Experimentally Induced Peripheral Venous Congestion Exacerbates Inflammation, Oxidative Stress, and Neurohormonal and Endothelial Cell Activation in Patients With Systolic Heart Failure

BACKGROUND

Venous congestion (VC) is a hallmark of symptomatic heart failure (HF) requiring hospitalization; however, its role in the pathogenesis of HF progression remains unclear. We investigated whether peripheral VC exacerbates inflammation, oxidative stress and neurohormonal and endothelial cell (EC) activation in patients with HF with reduced ejection fraction (HFrEF).

METHODS AND RESULTS

Two matched groups of patients with HFrEF and with no peripheral VC vs without recent HF hospitalization were studied. We modeled peripheral VC by inflating a cuff around the dominant arm, targeting ∼ 30 mmHg increase in venous pressure (venous stress test [VST]). Blood and ECs were sampled before and after 90 minutes of VST. We studied 44 patients (age 53 ± 12 years, 32% female). Circulating endothelin-1, tumor necrosis factor-α, interleukin-6, isoprostane, angiotensin II (ang-2), angiopoietin-2, vascular cell adhesion molecule-1, and CD146 significantly increased after the VST. Enhanced endothelin-1 and angiopoietin-2 responses to the VST were present in patients with vs without recent hospitalization and were prospectively associated with incident HF-related events; 6698 messenger ribonucleic acid (mRNA probe sets were differentially expressed in ECs after VST.

CONCLUSIONS

Experimental VC exacerbates inflammation, oxidative stress, neurohormonal and EC activation and promotes unfavorable transcriptome remodeling in ECs of patients with HFrEF. A distinct biological sensitivity to VC appears to be associated with high risk for HF progression.

CPAP may promote an endothelial inflammatory milieu in sleep apnoea after coronary revascularization

BACKGROUND

Continuous positive airway pressure (CPAP) has failed to reduce cardiovascular risk in obstructive sleep apnoea (OSA) in randomized trials. CPAP increases angiopoietin-2, a lung distension-responsive endothelial proinflammatory marker associated with increased cardiovascular risk. We investigated whether CPAP has unanticipated proinflammatory effects in patients with OSA and cardiovascular disease.

METHODS

Patients with OSA (apnoea-hypopnea index [AHI] ≥15 events/h without excessive sleepiness) in the Randomized Intervention with CPAP in Coronary Artery Disease and OSA study were randomized to CPAP or usual care following coronary revascularization. Changes in plasma levels of biomarkers of endothelial (angiopoietin-2, Tie-2, E-selectin, vascular endothelial growth factor [VEGF-A]) and lung epithelial (soluble receptor of advanced glycation end-products [sRAGE]) function from baseline to 12-month follow-up were compared across groups and associations with cardiovascular morbidity and mortality assessed.

FINDINGS

Patients with OSA (n = 189; 84% men; age 66 ± 8 years, BMI 28 ± 3.5 kg/m2, AHI 41 ± 23 events/h) and 91 patients without OSA participated. Angiopoietin-2 remained elevated whereas VEGF-A declined significantly over 12 months in the CPAP group (n = 91). In contrast, angiopoietin-2 significantly declined whereas VEGF-A remained elevated in the usual care (n = 98) and OSA-free groups. The changes in angiopoietin-2 and VEGF-A were significantly different between CPAP and usual care, whereas Tie-2, sRAGE and E-selectin were similar. Greater 12-month levels of angiopoietin-2 were associated with greater mortality. Greater CPAP levels were associated with worse cardiovascular outcomes.

INTERPRETATION

Greater CPAP levels increase proinflammatory, lung distension-responsive angiopoietin-2 and reduce cardioprotective angiogenic factor VEGF-A compared to usual care, which may counteract the expected cardiovascular benefits of treating OSA.

FUNDING

National Institutes of Health/National Heart, Lung, and Blood Institute; Swedish Research Council; Swedish Heart-Lung Foundation; ResMed Foundation.

Chronic Insufficient Sleep in Women Impairs Insulin Sensitivity Independent of Adiposity Changes: Results of a Randomized Trial

OBJECTIVE

Insufficient sleep is associated with type 2 diabetes, yet the causal impact of chronic insufficient sleep on glucose metabolism in women is unknown. We investigated whether prolonged mild sleep restriction (SR), resembling real-world short sleep, impairs glucose metabolism in women.

