Impact of zolpidem and lemborexant on sleep and morning symptoms when used as a single dose for polysomnography

This study evaluated the effect of zolpidem and lemborexant on sleep and morning symptoms in patients undergoing type-1 polysomnography for suspected sleep-disordered breathing based on questionnaires and polysomnography results. We enrolled 127 patients (lemborexant: N = 57, zolpidem: N = 25, without hypnotics: N = 45). Rapid eye movement sleep in patients on lemborexant was higher than that in patients without hypnotics (P = 0.02). Frequency of unsteadiness in the morning was higher in patients on zolpidem than that in patients without hypnotics (P = 0.04), which remained after adjustment for potential confounders (P = 0.03). Low-dose lemborexant might be suitable when administered as a single dose during polysomnography.

Multimodal Telemonitoring for Weight Reduction in Patients With Sleep Apnea: A Randomized Controlled Trial

BACKGROUND

Telemonitoring the use of CPAP devices and remote feedback on device data effectively optimizes CPAP adherence in patients with OSA.

RESEARCH QUESTION

Can expanding the scope of telemonitoring and remote feedback to body weight (BW), BP, and physical activity enhance efforts for BW reduction in Patients with OSA receiving CPAP?

STUDY DESIGN AND METHODS

Participants were recruited from patients at 16 sleep centers in Japan with OSA and obesity who were receiving CPAP therapy. Obesity was defined as a BMI of ≥ 25 kg/m², based on Japanese obesity guidelines. Implementation of CPAP telemonitoring was enhanced with electronic scales, BP monitors, and pedometers that could transmit data from devices wirelessly. Participants were randomized to the multimodal telemonitoring group or the usual CPAP telemonitoring group and were followed up for 6 months. Attending physicians provided monthly telephone feedback calls to the usual CPAP telemonitoring group on CPAP data obtained remotely. In the multimodal telemonitoring group, physicians additionally encouraged participants to reduce their BW, after sharing the remotely obtained data on BW, BP, and step count. The primary outcome was set as ≥ 3% BW reduction from baseline.

RESULTS

One hundred sixty-eight participants (BMI, 31.7 ± 4.9 kg/m²) completed the study, and ≥ 3% BW reduction occurred in 33 of 84 participants (39.3%) and 21 of 84 participants (25.0%) in the multimodal telemonitoring and usual CPAP telemonitoring groups, respectively (P = .047). Whereas no significant differences were found between the two groups in the change in office and home BP, daily step counts during the study period were significantly higher in the multimodal telemonitoring group than in the usual CPAP telemonitoring group (4,767 steps/d [interquartile range (IQR), 2,864-6,617 steps/d] vs 3,592 steps/d [IQR, 2,117-5,383 steps/d]; P = .02) INTERPRETATION: Multimodal telemonitoring may enhance BW reduction efforts in patients with OSA and obesity.

TRIAL REGISTRY

UMIN Clinical Trials Registry; No.: UMIN000033607; URL: www.umin.ac.jp/ctr/index.htm.

Effect of ipragliflozin on carotid intima-media thickness in patients with type 2 diabetes: a multicenter, randomized, controlled trial

AIMS

To examine the effects of a 24-month treatment with ipragliflozin on carotid intima-media thickness (IMT) in type 2 diabetes patients.

METHODS AND RESULTS

In this multicenter, prospective, randomized, open-label, and blinded-endpoint investigator-initiated clinical trial, adults with type 2 diabetes and haemoglobin A1C (HbA1c) of 6.0-10.0% (42-86 mmol/mol) were randomized equally to ipragliflozin (50 mg daily) and non-sodium-glucose cotransporter-2 (SGLT2) inhibitor use of standard-care (control group) for type 2 diabetes and were followed-up to 24 months. The primary endpoint was the change in mean common carotid artery IMT (CCA-IMT) from baseline to 24 months. A total of 482 patients were equally allocated to the ipragliflozin (N = 241) and control (N = 241) groups, and 464 patients (median age 68 years, female 31.7%, median type 2 diabetes duration 8 years, median HbA1c 7.3%) were included in the analyses. For the primary endpoint, the changes in the mean CCA-IMT from baseline to 24 months were 0.0013 [95% confidence interval (CI), -0.0155-0.0182] mm and 0.0015 (95% CI, -0.0155-0.0184) mm in the ipragliflozin and control groups, respectively, with an estimated group difference (ipragliflozin-control) of -0.0001 mm (95% CI, -0.0191-0.0189; P = 0.989). A group difference in HbA1c change at 24 months was also non-significant between the treatment groups [-0.1% (95% CI, -0.2-0.1); P = 0.359].

