OBJECTIVES We compared the relative effectiveness of MAD vs CPAP in reducing 24-hour ambulatory blood pressure (BP). METHODS In an investigator-initiated, randomized, noninferiority trial (prespecified margin 1.5 mm Hg), 321 participants aged ≥40 years with hypertension and increased cardiovascular risk were recruited at 3 public hospitals for polysomnography. Of these, 220 participants with moderate-to-severe OSA (apnea-hypopnea index ≥15 events per hour) were randomized to either MAD or CPAP (1:1). The primary outcome was the difference between the 24-hour mean arterial BP at baseline and 6 months. RESULTS Compared with baseline, the 24-hour mean arterial BP decreased by 2.5 mm Hg (P = 0.003) at 6 months in the MAD group, whereas no change was observed in the CPAP group (P = 0.374). The between-group difference was -1.6 mm Hg (95% CI: -3.51 to 0.24, noninferiority P < 0.001). The MAD group demonstrated a larger between-group reduction in all secondary ambulatory BP parameters compared with the CPAP group, with the most pronounced effects observed in the asleep BP parameters. Both the MAD and CPAP improved daytime sleepiness, with the between-group difference similar (P = 0.384). There were no between-group differences in cardiovascular biomarkers. CONCLUSIONS MAD is noninferior to CPAP for reducing 24-hour mean arterial BP in participants with hypertension and increased cardiovascular risk. (Cardiosleep Research Program on Obstructive Sleep Apnea, Blood Pressure Control and Maladaptive Myocardial Remodeling-Non-inferiority Trial [CRESCENT]; NCT04119999).
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Affiliation(s)
- Yi-Hui Ou
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Juliana Tereza Colpani
- Department of Endodontics, Operative Dentistry and Prosthodontics, Faculty of Dentistry, National University of Singapore, Singapore
| | - Crystal S Cheong
- Department of Otolaryngology-Head & Neck Surgery, National University Hospital, Singapore, Singapore
| | - Weiqiang Loke
- Department of Endodontics, Operative Dentistry and Prosthodontics, Faculty of Dentistry, National University of Singapore, Singapore
| | - As Tar Thant
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - E' Ching Shih
- Department of Otolaryngology-Head & Neck Surgery, National University Hospital, Singapore, Singapore
| | - Frank Lee
- Department of Endodontics, Operative Dentistry and Prosthodontics, Faculty of Dentistry, National University of Singapore, Singapore
| | - Siew-Pang Chan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Cardiovascular Research Institute, National University Heart Centre, Singapore, Singapore; Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Chieh-Yang Koo
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Serene Wong
- Department of Medicine, Alexandra Hospital, Singapore
| | - Aiping Chua
- Department of Medicine, Ng Teng Fong General Hospital, Singapore
| | - Chin-Meng Khoo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - William Kong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Calvin W Chin
- Department of Cardiology, National Heart Centre Singapore, Singapore; Cardiovascular ACP, Duke-NUS Medical School, Singapore
| | - Pipin Kojodjojo
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | | | - Mark Y Chan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Cardiovascular Research Institute, National University Heart Centre, Singapore, Singapore; Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - A Mark Richards
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Cardiovascular Research Institute, National University Heart Centre, Singapore, Singapore; Department of Cardiology, National University Heart Centre, Singapore, Singapore; Christchurch Heart Institute, University of Otago, Dunedin, New Zealand
| | - Peter A Cistulli
- Sleep Research Group, Charles Perkins Centre and Northern Clinical School, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia; Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Chi-Hang Lee
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Cardiovascular Research Institute, National University Heart Centre, Singapore, Singapore; Department of Cardiology, National University Heart Centre, Singapore, Singapore.
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Ou YH, Ong J, Thant AT, Koo CY, Leung L, Sia CH, Chan SP, Wong S, Lee CH. The Belun sleep platform to diagnose obstructive sleep apnea in patients with hypertension and high cardiovascular risk. J Hypertens 2023; 41:1011-1017. [PMID: 37071415 DOI: 10.1097/hjh.0000000000003426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 04/19/2023]
Abstract
STUDY OBJECTIVE Current hypertension guidelines recommend that at-risk individuals be screened for obstructive sleep apnea (OSA). The Belun Ring is a wearable OSA diagnostic device worn on the palmar side of the proximal phalanx of the index finger. METHODS We recruited 129 participants (age: 60 ± 8 years, male sex: 88%, BMI: 27 ± 4 kg/m 2 ) with hypertension and high cardiovascular risk for a simultaneous polysomnography and Belun Ring monitoring for one night. Epworth Sleepiness Scale score more than 10 was detected in 27 (21.0%) participants. RESULTS In the 127 participants who completed the study, the apnea-hypopnea index (AHI) derived from polysomnography was 18.1 (interquartile range: 33.0) events/h and that derived from the Belun Ring was 19.5 (interquartile range: 23.3) events/h [intraclass correlation coefficient: 0.882, 95% confidence interval (95% CI): 0.837-0.916]. A Bland-Altman plot showed the difference between the Belun Ring and polysomnography AHIs to be -1.3 ± 10.4 events/h. Area under the receiver operating characteristic for the Belun Ring AHI was 0.961 (95% CI: 0.932-0.990, P < 0.001). When the Belun Ring AHI of at least 15 events/h was used to diagnose OSA, the sensitivity, specificity, positive predictive value, and negative predictive value were 95.7, 77.6, 85.3, and 93.8%, respectively. The overall accuracy was 87.4%. The Cohen's kappa agreement was 0.74 ± 0.09 ( P < 0.001). Similar results were obtained when the oxygen desaturation index was used to diagnose OSA. CONCLUSION A high prevalence of OSA was detected in patients with hypertension and high cardiovascular risk. The Belun Ring is a reliable device for OSA diagnosis similar to polysomnography.