RESEARCH DESIGN AND METHODS

Women (aged 20-75 years) without cardiometabolic diseases and with actigraphy-confirmed habitual total sleep time (TST) of 7-9 h/night were recruited to participate in this randomized, crossover study with two 6-week phases: maintenance of adequate sleep (AS) and 1.5 h/night SR. Outcomes included plasma glucose and insulin levels, HOMA of insulin resistance (HOMA-IR) values based on fasting blood samples, as well as total area under the curve for glucose and insulin, the Matsuda index, and the disposition index from an oral glucose tolerance test.

RESULTS

Our sample included 38 women (n = 11 postmenopausal women). Values are reported with ±SEM. Linear models adjusted for baseline outcome values demonstrated that TST was reduced by 1.34 ± 0.04 h/night with SR versus AS (P < 0.0001). Fasting insulin (β = 6.8 ± 2.8 pmol/L; P = 0.016) and HOMA-IR (β = 0.30 ± 0.12; P = 0.016) values were increased with SR versus AS, with effects on HOMA-IR more pronounced in postmenopausal women compared with premenopausal women (β = 0.45 ± 0.25 vs. β = 0.27 ± 0.13, respectively; P for interaction = 0.042). Change in adiposity did not mediate the effects of SR on glucose metabolism or change results in the full sample when included as a covariate.

CONCLUSIONS

Curtailing sleep duration to 6.2 h/night, reflecting the median sleep duration of U.S. adults with short sleep, for 6 weeks impairs insulin sensitivity, independent of adiposity. Findings highlight insufficient sleep as a modifiable risk factor for insulin resistance in women to be targeted in diabetes prevention efforts.

Paradoxical Effects of Prolonged Insufficient Sleep on Lipid Profile: A Pooled Analysis of 2 Randomized Trials

Background Insufficient sleep is associated with increased cardiovascular disease risk, but causality is unclear. We investigated the impact of prolonged mild sleep restriction (SR) on lipid and inflammatory profiles. Methods and Results Seventy-eight participants (56 women [12 postmenopausal]; age, 34.3±12.5 years; body mass index, 25.8±3.5 kg/m2) with habitual sleep duration 7 to 9 h/night (adequate sleep [AS]) underwent two 6-week conditions in a randomized crossover design: AS versus SR (AS-1.5 h/night). Total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol, triglycerides, and inflammatory markers (CRP [C-reactive protein], interleukin 6, and tumor necrosis factor-α) were assessed. Linear models tested effects of SR on outcomes in the full sample and by sex+menopausal status (premenopausal versus postmenopausal women+men). In the full sample, SR increased high-density lipoprotein cholesterol compared with AS (β=1.2±0.5 mg/dL; P=0.03). Sex+menopausal status influenced the effects of SR on change in total cholesterol (P-interaction=0.04), LDL-C (P-interaction=0.03), and interleukin 6 (P-interaction=0.07). Total cholesterol and LDL-C decreased in SR versus AS in premenopausal women (total cholesterol: β=-4.2±1.9 mg/dL; P=0.03; LDL-C: β=-6.3±2.0 mg/dL; P=0.002). Given paradoxical effects of SR on cholesterol concentrations, we explored associations between changes in inflammation and end point lipids under each condition. Increases in interleukin 6 and tumor necrosis factor-α during SR tended to relate to lower LDL-C in premenopausal women (interleukin 6: β=-5.3±2.6 mg/dL; P=0.051; tumor necrosis factor-α: β=-32.8±14.2 mg/dL; P=0.027). Conclusions Among healthy adults, prolonged insufficient sleep does not increase atherogenic lipids. However, increased inflammation in SR tends to predict lower LDL-C in premenopausal women, resembling the "lipid paradox" in which low cholesterol associates with increased cardiovascular disease risk in proinflammatory conditions. Registration URL: https://www.clinicaltrials.gov; Unique identifiers: NCT02835261, NCT02960776.