CONCLUSION

Twenty-four months of ipragliflozin treatment did not affect carotid IMT status in patients with type 2 diabetes recruited in the PROTECT study, relative to the non-SGLT2 inhibitor-use standard care for type 2 diabetes.

Obstructive sleep apnea and its management in patients with atrial fibrillation: An International Collaboration of Sleep Apnea Cardiovascular Trialists (INCOSACT) global survey of practicing cardiologists

Background

Among international cardiologists it is unclear whether equipoise exists regarding the benefit of diagnosing and managing obstructive sleep apnea (OSA) to improve atrial fibrillation (AF) outcomes and whether clinical practice and equipoise are linked.

Methods

Between January 2019 and June 2020 we distributed a web-based 12-question survey regarding OSA and AF management to practicing cardiologists in 16 countries.

Results

The United States, Japan, Sweden, and Turkey accounted for two-thirds of responses. 863 cardiologists responded; half were general cardiologists, a quarter electrophysiologists. Responses regarding treating OSA with CPAP to improve AF endpoints were mixed. 33% of respondents referred AF patients for OSA screening. OSA was diagnosed in 48% of referred patients and continuous positive airway pressure (CPAP) was prescribed for 59% of them. Nearly 70% of respondents believed randomized controlled trials (RCTs) of OSA treatment in AF patients were necessary and indicated willingness to contribute to such trials.

Conclusions

There was no clinical equipoise among surveyed cardiologists; a majority expressed certainty that combined OSA and AF treatment is superior to AF treatment alone for improving AF outcomes. However, a minority of surveyed cardiologists referred AF patients for OSA testing, and while half of screened AF patients had OSA, CPAP was prescribed in little more than half of them, reflecting the view that better clinical trial evidence is needed to support this practice. Our results underscore the need for larger, multi-national prospective studies of OSA treatment and AF outcomes to inform more uniform society guideline recommendations.

Sex differences in the effectiveness and affecting factors to adherence of continuous positive airway pressure therapy

Although sex differences in clinical backgrounds of patients with obstructive sleep apnea (OSA) are well known, studies of sex differences about the influencing factors on adherence to continuous positive airway pressure (CPAP) are very sparse. Our aim was to investigate the effects of CPAP use affecting therapeutic adherence in sex differences. We retrospectively assessed demographic data, clinical characteristics, OSA-related symptoms, and effects and adherence of CPAP use in 348 patients (264 males, median age 58 years) who continued CPAP for at least 1 year. Poor adherence was defined as CPAP dropout within 1 year after starting CPAP or the average cumulative CPAP use less than four hours/night. We also studied the predictors or influencing factors of CPAP adherence by multivariate logistic regression analyses. Age was higher and the severity of OSA was lower in female patients. Although the adherence level itself was not significantly different between both sexes, influencing factors were different. OSA severity, such as apnea-hypopnea index and sleepiness, and many effects from CPAP use (respiratory difficulty, difficult adaptation to CPAP use, improved awakening, reduced nocturia, and easy adaptation to CPAP) influenced adherence only in men. Common factors of poor adherence in both sexes were lower age, insomnia by CPAP use, and improved daytime sleepiness. No other specific factors predicted poor adherence in women. We found that there were sex differences in influencing factors on CPAP adherence not only in clinical characteristics of OSA, but also in effectiveness and side effects of CPAP use.

Idiopathic and secondary restless legs syndrome during pregnancy in Japan: Prevalence, clinical features and delivery-related outcomes

Objective

The aim of this study was to investigate prevalence of idiopathic and secondary restless legs syndrome (RLS) according to pregnancy trimester, and its effects on delivery-related outcomes among pregnant women in Japan.

Methods

This was a single-center, prospective observational study. One hundred eighty-two consecutive pregnant women participated in the study from June 2014 to March 2016. Participants were interviewed and examined in the second and third trimesters of pregnancy and 1 month after delivery. At each term, RLS was identified by a research assistant and then specialist in sleep medicine based on the diagnostic criteria of the International Restless Legs Syndrome Study Group. Delivery-related data was collected from medical charts. RLS was classified as idiopathic RLS, which originally existed before the index pregnancy, or secondary RLS, which newly appeared during the index pregnancy.

