Management of hypertension in obstructive sleep apnea

Obstructive sleep apnea (OSA) plays an important role in the development of hypertension. Thus, this review summarizes pharmacological and non-pharmacological approaches to blood pressure (BP) control in patients with OSA. Current treatments for OSA, such as continuous positive airway pressure, are effective at lowering BP. However, they only provide a modest BP reduction, and pharmacological treatment remains important for achieving optimal BP control. Furthermore, current guidelines for the treatment of hypertension do not make specific recommendations on pharmacological treatment protocols for controlling BP in patients with OSA. Moreover, the BP-lowering effects of various classes of antihypertensives may be different in hypertensive patients with OSA than in those without OSA due to the underlying mechanisms that promote hypertension in OSA. The acute and chronic increase in sympathetic nerve activity in patients with OSA explain the effectiveness of beta blockers in controlling BP in these patients. As activation of the renin-angiotensin-aldosterone system may also promote hypertension in OSA, angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers have generally been found effective for lowering BP in hypertensive patients with OSA. The aldosterone antagonist spironolactone also produces a good antihypertensive response in patients with OSA and resistant hypertension. However, there are limited data available that compare the effects of various classes of antihypertensive medication on BP control in those with OSA, and most data have been obtained from small-scale studies. This demonstrates the need for large-scale randomized controlled trials to evaluate a range of BP-lowering regimens in patients with OSA and hypertension.

Consumer-Led Screening for Atrial Fibrillation: A Report From the mAFA-II Trial Long-Term Extension Cohort

BACKGROUND

There are limited data on mobile health detection of prevalent atrial fibrillation (AF) and its related risk factors over time.

OBJECTIVES

This study aimed to report the trends on prevalent AF detection over time and risk factors, with a consumer-led photoplethysmography screening approach.

METHODS

3,499,461 subjects aged over 18 years, who use smart devices (Huawei Technologies Co.) were enrolled between October 26, 2018, and December 1, 2021.

RESULTS

Among 2,852,217 subjects for AF screening, 12,244 subjects (0.43%; 83.2% male, mean age 57 ± 15 years) detected AF episodes. When compared with 2018, the risk (adjusted HRs, 95% CI) for monitored prevalent AF increased significantly for subjects when monitoring started in 2020 (adjusted HR: 1.34; 95% CI: 1.27-1.40; P < .001) or in 2021 (adjusted HR: 1.67; 95% CI: 1.59-1.76; P < 0.001). Of the 961,931 subjects who screening for both AF and OSA, 18,032 (1.9%, 97.8% male, mean age 44 ±17 years) were identified as high risk for OSA, which resulted in a 1.5-fold increase (95% CI: 1.30-fold to 1.75-fold) in the prevalent AF. A total of 5,227 (53.3%, 5,227/9,797) subjects were effectively followed up, from which 4,903 (93.8%, 4,903/5,227) subjects were confirmed with the diagnosis of AF, by the mAFA Telecare Team health providers.

CONCLUSIONS

Photoplethysmography-based smart devices can facilitate screening for AF with >93% confirmation of detected AF episodes even for the low-risk general population, highlighting the increased risk for detecting prevalent AF and the need for modification of OSA that increase AF susceptibility. (Mobile Health [mHealth] Technology for Improved Screening, Patient Involvement and Optimizing Integrated Care in Atrial Fibrillation [mAFA (mAF-App) II study]; ChiCTR-OOC-17014138).

Continuous Positive Airway Pressure Adherence and Treatment Cost in Patients With Obstructive Sleep Apnea and Cardiovascular Disease

Objective

To determine whether continuous positive airway pressure (CPAP) adherence reduces health care–related costs or use in patients with obstructive sleep apnea (OSA) and comorbid cardiovascular disease (CVD).

Patients

A total of 23 million patients with CVD were identified in the Medicare fee-for-service database. Of the 65,198 who completed a sleep study between January 2016 and September 2018, 55,125 were diagnosed as having OSA and 1758 were identified in the 5% Medicare durable medical equipment (DME) database.

Methods

Patients with DME claims were categorized as adherent (AD, treatment evidenced ≥91 days after CPAP initiation; n=614) or nonadherent (nAD, n=242) to CPAP therapy. In addition, 9881 individuals with CVD who were not diagnosed as having OSA after sleep testing and without CPAP initiation were included as control patients. Propensity score matching balanced the groups for age, sex, and comorbidities (eg, diabetes mellitus), resulting in 241 participants per cohort. Dependent variables included total episode-of-care, inpatient, outpatient, skilled nursing, home health, and DME costs across 12 months.