Mild sleep restriction increases endothelial oxidative stress in female persons

Sleep restriction is associated with increased cardiovascular risk, which is more pronounced in female than male persons. We reported recently first causal evidence that mild, prolonged sleep restriction mimicking "real-life" conditions impairs endothelial function, a key step in the development and progression of cardiovascular disease, in healthy female persons. However, the underlying mechanisms are unclear. In model organisms, sleep restriction increases oxidative stress and upregulates antioxidant response via induction of the antioxidant regulator nuclear factor (erythroid-derived 2)-like 2 (Nrf2). Here, we assessed directly endothelial cell oxidative stress and antioxidant responses in healthy female persons (n = 35) after 6 weeks of mild sleep restriction (1.5 h less than habitual sleep) using randomized crossover design. Sleep restriction markedly increased endothelial oxidative stress without upregulating antioxidant response. Using RNA-seq and a predicted protein-protein interaction database, we identified reduced expression of endothelial Defective in Cullin Neddylation-1 Domain Containing 3 (DCUN1D3), a protein that licenses Nrf2 antioxidant responses, as a mediator of impaired endothelial antioxidant response in sleep restriction. Thus, sleep restriction impairs clearance of endothelial oxidative stress that over time increases cardiovascular risk.Trial Registration: NCT02835261 .

Statins Restore Endothelial Protection against Complement Activity in Obstructive Sleep Apnea: A Randomized Clinical Trial

Rationale: Increased cardiovascular risk in obstructive sleep apnea (OSA) persists after continuous positive airway pressure (CPAP) and alternative therapies are needed. Impaired endothelial protection against complement is a cholesterol-dependent process that initiates endothelial inflammation in OSA, which increases cardiovascular risk. Objectives: To investigate directly whether lowering cholesterol improves endothelial protection against complement and its proinflammatory effects in OSA. Methods: Newly diagnosed patients with OSA (n = 87) and OSA-free controls (n = 32) participated. Endothelial cells and blood were collected at baseline, after 4 weeks of CPAP therapy, and again after 4 weeks of 10 mg atorvastatin versus placebo using a randomized, double-blind, parallel-group design. Primary outcome was the proportion of a complement inhibitor, CD59, on the endothelial cell plasma membrane in OSA patients after 4 weeks of statins versus placebo. Secondary outcomes were complement deposition on endothelial cells and circulating levels of its downstream proinflammatory factor, angiopoietin-2, after statins versus placebo. Results: Baseline expression of CD59 was lower, whereas complement deposition on endothelial cells and levels of angiopoietin-2 were greater, in patients with OSA compared with controls. CPAP did not affect expression of CD59 or complement deposition on endothelial cells in patients with OSA, regardless of adherence. Compared with placebo, statins increased expression of endothelial complement protector CD59 and lowered complement deposition in patients with OSA. Good CPAP adherence was associated with increased angiopoietin-2 levels, which was reversed by statins. Conclusions: Statins restore endothelial protection against complement and reduce its downstream proinflammatory effects, suggesting a potential approach to reduce residual cardiovascular risk after CPAP in patients with OSA. Clinical trial registered with www.clinicaltrials.gov (NCT03122639).

Racial/ethnic disparities in sleep-disordered breathing during pregnancy in the nuMoM2b study

OBJECTIVE

The aim of this study was to assess the prevalence and severity of sleep-disordered breathing (SDB) across racial/ethnic groups in 3702 pregnant people at 6 to 15 and 22 to 31 weeks gestational age, examine whether BMI modifies the association between race/ethnicity and SDB, and investigate whether interventions to reduce weight might reduce racial/ethnic disparities in SDB.

METHODS

Differences by race/ethnicity in SDB prevalence and severity were quantified via linear, logistic, or quasi-Poisson regression. Controlled direct effect was used to estimate whether intervening on BMI would remove/diminish differences by race/ethnicity in SDB severity.

RESULTS

This study comprised 61.2% non-Hispanic White (nHW), 11.9% non-Hispanic Black (nHB), 18.5% Hispanic, and 3.7% Asian people. SDB prevalence was higher for nHB compared with nHW pregnant people at 6 to 15 weeks (odds ratio [OR] 1.81, 95% CI [1.07, 2.97]), whereas at 21 to 32 weeks, Asian pregnant people had a higher SDB prevalence than nHW (OR 2.2, 95% CI [1.1, 4.0]). The severity of SDB differed across racial/ethnic groups in early pregnancy, with nHB pregnant people having a higher apnea-hypopnea index (AHI) (OR 1.35, 95% CI [1.07, 1.69]) compared with nHW. Having overweight/obesity was associated with a higher AHI (β = 2.36, 95% CI [1.97, 2.84]). Controlled direct effect analyses indicated that in early pregnancy, nHB and Hispanic pregnant people would have a lower AHI compared with nHW people had they had normal weight.