Results

The prevalence of RLS was 4.9% (idiopathic 3.3%, secondary 1.6%) in the second trimester, 5.0% (idiopathic 0.0%, secondary 5.0%) in the third trimester, and 0.6% (idiopathic 0.0%, secondary 0.6%) after delivery. Prolonged labor, emergency Cesarean section, and arrest of labor tended to be more frequent in idiopathic and/or second RLS (all p<0.05).

Conclusions

The prevalence of RLS during pregnancy was 4–5% and decreases after delivery in current Japan. The presence of RLS was associated with an increase in some delivery-related outcomes. Early detection and treatment of RLS during pregnancy may be beneficial to safe delivery for pregnant women.

The severity of obstructive sleep apnea syndrome cannot predict the accumulation of brain amyloid by imaging with [11C]-Pittsburgh compound B PET computed tomography in patients with a normal cognitive function

OBJECTIVE

Disturbed sleep due to obstructive sleep apnea syndrome (OSAS) might accelerate amyloidβ (Aβ) deposition, which can be a crucial factor in Alzheimer's disease. We studied Aβ deposition in untreated OSAS patients with normal cognition.

METHOD

We performed polysomnography (PSG) and Aβ imaging with [¹¹C]-Pittsburgh compound B PET computed tomography (¹¹C-PiB PET CT) in 14 untreated OSAS patients (apnea-hypopnea index: 43.8 ± 26.3/h).

RESULTS

The abnormal accumulation of enhanced ¹¹C-PiB PET was observed only one patient with severe, but not the most severe.

CONCLUSIONS

The OSAS severity alone may not predict Aβ deposition in OSAS patients with normal cognition.

Ischemic or Nonischemic Functional Mitral Regurgitation and Outcomes in Patients With Acute Decompensated Heart Failure With Preserved or Reduced Ejection Fraction

The aim of this study was to evaluate the association of functional mitral regurgitation (FMR), preserved or reduced ejection fraction (EF), and ischemic or nonischemic origin with outcomes in patients discharged alive after hospitalization for acute decompensated heart failure (HF). Of the 4,842 patients enrolled in the Acute Decompensated Heart Failure Syndromes (ATTEND) registry, 3,357 patients were evaluated to assess the association of FMR, preserved or reduced EF, and ischemic or nonischemic origin with the primary end point (all-cause death and readmission for HF after discharge). At the time of discharge, FMR was assessed semiquantitatively (classified as none, mild, or moderate to severe) by color Doppler analysis of the regurgitant jet area. According to multivariable analysis, in the ischemic group, either mild or moderate to severe FMR in patients with a preserved EF had a significantly higher risk of the primary end point than patients without FMR (hazard ratio [HR] 1.60; 95% confidence interval [CI] 1.12 to 2.29; p = 0.010 and HR 1.98; 95% CI 1.30 to 3.01; p = 0.001, respectively). In patients with reduced EF with an ischemic origin, only moderate to severe FMR was associated with a significantly higher risk of the primary end point (HR 1.67; 95% CI 1.11 to 2.50; p = 0.014). In the nonischemic group, there was no significant association between FMR and the primary end point in patients with either a preserved or reduced EF. In conclusion, among patients with acute decompensated HF with a preserved or reduced EF, the association of FMR with adverse outcomes may differ between patients who had an ischemic or nonischemic origin of HF.

Cumulative Hypoxemia During Sleep Predicts Vascular Endothelial Dysfunction in Patients With Sleep-Disordered Breathing

BACKGROUND

Sleep-disordered breathing (SDB) is associated with repeated intermittent hypoxemia, and it is known as one of the risk factors for cardiovascular diseases. Previous studies assessing the effects of frequency and depth of hypoxemia on cardiovascular diseases have shown conflicting results. The aim of the current study was to clarify what SDB-related parameters most predict endothelial dysfunction to better understand the pathogenesis of endothelial dysfunction in patients with SDB.

METHODS

We conducted polysomnography (PSG) and measured flow-mediated vasodilation response (%FMD) in 50 outpatients suspected of SDB. Evaluated indices included: apnea-hypopnea index (AHI), 3% oxygen desaturation index (3%ODI), averaged arterial oxygen saturation (averaged SpO2), lowest arterial oxygen saturation (lowest SpO2), ratio of arterial oxygen saturation <90% (<SpO2 90%), and averaged time desaturation summation index (TDS: [100%-averaged SpO2] × total sleep time).