Results

Total episode-of-care costs of AD participants ($6825) were lower than those of nAD ($11,312; P<.05) and control ($8102) participants. This difference (Δ) was attributable to fewer outpatient expenses (Δ$2290; P<.05) relative to the nAD group and fewer inpatient expenses (Δ$745) relative to the control group because skilled nursing costs were comparable between groups (P=.73).

Conclusion

Adherence to CPAP treatment reduces annual health care–related expenses by 40% in Medicare patients with CVD and OSA.

Research Opportunities in Autonomic Neural Mechanisms of Cardiopulmonary Regulation: A Report From the National Heart, Lung, and Blood Institute and the National Institutes of Health Office of the Director Workshop

This virtual workshop was convened by the National Heart, Lung, and Blood Institute, in partnership with the Office of Strategic Coordination of the Office of the National Institutes of Health Director, and held September 2 to 3, 2020. The intent was to assemble a multidisciplinary group of experts in basic, translational, and clinical research in neuroscience and cardiopulmonary disorders to identify knowledge gaps, guide future research efforts, and foster multidisciplinary collaborations pertaining to autonomic neural mechanisms of cardiopulmonary regulation. The group critically evaluated the current state of knowledge of the roles that the autonomic nervous system plays in regulation of cardiopulmonary function in health and in pathophysiology of arrhythmias, heart failure, sleep and circadian dysfunction, and breathing disorders. Opportunities to leverage the Common Fund's SPARC (Stimulating Peripheral Activity to Relieve Conditions) program were characterized as related to nonpharmacologic neuromodulation and device-based therapies. Common themes discussed include knowledge gaps, research priorities, and approaches to develop novel predictive markers of autonomic dysfunction. Approaches to precisely target neural pathophysiological mechanisms to herald new therapies for arrhythmias, heart failure, sleep and circadian rhythm physiology, and breathing disorders were also detailed.

Aberrant waste disposal in neurodegeneration: why improved sleep could be the solution

Sleep takes up a large percentage of our lives and the full functions of this state are still not understood. However, over the last 10 years a new and important function has emerged as a mediator of brain clearance. Removal of toxic metabolites and proteins from the brain parenchyma generated during waking activity and high levels of synaptic processing is critical to normal brain function and only enabled during deep sleep. Understanding of this process is revealing how impaired sleep contributes an important and likely causative role in the accumulation and aggregation of aberrant proteins such as β-amyloid and phosphorylated tau, as well as inflammation and neuronal damage. We are also beginning to understand how brain slow-wave activity interacts with vascular function allowing the flow of CSF and interstitial fluid to drain into the body's lymphatic system. New methodology is enabling visualization of this process in both animals and humans and is revealing how these processes break down during ageing and disease. With this understanding we can begin to envisage novel therapeutic approaches to the treatment of neurodegeneration, and how reversing sleep impairment in the correct manner may provide a way to slow these processes and improve brain function.

Hypoglossal Nerve Stimulator-Induced Neurapraxia Following Electrical Cardioversion for Atrial Fibrillation

An increasing proportion of patients with atrial fibrillation are undergoing implantation with hypoglossal nerve stimulators for the treatment of obstructive sleep apnea. We present a case of hypoglossal nerve stimulator-associated neurapraxia following electrical cardioversion of atrial fibrillation. (Level of Difficulty: Advanced.).

Unmasking Hydroxychloroquine Cardiotoxicity in a Patient With Heart Failure and Chronotropic Incompetence

Chronic use of hydroxychloroquine can result in cardiomyopathy and conduction disturbances. Here, we describe a case of hydroxychloroquine cardiotoxicity in a patient with heart failure with preserved ejection fraction and severe chronotropic incompetence. (Level of Difficulty: Intermediate.).

Extra-Hepatic Manifestations of Nonalcoholic Fatty Liver Disease: A Review

Nonalcoholic fatty liver disease (NAFLD) is now the leading cause of chronic liver disease worldwide with a strong association with metabolic syndrome. NAFLD is truly a systemic disease and is associated with a plethora of extra-hepatic manifestations or comorbidities. These are either related to secondary effects of associated obesity or from pathophysiological effects of insulin resistance in NAFLD. Three most common causes of increased morbidity and mortality associated with NAFLD are cardiovascular disease, liver disease, and cancer. In this narrative review, we will discuss comprehensively on cardiovascular disease, type 2 diabetes mellitus, and chronic kidney disease and will also highlight on malignancy especially colorectal cancer, pulmonary disorders including obstructive sleep apnea, endocrine disorders such as hypothyroidism and polycystic ovarian syndrome, dermatological disorders especially psoriasis, and hematological associations including iron overload and susceptibility to thrombosis. In addition to focusing on pathogenesis of these extrahepatic manifestations, we will highlight their clinical implications for physicians in routine clinical practice. Further, there remains an unmet need for safe and effective therapies and examining their benefits on these extra-hepatic manifestations among patients with NAFLD.