CONCLUSIONS

This study extends knowledge on racial/ethnic disparities in SDB to a pregnant population.

Effect of positive airway pressure therapy of obstructive sleep apnea on circulating Angiopoietin-2

BACKGROUND

Obstructive sleep apnea (OSA) has been identified as a possible contributor to interstitial lung disease. While positive airway pressure (PAP) is effective therapy for OSA, it causes large increases in lung volumes during the night that are potentially deleterious, analogous to ventilator-induced lung injury, although this has not been previously studied. The goal of this study was to assess the impact of PAP therapy on four biomarkers of alveolar epithelial and endothelial injury and extracellular matrix remodeling in patients with OSA.

METHODS

In 82 patients with moderate to severe OSA who were adherent to PAP therapy, surfactant protein D, osteopontin, angiopoietin-2, and matrix metalloprotease-7 were measured by ELISA in serum samples collected before and 3- to 6-months after initiation of PAP therapy.

RESULTS

An increase in angiopoietin-2 level of 0.28 ng/mL following PAP therapy was observed (p = 0.007). This finding was replicated in an independent sample of OSA patients. No significant change was detected in surfactant protein D, osteopontin, or matrix metalloprotease-7.

CONCLUSIONS

This finding raises concern for a possible adverse impact of PAP therapy on vascular endothelium.

Abstract MP05: Night-to-night Variability In Sleep Duration Is Associated With Higher Energy Intake And Poorer Diet Quality In The Multi-Ethnic Study Of Atherosclerosis

Introduction: Variability in sleep patterns is an emerging risk factor for metabolic and cardiovascular diseases (CVD). Poor diet likely contributes to these relations, given the intricate link between sleep and diet, both of which are important determinants of cardiometabolic health. However, associations of irregular sleep with energy intake and consumption of a Mediterranean diet pattern, key markers of diet quantity and quality predictive of CVD risk, have not been evaluated.

Hypothesis: Greater night-to-night variability in sleep duration will be associated with higher energy intake and poorer diet quality, defined as lower alternate Mediterranean (aMed) diet scores (range: 0-9).

Methods: This was a cross-sectional analysis of 2,007 men and women (age: 68.6±9.2 y, 61% racial/ethnic minority) from the Multi-Ethnic Study of Atherosclerosis Sleep Ancillary Study. The standard deviation (SD) of sleep duration, derived from 1-wk of wrist actigraphy, was used as a measure of sleep duration variability. Diet, including daily energy intake, aMed score, and consumption of aMed components, was ascertained from a food frequency questionnaire. Multivariable linear regression models adjusted for age, race/ethnicity, sex, study site, marital status, and education, evaluated associations of sleep duration variability with diet. Sensitivity analyses, also adjusted for sociodemographic factors, were conducted to evaluate relations of weekday sleep duration SD, a potentially more representative measure of habitual sleep, with diet.

Results: Mean sleep duration variability was 84±48 min. Greater sleep duration variability was associated with higher energy intake and lower aMed score; each 30-min increase in sleep duration SD related to 23±11 more kcal/d (P=0.04) and 0.06±0.02 lower aMed score (P=0.02). Higher sleep duration SD (per 30 min increase) was also associated with lower intakes of whole grains (β=-0.01±0.01, P<0.05), nuts/seeds (β=-0.01±0.01, P=0.02), and monounsaturated to saturated fat ratio (β=-0.02±0.01, P=0.02). Results of sensitivity analyses showed that each 30-min increase in weekday sleep duration SD was associated with 28±11 kcal higher energy intake (P=0.01) and 0.06±0.02 lower aMed score (P=0.02) as well as 0.02±0.01 and 0.01±0.01 fewer servings (per 1000 kcal) of whole grains and seeds/nuts, respectively (P<0.01).