RESULTS

Significant differences were observed only in the TDS between the first and third (P = 0.03) and between the first and forth (P = 0.04) quartile groups, stratified by %FMD. The %FMD showed a significant relationship with TDS (β = -0.47, P = 0.001), even after adjusting for confounding factors (β = -0.33, P = 0.02). In contrast, AHI, 3%ODI, averaged SpO2, lowest SpO2, and <SpO2 90% showed no significant relationships.

CONCLUSIONS

This study shows the validity of TDS in predicting endothelial damage in patients with SDB. Cumulative hypoxemia, rather than the frequency of hypoxemic events presented as AHI, may be a greater contributing factor in causing endothelial dysfunction. A simple index like TDS may be a useful and novel indicator of the influence of SDB on the vasculature.

Prognostic Impacts of Metabolic Syndrome in Patients With Chronic Heart Failure - A Multicenter Prospective Cohort Study

BACKGROUND

Metabolic syndrome (MetS) is involved in the increased risk of atherosclerotic cardiovascular diseases. We have previously reported that the prevalence of MetS is more than 2-fold greater in patients with chronic heart failure (CHF) than in the general population in Japan. However, the prognostic impact of MetS in CHF patients remains to be elucidated.

METHODS AND RESULTS

In the present nationwide, large-scale clinical study in Japan, we enrolled 4,762 patients with Stage C/D CHF. The prevalence of MetS by the definition of the Japanese Committee for the Diagnostic Criteria in 2005 was 41.3% (50.6% in males, 21.5% in females). MetS was characterized by higher prevalence of males, obesity and lifestyle-related comorbidities, including glucose intolerance, dyslipidemia and hypertension. Multivariate Cox hazard analysis showed that MetS was associated with increased incidence of the composite of all-cause death and atherosclerotic events in males (hazard ratio [HR] 1.28; 95% confidence interval [CI] 1.06-1.54, P=0.011) but not in females (HR 1.23, 95% CI 0.87-1.75, P=0.241). Among the components of MetS, over waist circumference and glucose intolerance were significantly associated with increased incidence of the composite endpoint (HR 1.23, P=0.038, and HR 1.29, P<0.001, respectively) in males but not in females.

CONCLUSIONS

The results indicate that MetS only has a negative prognostic impact in male CHF patients. (Circ J 2016; 80: 677-688).

A randomised controlled trial for the evaluation of risk for type 2 diabetes in hypertensive patients receiving thiazide diuretics: Diuretics In the Management of Essential hypertension (DIME) study

OBJECTIVES

Thiazide diuretics are one of the first choice antihypertensives but not optimally utilised because of concerns regarding their adverse effects on glucose metabolism. The Diuretics In the Management of Essential hypertension (DIME) study was designed, for the first time, to assess the risk for type 2 diabetes mellitus in patients with essential hypertension during antihypertensive treatment with low-dose thiazide diuretics compared to those not treated with diuretics.

DESIGN

Multicentre, unblinded, pragmatic, randomised, controlled trial with blinded assessment of end points and intention-to-treat analysis that was started in 2004 and finished in 2012.

SETTING

Hypertension clinics at 106 sites in Japan, including general practitioners' offices and teaching hospitals.

PARTICIPANTS

Non-diabetic patients with essential hypertension.

INTERVENTIONS

Antihypertensive treatment with low-dose thiazide diuretics at 12.5 mg/day of hydrochlorothiazide or equivalent (Diuretics group) or that without thiazide diuretics (No-diuretics group).

MAIN OUTCOME

The primary outcome was new onset of type 2 diabetes diagnosed according to WHO criteria and the criteria of Japanese Society of Diabetes.

RESULTS

1130 patients were allocated to Diuretics (n=544) or No-diuretics group (n=586). Complete end point information was collected for 1049 participants after a median follow-up of 4.4 years. Diabetes developed in 25 (4.6%) participants in the Diuretics group, as compared with 29 (4.9%) in the No-diuretics group (HR 0.93; 95% CI 0.55 to 1.58; p=0.800).

CONCLUSIONS

Antihypertensive treatment with thiazide diuretics at low doses may not be associated with an increased risk for new onset of type 2 diabetes. This result might suggest safety of use of low doses of thiazide diuretics.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT00131846.