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Affiliation(s)
- Yi-Hui Ou
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore
| | - Joy Ong
- Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore
| | - As Tar Thant
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore
| | - Chieh Yang Koo
- Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore
| | - Lydia Leung
- Belun Technology Company Limited, Hong Kong, People's Republic of China
| | - Ching Hui Sia
- Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore
| | - Siew Pang Chan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore
| | - Serene Wong
- Department of Respiratory Medicine, Alexandra Hospital, National University Health System, Singapore, Singapore
| | - Chi-Hang Lee
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore
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Seah SJS, Chiu ST, Thant AT, Chan SP, Ou YH, Teo YH, Wong S, Koo CY, Barbé F, Lee CH. Hour-to-hour variability of respiratory sleep indices and ambulatory blood pressure. Sleep 2023; 46:6708255. [PMID: 36130168 DOI: 10.1093/sleep/zsac227] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 04/30/2022] [Revised: 09/14/2022] [Indexed: 11/13/2022] Open
Abstract
STUDY OBJECTIVES Respiratory sleep indices are traditionally reported on the basis of the average total sleep time. The relationship between the hour-to-hour variability of these parameters and blood pressure (BP) has not been reported. METHODS We evaluated the associations of the hour-to-hour variability of the apnea-hypopnea index (AHI), oxygen desaturation index (ODI), and lowest oxygen saturation with the 24-h ambulatory BP in patients with hypertension and newly diagnosed obstructive sleep apnea. A total of 147 patients underwent polysomnography, based on which obstructive sleep apnea was diagnosed in 106 patients; these patients underwent 24-h ambulatory BP monitoring within the next 30 days. Each polysomnogram was divided into hourly reports to calculate the variability of the respiratory sleep indices. Variability independent of the mean was considered the primary measure of variability. RESULTS The median number of hourly polysomnogram reports was 7 (range, 4-8). The hour-to-hour variability of both AHI and ODI, but not of the lowest oxygen saturation, was correlated with the 24-h pulse pressure, 24-h systolic BP, and awake systolic BP (p < 0.05 for all). The fully adjusted linear regression analysis indicated that the hour-to-hour variability of AHI and ODI remained associated with the 24-h pulse pressure (AHI: β coefficient, 0.264 [95% CI = 0.033-0.495], p = 0.026; ODI: β coefficient, 0.450 [95% CI = 0.174-0.726], p = 0.002). CONCLUSIONS The hour-to-hour variability of AHI and ODI is independently associated with the 24-h pulse pressure. Further investigations are warranted to evaluate the clinical relevance of this new-found association.
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Affiliation(s)
- Shawn Jing-Sheng Seah
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Shi Ting Chiu
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - As Tar Thant
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Siew Pang Chan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Cardiovascular Research Institute, National University Heart Centre Singapore, Singapore, Singapore
| | - Yi-Hui Ou
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yao Hao Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Serene Wong
- Fast and Chronic Programmes, Alexandra Hospital, National University Health System, Singapore, Singapore
| | - Chieh-Yang Koo
- Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore
| | - Ferran Barbé
- Translational Research in Respiratory Medicine, Hospital Arnau de Vilanova-Santa Maria, IRBLleida, Lleida, CIBERES, Madrid, Spain
| | - Chi-Hang Lee
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Cardiovascular Research Institute, National University Heart Centre Singapore, Singapore, Singapore.,Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore
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Ou YH, Thant AT, Lee CH. Sudden deterioration of CPAP adherence after myocardial infarction in a Chinese patient: potential effect of ACEI-induced airway hyperresponsiveness. J Clin Sleep Med 2022; 18:1463-1465. [PMID: 35022127 PMCID: PMC9059603 DOI: 10.5664/jcsm.9880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A patient with obstructive sleep apnea was admitted to the hospital with non-ST segment elevation myocardial infarction. An angiotensin-converting enzyme inhibitor was prescribed upon discharge. She later became intolerant to continuous positive airway pressure therapy, and her adherence to the related device decreased precipitously. The intolerance subsided gradually after a switch in medication to an angiotensin receptor blocker, and her adherence to continuous positive airway pressure device usage returned to the baseline after 4 weeks.
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Affiliation(s)
- Yi-Hui Ou
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - As Tar Thant
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Chi-Hang Lee
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Department of Cardiology, National University Heart Centre Singapore, Singapore
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