Conclusions: We provide novel initial evidence that irregular sleep duration, particularly during weekdays, may contribute to overconsumption and poor diet quality. Further investigation into a possible mechanistic role of diet in the association of sleep variability with cardiometabolic disease risk is warranted. Longitudinal or experimental data are needed to elucidate a potential complex interplay between sleep duration variability, diet, and other health and lifestyle factors, including physical activity, obesity, and depression.

Go Red for Women Strategically Focused Research Network: Summary of Findings and Network Outcomes

The Go Red for Women movement was initiated by the American Heart Association (AHA) in the early 2000s to raise awareness concerning cardiovascular disease (CVD) risk in women. In 2016, the AHA funded 5 research centers across the United States to advance our knowledge of the risks and presentation of CVD that are specific to women. This report highlights the findings of the centers, showing how insufficient sleep, sedentariness, and pregnancy-related complications may increase CVD risk in women, as well as presentation and factors associated with myocardial infarction with nonobstructive coronary arteries and heart failure with preserved ejection fraction in women. These projects were augmented by collaborative ancillary studies assessing the relationships between various lifestyle behaviors, including nightly fasting duration, mindfulness, and behavioral and anthropometric risk factors and CVD risk, as well as metabolomic profiling of heart failure with preserved ejection fraction in women. The Go Red for Women Strategically Focused Research Network enhanced the evidence base related to heart disease in women, promoting awareness of the female-specific factors that influence CVD.

Complement promotes endothelial von Willebrand factor and angiopoietin-2 release in obstructive sleep apnea

STUDY OBJECTIVE

Obstructive sleep apnea (OSA) is highly prevalent and triples vascular thromboembolic risk. Intermittent hypoxia (IH) during transient cessation of breathing in OSA impairs endothelial protection against complement. Complement activation stimulates the endothelial release of a pro-thrombotic von Willebrand factor (vWF). We investigated whether increased complement activity in OSA promotes the endothelial release of vWF and pro-inflammatory angiopoietin-2. We further investigated whether improving complement protection with statins reverses these changes.

METHODS

Using endothelial cells (ECs) and blood collected from OSA patients (n = 109) and controls (n = 67), we assessed whether altered cellular localization of complement inhibitor CD59 in OSA modulates exocytosis of Weibel-Palade bodies (WPB), secretory granules that store vWF and angiopoietin-2. These interactions were also assessed in vitro in ECs exposed to normoxia or IH with or without recombinant complement C9 and with or without atorvastatin.

RESULTS

Circulating levels of angiopoietin-2 were greater in OSA than controls and levels of vWF cleavage products correlated with OSA severity. In cultured ECs, IH enhanced complement-stimulated angiopoietin-2 and vWF release by reducing EC surface and increasing intracellular expression of complement inhibitor CD59. Intracellular CD59 co-localized with WPB in OSA. IH increased binding of intracellular CD59 to syntaxin-3, which dissociated syntaxin-3 from voltage-sensitive calcium channel Cav1.2, and activated WPB exocytosis in a calcium-dependent manner. Atorvastatin reversed IH-enhanced endothelial release of vWF and angiopoietin-2.

CONCLUSIONS

IH promotes the complement-mediated release of vWF and angiopoietin-2, which may contribute to pro-thrombotic and pro-inflammatory conditions in OSA. Statin reversed these effects, suggesting a potential approach to reduce cardiovascular risk in OSA.

Prone Positioning in Awake, Nonintubated Patients With COVID-19 Hypoxemic Respiratory Failure

This cohort study investigates whether the prone position is associated with improved oxygenation and decreased risk for intubation in spontaneously breathing patients with severe COVID-19 hypoxemic respiratory failure.