Effect of a novel calcium channel blocker on abnormal nocturnal blood pressure in hypertensive patients

The authors examined the effect of cilnidipine, a unique L/N-type calcium channel blocker, on abnormal nocturnal blood pressure (BP) dipping in Japanese hypertensive patients in the real world. The Ambulatory Blood Pressure Control and Home Blood Pressure (Morning and Evening) Lowering by N-Channel Blocker Cilnidipine (ACHIEVE-ONE), a large-scale clinical study, was designed to evaluate the effects of cilnidipine in daily medical practice. Among the study, 24-hour ambulatory BP data were obtained from 615 patients and classified according to their nocturnal dipping status as extreme dippers, dippers, nondippers, or risers. A 12-week treatment with cilnidipine significantly reduced 24-hour BP in all groups (P<.001). Changes in nocturnal systolic BP (SBP) from baseline were -17.9 mm Hg from 154.6 mm Hg in risers and -11.9 mm Hg from 142.1 mm Hg, -6.6 mm Hg from 128.5 mm Hg, and 0.1 mm Hg from 115.8 mm Hg in nondippers, dippers, and extreme dippers, respectively. Changes from baseline in nocturnal SBP reduction rate were 8.2% in risers (P<.001) but -7.0% in extreme dippers (P<.001), while no change was observed in the nighttime SBP reduction rate for the total patients (-0.2%±9.6%, P=.617). Cilnidipine partially, but significantly, restored abnormal nocturnal dipping status toward a normal dipping pattern in hypertensive patients.

Mediastinal leiomyosarcoma concurrent with intra-aortic thrombosis

We report a case of a large intra-aortic thrombosis in an 83-year-old woman concurrent with metastatic mediastinal leiomyosarcoma. Imaging studies incidentally detected a mediastinal malignant tumour metastasising to bilateral adrenals and an extensive intra-aortic mass that was suspected to be intra-aortic thrombosis. One month later massive embolism developed in the lower limb and her condition deteriorated rapidly resulting in death. Autopsy revealed diffused proliferation of highly pleomorphic atypical cells accompanied by necrosis in the mediastinum tumours and bilateral adrenal glands. Leiomyosarcoma metastasising to bilateral adrenals was confirmed by the results of immunostaining. The intra-aortic mass suggested that the fragmented thrombus might be the cause of a sudden lower-limb embolism. Microscopic examination showed that the mass lesion in the aortic arch was composed of a blood clot containing neutrophils. We report this case because leiomyosarcoma arising from the mediastinum and, especially, associated with an extraordinarily large intra-aortic thrombosis is very rare.

Enhancement of cardiac performance by bilevel positive airway pressure ventilation in heart failure

BACKGROUND

Recent studies have reported the clinical usefulness of positive airway pressure ventilation therapy with various kinds of pressure support compared with simple continuous positive airway pressure (CPAP) for heart failure patients. However, the mechanism of the favorable effect of CPAP with pressure support can not be explained simply from the mechanical aspect and remains to be elucidated.

METHODS AND RESULTS

In 18 stable chronic heart failure patients, we performed stepwise CPAP (4, 8, 12 cm H(2)O) while the cardiac output and intracardiac pressures were continuously monitored, and we compared the effects of 4 cm H(2)O CPAP with those of 4 cm H(2)O CPAP plus 5 cm H(2)O pressure support. Stepwise CPAP decreased cardiac index significantly in patients with pulmonary arterial wedge pressure (PAWP) <12 mm Hg (n = 10), but not in those with PAWP ≥12 mm Hg (n = 8). Ventilation with CPAP plus pressure support increased cardiac index slightly but significantly from 2.2 ± 0.7 to 2.3 ± 0.7 L min(-1) m(-2) (P = .001) compared with CPAP alone, regardless of basal filling condition or cardiac index.

CONCLUSIONS

Our results suggest that CPAP plus pressure support is more effective than simple CPAP in heart failure patients and that the enhancement might be induced by neural changes and not simply by alteration of the preload level.