Neuromodulation for the Treatment of Heart Rhythm Disorders

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Derangement of autonomic nervous signaling is an important contributor to cardiac arrhythmogenesis.

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Modulation of autonomic nervous signaling holds significant promise for the prevention and treatment of cardiac arrhythmias.

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Further clinical investigation is necessary to establish the efficacy and safety of autonomic modulatory therapies in reducing cardiac arrhythmias.

There is an increasing recognition of the importance of interactions between the heart and the autonomic nervous system in the pathophysiology of arrhythmias. These interactions play a role in both the initiation and maintenance of arrhythmias and are important in both atrial and ventricular arrhythmia. Given the importance of the autonomic nervous system in the pathophysiology of arrhythmias, there has been notable effort in the field to improve existing therapies and pioneer additional interventions directed at cardiac-autonomic targets. The interventions are targeted to multiple and different anatomic targets across the neurocardiac axis. The purpose of this review is to provide an overview of the rationale for neuromodulation in the treatment of arrhythmias and to review the specific treatments under evaluation and development for the treatment of both atrial fibrillation and ventricular arrhythmias.

The differences in the relationship between obstructive sleep apnea severity and trabecular bone score in men and women with type 2 diabetes

Aims

Type 2 diabetes mellitus (T2DM) and obstructive sleep apnea (OSA) may adversely affect bone. Gender is a well-established factor influencing bone health. We investigated the impact of OSA on bone mineral density (BMD) and trabecular bone score (TBS) in T2DM.

Methods

Eighty-one T2DM patients [33 men and 48 women] participated. OSA was diagnosed using an overnight monitor, with its severity assessed by an apnea hypopnia index (pAHI). The measurements of hypoxia, including the percentage of total sleep time in which oxygen saturation remains below 90% (pT90), the oxygen desaturation index (pODI) and minimum O₂ (min O₂), were reported. Lumbar spine (L1-4) and femoral neck (FN) BMD were measured using dual-energy X-ray absorptiometry (DXA). TBS was computed from DXA images.

Results

Sixty-five patients (80.2%) had OSA. pAHI, pT90, pODI and min O₂ were not correlated to L1-4 BMD, FN BMD or TBS in all participants by multiple regression analyses adjusting for age, gender and BMI. However, an interaction between gender and pAHI, and gender and pODI were significantly associated with TBS (b = 0.003, p = 0.034 and b = 0.004, p = 0.046, respectively). We therefore reassessed an association between pAHI or pODI and TBS separately between men and women. After adjusting for age and BMI, more severe OSA (higher pAHI) and higher pODI significantly associated with lower TBS (b = -0.002, p = 0.034 and b = -0.003, p = 0.021, respectively) in men. On the other hand, higher pAHI non-significantly associated with better trabecular microarchitecture as indicated by higher TBS (b = 0.002, p = 0.059) in women. When considered only postmenopausal (n = 33), higher pAHI and higher pODI were significantly associated with higher TBS (b = 0.004, p = 0.003 and b = 0.004, p = 0.008, respectively).

Conclusions

In T2DM patients, there is a complex interrelationship among OSA severity, gender and TBS. More severe OSA predicted lower TBS in men, but predicted higher TBS in postmenopausal women.

Magnitude of Nonalcoholic Fatty Liver Disease: Western Perspective

The incidence of nonalcoholic fatty liver disease (NAFLD) is continuing to rise worldwide, and it is estimated that this disquieting trend will continue for another 10-15 years before prevalence begins to decrease. NAFLD is the hepatic manifestation of metabolic syndrome. As obesity, diabetes, and other lifestyle-related diseases continue to rise, the spectrum of NAFLD, e.g., nonalcoholic steatohepatitis, liver fibrosis, liver cirrhosis, liver-related morbidity, and mortality, will increase in parallel. Its widespread prevalence and associated economic burden have drawn significant attention, and a multitude of pharmaceutical companies are participating in active research trying to find a "cure". Unfortunately, as of now, no targeted treatment exists to treat this condition, and therefore, emphasis has been on its prevention. The current review focuses on the epidemiology, clinical characteristics, risk factors, and clinical outcomes of NAFLD in Western countries. It is important to understand the magnitude of NAFLD and its risk factors in Western countries where the prevalence of NAFLD has now reached epidemic proportions to identify the best strategy to prevent and possibly control this epidemic.