Impact of change in bedtime variability on body composition and inflammation: secondary findings from the Go Red for Women Strategically Focused Research Network

Variability in daily sleep patterns is an emerging factor linked to metabolic syndrome. However, whether reducing bedtime variability improves markers of disease risk has not been tested. Here, we assessed whether body composition and inflammation were impacted by changes in bedtime variability over a 6-week period, during which, women were instructed to maintain healthy, habitual sleep (HS) patterns (one arm of a randomized trial). Data were available for 37 women (age 34.9 ± 12.4 years, BMI 24.7 ± 2.9 kg/m2, sleep duration 7.58 ± 0.49 h/night). Body composition and leukocyte platelet aggregates (LPA) were measured at baseline and endpoint using magnetic resonance imaging and flow cytometry, respectively. Sleep data were collected daily using wrist actigraphy. Change in bedtime variability was calculated as the difference in the standard deviation (SD) of bedtimes measured during the 2-week screening period and the 6-week intervention period. Results showed that women who reduced their bedtime variability (n = 29) during the intervention had reductions in total (P < 0.001) and subcutaneous adipose tissue (P < 0.001) relative to women who increased/maintained (n = 8) bedtime variability. Similar effects were observed for LPA levels between women who reduced vs increased/maintained bedtime variability (P = 0.011). Thus, reducing bedtime variability, without changing sleep duration, could improve cardiometabolic health by reducing adiposity and inflammation.

Sleep Regularity and Cardiometabolic Heath: Is Variability in Sleep Patterns a Risk Factor for Excess Adiposity and Glycemic Dysregulation?

PURPOSE OF REVIEW

Night-to-night variability in sleep patterns leads to circadian disruption and, consequently, could increase cardiometabolic risk. The purpose of this review is to summarize findings from studies published between 2015 and 2020 examining various measures of night-to-night variability in sleep in relation to metabolic syndrome (MetS), type 2 diabetes (T2D), and their risk factors. We illustrate a potential causal pathway between irregular sleep patterns and T2D, highlighting knowledge gaps along the way.

RECENT FINDINGS

Across different measures of sleep variability, irregular sleep patterns were associated with poorer cardiometabolic outcomes. Higher standard deviations (SD) across nights of sleep duration and onset or midpoint of sleep were associated with increased odds of having MetS and clusters of metabolic abnormalities as well as greater adiposity and poorer glycemic control. Conversely, greater regularity of rest-activity patterns related to lower risk for T2D. Social jetlag was associated with glycemic dysregulation, adiposity, T2D, and MetS. These associations are often observed in both metabolically healthy and unhealthy individuals; both higher SD of sleep duration and social jetlag relate to poorer glucose regulation in individuals with diabetes. There is consistent evidence of associations of sleep variability with increased risk for adiposity, glucose dysregulation, T2D, and MetS. Although experimental evidence is needed to determine causation, there is support to recommend stabilizing sleep patterns for cardiometabolic risk prevention.

Activated Platelets Induce Endothelial Cell Inflammatory Response in Psoriasis via COX-1

OBJECTIVE

Patients with psoriasis have impaired vascular health and increased cardiovascular disease (CVD). Platelets are key players in the pathogenesis of vascular dysfunction in cardiovascular disease and represent therapeutic targets in cardiovascular prevention. The object of this study was to define the platelet phenotype and effector cell properties on vascular health in psoriasis and evaluate whether aspirin modulates the platelet-induced phenotype. Approach and Results: Platelets from psoriasis patients (n=45) exhibited increased platelet activation (relative to age- and gender-matched controls, n=18), which correlated with psoriasis skin severity. Isolated platelets from psoriasis patients demonstrated a 2- to 3-fold (P<0.01) increased adhesion to human aortic endothelial cells and induced proinflammatory transcriptional changes, including upregulation of IL 8 (interleukin 8), IL1β, and Cox (cyclooxygenase)-2 Platelet RNA sequencing revealed an interferon signature and elevated expression of COX-1, which correlated with psoriasis disease severity (r=0.83, P=0.01). In a randomized trial of patients with psoriasis, 2 weeks of 81 mg low-dose aspirin, a COX-1 inhibitor, reduced serum thromboxane (Tx) B2 and reduced brachial vein endothelial proinflammatory transcript expression >70% compared with the no-treatment group (P<0.01). Improvement in brachial vein endothelial cell inflammation significantly correlated with change in serum TxB2 (r=0.48, P=0.02).

CONCLUSIONS

In patients with psoriasis, platelets are activated and induce endothelial cell inflammation. Low-dose aspirin improved endothelial cell health in psoriasis via platelet COX-1 inhibition. These data demonstrate a previously unappreciated role of platelets in psoriasis and endothelial cell inflammation and suggests that aspirin may be effective in improving vascular health in patients with psoriasis. Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT03228017.