A new electrocardiographic criterion to differentiate between Takotsubo cardiomyopathy and anterior wall ST-segment elevation acute myocardial infarction

Several studies have examined the ability of electrocardiography to differentiate between takotsubo cardiomyopathy (TC) and anterior wall acute ST-segment elevation myocardial infarction (AA-STEMI). In those studies, the magnitude of ST-segment elevation was not measured at the J point. The American Heart Association, American College of Cardiology Foundation, and Heart Rhythm Society guidelines recommend that the magnitude of ST-segment elevation should be measured at the J point. Accordingly, the aim of this study was to retrospectively examine whether electrocardiography, using the magnitude of ST-segment elevation measured at the J point, could differentiate 62 patients with TC from 280 with AA-STEMI. Patients with AA-STEMI were divided into following subgroups: 140 with left anterior descending coronary artery occlusions proximal to the first diagonal branch (AA-STEMI-P), 120 with left anterior descending occlusions distal to the first diagonal branch and proximal to the second diagonal branch (AA-STEMI-M), and 20 with left anterior descending occlusions distal to the second diagonal branch (AA-STEMI-D). TC had a much lower prevalence of ST-segment elevation ≥1 mm in lead V(1) (19.4%) compared to AA-STEMI (80.4%, p <0.01), AA-STEMI-P (80.7%, p <0.01), AA-STEMI-M (80%, p <0.01), and AA-STEMI-D (80%, p <0.01). ST-segment elevation ≥1 mm in ≥1 of leads V(3) to V(5) without ST-segment elevation ≥1 mm in lead V(1) identified TC with sensitivity of 74.2% and specificity of 80.6%. Furthermore, this criterion could differentiate TC from each AA-STEMI subgroup, with similar diagnostic values. In conclusion, using the magnitude of ST-segment elevation measured at the J point, a new electrocardiographic criterion is proposed with an acceptable ability to differentiate TC from AA-STEMI.

Simple standing test predicts and water ingestion prevents vasovagal reaction in the high-risk blood donors

BACKGROUND

One of the serious complications of blood donation is vasovagal reaction (VVR) with syncope. This study was performed to determine if the measurement of hemodynamic responses to standing before blood collection (BC) was useful to identify the high-risk donors for VVR and also examined the effect of 300 mL of water ingestion in the prevention of VVR.

STUDY DESIGN AND METHODS

Blood pressure and heart rate (HR) during 5 minutes of standing were examined before and after BC in 93 donors. Because HR increase of 6 of 7 donors who developed syncopal VVR during standing after BC was 15 beats per minute (bpm) or greater, those with HR increase of 15 bpm or greater were determined as high-risk donors (n = 31). In another group (n = 117), 45 donors were identified as high risk based on the HR response before BC (15 bpm). The effect of 300 mL of water ingestion 15 minutes before BC on hemodynamic responses to standing and the rate of VVR after BC were analyzed.

RESULTS

Water ingestion given to the high-risk donors of the second group reduced HR increase with standing before BC (-6.6 ± 13.6 bpm, p < 0.02 vs. HR increase before water ingestion) and significantly suppressed VVR rate (2 of 45 donors with high risk, 4.4%,p < 0.04 vs. the first group; 6 of 31 high-risk donors, 19.4%).

CONCLUSION

HR response to standing before BC may detect the high-risk donors for VVR. For the high-risk donors, 300 mL of water ingestion may be a simple and effective way of prevention against syncopal VVR.

Left ventricular false-pseudo and pseudo aneurysm: serial observations by cardiac magnetic resonance imaging

A case of extensive inferior myocardial infarction complicated by a large ventricular aneurysm is presented. Magnetic resonance (MR) imaging 4 days after the onset showed a small protrusion from the necrotic inferior myocardium, which expanded 10 days after onset with a marked pericardial effusion. The follow-up examination by MR and CT imaging 6 months after the onset revealed a large ventricular aneurysm from the inferior cardiac wall. After the aneurysmectomy, the histological study revealed that the aneurysm wall was made up of 2 different types of walls; the peripheral part was a false-pseudo aneurysm and the central part was a pseudo aneurysm. From the serial MR imaging, it is considered that such an aneurysm is primarily formed from a small discontinuation of the LV wall followed by oozing type rupture. Finally, the ruptured central part of the LV wall, which was covered by the pericardium, formed a pseudo aneurysm and the stretched peripheral area, which contains myocardium, formed a false-pseudo aneurysm afterward and then they extended together. Thus, MR imaging provided the important information for the understanding of the formation process of the pseudo and false pseudo LV aneurysm.

Cardiovascular effects of continuous positive airway pressure in patients with heart failure and obstructive sleep apnea

BACKGROUND

Obstructive sleep apnea subjects the failing heart to adverse hemodynamic and adrenergic loads and may thereby contribute to the progression of heart failure. We hypothesized that treatment of obstructive sleep apnea by continuous positive airway pressure in patients with heart failure would improve left ventricular systolic function.