Sex-specific hippocampus volume changes in obstructive sleep apnea

Introduction

Obstructive sleep apnea (OSA) patients show hippocampal-related autonomic and neurological symptoms, including impaired memory and depression, which differ by sex, and are mediated in distinct hippocampal subfields. Determining sites and extent of hippocampal sub-regional injury in OSA could reveal localized structural damage linked with OSA symptoms.

Methods

High-resolution T1-weighted images were collected from 66 newly-diagnosed, untreated OSA (mean age ± SD: 46.3 ± 8.8 years; mean AHI ± SD: 34.1 ± 21.5 events/h;50 male) and 59 healthy age-matched control (46.8 ± 9.0 years;38 male) participants. We added age-matched controls with T1-weighted scans from two datasets (IXI, OASIS-MRI), for 979 controls total (426 male/46.5 ± 9.9 years). We segmented the hippocampus and analyzed surface structure with “FSL FIRST” software, scaling volumes for brain size, and evaluated group differences with ANCOVA (covariates: total-intracranial-volume, sex; P < .05, corrected).

Results

In OSA relative to controls, the hippocampus showed small areas larger volume bilaterally in CA1 (surface displacement ≤0.56 mm), subiculum, and uncus, and smaller volume in right posterior CA3/dentate (≥ − 0.23 mm). OSA vs. control males showed higher bilateral volume (≤0.61 mm) throughout CA1 and subiculum, extending to head and tail, with greater right-sided increases; lower bilateral volumes (≥ − 0.45 mm) appeared in mid- and posterior-CA3/dentate. OSA vs control females showed only right-sided effects, with increased CA1 and subiculum/uncus volumes (≤0.67 mm), and decreased posterior CA3/dentate volumes (≥ − 0.52 mm). Unlike males, OSA females showed volume decreases in the right hippocampus head and tail.

Conclusions

The hippocampus shows lateralized and sex-specific, OSA-related regional volume differences, which may contribute to sex-related expression of symptoms in the sleep disorder. Volume increases suggest inflammation and glial activation, whereas volume decreases suggest long-lasting neuronal injury; both processes may contribute to dysfunction in OSA.

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The hippocampus in OSA shows areas of increased and decreased volume.

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The injury is sex-specific, in subregions related to symptoms in females and males.

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Injury may be inflammation (volume increases) or cell death (volume decreases).

Normalization of Testosterone Levels After Testosterone Replacement Therapy Is Not Associated With Reduced Myocardial Infarction in Smokers

Objective

To examine the effect of cigarette smoking (CS) status and total testosterone (TT) levels after testosterone replacement therapy (TRT) on all-cause mortality, myocardial infarction (MI), and stroke in male smokers and nonsmokers without history of MI and stroke.

Participants and Methods

Data from 18,055 males with known CS status and low TT levels who received TRT at the Veterans Health Administration between December 1, 1999, and May 31, 2014, were grouped into (1) current smokers with normalized TT, (2) current smokers with nonnormalized TT, (3) nonsmokers with normalized TT, and (4) nonsmokers with nonnormalized TT. Combined effect of CS status and TT level normalization after TRT on all-cause mortality, MI, and stroke was compared using propensity score–weighted Cox proportional hazard models.

Results

Normalization of serum TT levels in nonsmokers was associated with a significant decrease in all-cause mortality (hazard ratio [HR]=0.526; 95% CI, 0.477-0.581; P<.001) and MI (HR=0.717; 95% CI, 0.522-0.986; P<.001). Among current smokers, normalization of serum TT levels was associated with a significant decrease in only all-cause mortality (HR=0.563; 95% CI, 0.488-0.649; P<.001) without benefit in MI (HR=1.096; 95% CI, 0.698-1.720; P=.69). Importantly, compared with nonsmokers with normalized TT, all-cause mortality (HR=1.242; 95% CI, 1.104-1.396; P<.001), MI (HR=1.706; 95% CI, 1.242-2.342; P=.001), and stroke (HR=1.590; 95% CI, 1.013-2.495; P=.04) were significantly higher in current smokers with normalized TT.

Conclusion

We conclude that active CS may negate the protective effect of testosterone level normalization on all-cause mortality and MI after TRT.

The family role in children׳s sleep disturbances: Results from a cross-sectional study in a Portuguese Urban pediatric population

Background

Sleep Disorders (SlD) are frequently undervalued complaints in childhood. Several factors influence sleep, particularly socio-cultural environment and medical conditions such as breathing disorders. Poor sleep hygiene has physical, educational and social consequences. In Portugal, there are few published studies about children׳s sleep habits and rarely based on validated questionnaires.

Aim

To study the prevalence of SlD and associated factors, in an outpatient pediatric population of a Primary Health Care Center (PHCC).

Methods

Cross-sectional study of children admitted to a PHCC on a suburban area of Lisbon. Children Sleep Habits Questionnaire, validated for the Portuguese population (CSHQ-PT) for the screening of SlD (cut-off=44), was applied to parents, as well as a demographic inquiry. Body mass index z-score was evaluated. Children scoring 44 or above were sent to Pediatric Sleep Disorders consultation (PSDC). Parametric and non-parametric tests were used whenever appropriate.

Results

From 128 children, 57.8% were male; the median age was 6.0 years (P₂₅=5.0; P₇₅=8.0). The median of cohabitants per family was 4.0 (P₂₅=3.0; P₇₅=5.0); 21.1% lived in a single-parent family. From CSHQ-PT, 59.4% (76) scored above the cut-off. Data showed that children from a single-parent family have more SlD (p=0.048), particularly parasomnia (p=0.019). Children with sleep disordered breathing (SDB) suffer more daytime sleepiness (p=0.034). From 63 children sent to PSDC, 33 attended. Regarding these children, a difference was found between BMI z-scores of those with and without SDB (p=0.06).

Conclusion

Family structure plays a non-negligible role in children’s sleep habits. Daily performance of children with SDB may become compromised.

Association of Sleep Disorders with Nonalcoholic Fatty Liver Disease (NAFLD): A Population-based Study

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is a major cause of chronic liver disease. In smaller studies, sleep apnea has been previously associated with NAFLD. The aim of this study was to assess the prevalence and independent associations of sleep disorders in patients with NAFLD using recent population-based data.

METHODS

Three cycles of the National Health and Nutrition Examination Survey (NHANES) conducted between 2005 and 2010 were used. The diagnosis of NAFLD was established as elevated liver enzymes in the absence of all other causes of chronic liver disease. Sleep disorders were diagnosed using sleep disorder questionnaires completed by NHANES participants, and included self-reported history of sleep apnea, insomnia, and restless leg syndrome. The prevalence of sleep disorders was compared between those with and without NAFLD.

RESULTS

A total of 10,541 adult NHANES participants with complete demographic, clinical, and laboratory data were included. Of those, 15.0% had NAFLD and 7.2% reported having sleep disorders. Of those with sleep disorders, 64.7% reported history of sleep apnea, 16.0% had history of insomnia, and 4.0% had restless leg syndrome. Individuals with NAFLD were more likely to be male (53.8% vs. 45.7%, P < 0.0001), obese (50.1% vs. 33.4%, P < 0.0001) and had higher prevalence of sleep disorders (9.1% vs. 6.9%, P = 0.0118). In multivariate analysis, having any sleep disorder, sleep apnea and insomnia were all independently associated with NAFLD [OR (95% CI) = 1.40 (1.11-1.76), OR = 1.39 (0.98-1.97), and OR = 2.17 (1.19-3.95); respectively)].

CONCLUSIONS

This large population-based data suggests that NAFLD is associated with sleep disorders. Although the exact mechanism is unknown, this association is most likely through metabolic conditions associated with NAFLD.

Epidemiology and Natural History of Non-alcoholic Fatty Liver Disease

Non-alcoholic fatty liver disease (NAFLD) is an important cause of liver disease burden across the world. By definition, although the histopathologic features of NAFLD are identical to that of alcoholic liver disease, its diagnosis requires absence of significant alcohol use and absence of other causes of chronic liver disease. We now know that NAFLD is not simply a disease of the Western world. It is manifested across the world, in varying rates, across gender, across varying ethnicities, and in its association with other host factors. In this review article, the definition of NAFLD, its spectrum, ranging from mild steatosis to hepatocellular injury and inflammation defined as non-alcoholic steatohepatitis (NASH) is discussed. Mild steatosis is generally a stable disease whereas NASH can be progressive. Based on current published literature, current incidence and prevalence of NAFLD and NASH are discussed. It is also accepted that these processes will continue to increase in prevalence with the rise of obesity, type II diabetes, and associated metabolic syndrome. Some of the risk factors have been well-established and are discussed. In addition, this review also presents emerging associations with other risk factors for NAFLD. Natural history of NAFLD is variable depending upon the histologic subtypes and other underlying comorbidities and is discussed in this review as well.