METHODS

Twenty-four patients with a depressed left ventricular ejection fraction (45 percent or less) and obstructive sleep apnea who were receiving optimal medical treatment for heart failure underwent polysomnography. On the following morning, their blood pressure and heart rate were measured by digital photoplethysmography, and left ventricular dimensions and left ventricular ejection fraction were assessed by echocardiography. The subjects were then randomly assigned to receive medical therapy either alone (12 patients) or with the addition of continuous positive airway pressure (12 patients) for one month. The assessment protocol was then repeated.

RESULTS

In the control group of patients who received only medical therapy, there were no significant changes in the severity of obstructive sleep apnea, daytime blood pressure, heart rate, left ventricular end-systolic dimension, or left ventricular ejection fraction during the study. In contrast, continuous positive airway pressure markedly reduced obstructive sleep apnea, reduced the daytime systolic blood pressure from a mean (+/-SE) of 126+/-6 mm Hg to 116+/-5 mm Hg (P=0.02), reduced the heart rate from 68+/-3 to 64+/-3 beats per minute (P=0.007), reduced the left ventricular end-systolic dimension from 54.5+/-1.8 to 51.7+/-1.2 mm (P=0.009), and improved the left ventricular ejection fraction from 25.0+/-2.8 to 33.8+/-2.4 percent (P<0.001).

CONCLUSION

In medically treated patients with heart failure, treatment of coexisting obstructive sleep apnea by continuous positive airway pressure reduces systolic blood pressure and improves left ventricular systolic function. Obstructive sleep apnea may thus have an adverse effect in heart failure that can be addressed by targeted therapy.

Augmented sympathetic neural response to simulated obstructive apnoea in human heart failure

Sleep apnoea in heart failure increases mortality risk, possibly as a result of greater activation of the sympathetic nervous system. In healthy subjects, simulated central apnoeas (holding breath) and obstructive apnoeas (Mueller manoeuvres) increase muscle sympathetic activity equally, primarily through chemoreceptor stimulation. In heart failure, however, Mueller manoeuvres cause greater reductions in blood pressure than breath holds. We hypothesized that in heart failure, the summation of arterial baroreceptor unloading and chemoreceptor stimulation would increase sympathetic activity more during obstructive than central apnoeas. Healthy human subjects and heart failure patients (seven of each) performed 15-s breath holds and 15-s Mueller manoeuvres. Breath holds evoked a progressive increase in muscle sympathetic nerve activity in both groups, but had no effect on blood pressure. In healthy subjects, breath holds and Mueller manoeuvres caused equal peaks in sympathetic activity. In contrast, in heart failure patients, Mueller manoeuvres caused a progressive decrease in blood pressure (P < 0.05) and greater increases in sympathetic activity than breath holds (P < 0.01). In heart failure, simulated obstructive apnoea elicits greater increases in sympathetic activity than simulated central apnoea, due to its additional hypotensive effect. These present findings offer novel insight into the potential role of sleep apnoea in augmenting sympathetic activity and accelerating disease progression in heart failure.

Differential sympathetic nerve and heart rate spectral effects of nonhypotensive lower body negative pressure

Lower body negative pressure (LBNP; -5 and -15 mmHg) was applied to 14 men (mean age 44 yr) to test the hypothesis that reductions in preload without effect on stroke volume or blood pressure increase selectively muscle sympathetic nerve activity (MSNA), but not the ratio of low- to high-frequency harmonic component of spectral power (P(L)/P(H)), a coarse-graining power spectral estimate of sympathetic heart rate (HR) modulation. LBNP at -5 mmHg lowered central venous pressure and had no effect on stroke volume (Doppler) or systolic blood pressure but reduced vagal HR modulation. This latter finding, a manifestation of arterial baroreceptor unloading, refutes the concept that low levels of LBNP interrogate, selectively, cardiopulmonary reflexes. MSNA increased, whereas P(L)/P(H) and HR were unchanged. This discordance is consistent with selectivity of efferent sympathetic responses to nonhypotensive LBNP and with unloading of tonically active sympathoexcitatory atrial reflexes in some subjects. Hypotensive LBNP (-15 mmHg) increased MSNA and P(L)/P(H), but there was no correlation between these changes within subjects. Therefore, HR variability has limited utility as an estimate of the magnitude of orthostatic changes in sympathetic discharge to muscle.