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Imani MM, Sadeghi M, Khazaie H, Emami M, Sadeghi Bahmani D, Brand S. Serum and Plasma Tumor Necrosis Factor Alpha Levels in Individuals with Obstructive Sleep Apnea Syndrome: A Meta-Analysis and Meta-Regression. Life (Basel) 2020; 10:E87. [PMID: 32545460 PMCID: PMC7345342 DOI: 10.3390/life10060087] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/02/2020] [Accepted: 06/09/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Obstructive sleep apnea syndrome (OSAS) is associated with a variety of inflammatory factors. Specifically, proinflammatory cytokines appear to be associated with the pathogenesis of OSAS. METHODS For the present meta-analysis and meta-regression on serum and plasma tumor necrosis factor alpha (TNF-α) levels in individuals with and without OSAS, we performed a systematic search without any restrictions of the PubMed/Medline, Scopus, Cochrane Library, and Web of Science databases to find relevant articles published up to February 1, 2020. RESULTS Fifty-five (adults: 29 studies on serum and 17 studies on plasma; children: 4 studies on serum and 5 studies on plasma) were included and analyzed. Always compared to age-matched healthy controls, the pooled MDs were as follows: adults, serum: 10.22 pg/mL (95% CI = 8.86, 11.58; p < 0.00001); adults, plasma: 5.90 pg/mL (95% CI = 4.00, 7.80; p < 0.00001); children, serum: 0.21 pg/mL (95% CI = 0.05, 0.37; p = 0.01); children, plasma: 5.90 pg/mL (95% CI = 4.00, 7.80; p < 0.00001). CONCLUSIONS Compared to healthy and age-matched controls, adult individuals with OSAS had significantly higher serum/plasma TNF-α levels. For children with OSAS, significantly higher levels were observed for TNF-α in serum but not in plasma.
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Affiliation(s)
- Mohammad Moslem Imani
- Department of Orthodontics, Kermanshah University of Medical Sciences, 6713954658 Kermanshah, Iran;
| | - Masoud Sadeghi
- Medical Biology Research Center, Kermanshah University of Medical Sciences, 6714415185 Kermanshah, Iran;
| | - Habibolah Khazaie
- Sleep Disorders Research Center, Kermanshah University of Medical Sciences, 6719851115 Kermanshah, Iran; (H.K.); (D.S.B.)
| | - Mehrdad Emami
- Students Research Committee, Kermanshah University of Medical Sciences, 6715847141 Kermanshah, Iran;
| | - Dena Sadeghi Bahmani
- Sleep Disorders Research Center, Kermanshah University of Medical Sciences, 6719851115 Kermanshah, Iran; (H.K.); (D.S.B.)
- Center for Affective, Stress and Sleep Disorders, University of Basel, Psychiatric Clinics, 4001 Basel, Switzerland
- Substance Abuse Prevention Research Center, Kermanshah University of Medical Sciences, 6715847141 Kermanshah, Iran
- Departments of Physical Therapy, University of Alabama at Birmingham, Birmingham, AL 35209, USA
| | - Serge Brand
- Sleep Disorders Research Center, Kermanshah University of Medical Sciences, 6719851115 Kermanshah, Iran; (H.K.); (D.S.B.)
- Center for Affective, Stress and Sleep Disorders, University of Basel, Psychiatric Clinics, 4001 Basel, Switzerland
- Substance Abuse Prevention Research Center, Kermanshah University of Medical Sciences, 6715847141 Kermanshah, Iran
- Department of Sport, Exercise and Health, Division of Sport Science and Psychosocial Health, University of Basel, 4052 Basel, Switzerland
- School of Medicine, Tehran University of Medical Sciences, 1416753955 Tehran, Iran
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Risk Factors for Fellow Eye Involvement in Nonarteritic Anterior Ischemic Optic Neuropathy. J Neuroophthalmol 2020; 39:147-152. [PMID: 30300257 DOI: 10.1097/wno.0000000000000715] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Nonarteritic anterior ischemic optic neuropathy (NAION) is the most common acute optic neuropathy in individuals older than 50 years. Demographic, ocular, and systemic risk factors for NAION have been identified, and we sought to determine which, if any, of these factors also increase risk of NAION in the fellow eye. METHODS We performed a retrospective chart review of patients with "ischemic optic neuropathy" (based on International Classification of Disease [ICD] codes) seen at a single eye center between 2007 and 2017. Patients who met diagnostic criteria for unilateral NAION without fellow eye optic neuropathy at diagnosis were included. Demographic information, ocular comorbidities, and systemic diagnoses were recorded, in addition to whether the fellow eye developed NAION during the follow-up period. Univariate and multivariate Cox proportional hazard regression were used to calculate hazard ratios (HRs) for fellow eye involvement. RESULTS Three hundred eighteen patients were identified by ICD codes, and 119 were included in the study. Twenty-nine (24%) patients developed NAION in the fellow eye over the mean follow-up period of 3.6 years (range: 1 month-11 years). Significant risk factors for fellow eye NAION included the presence of bilateral optic disc drusen (ODD, HR 2.78, 95% confidence interval [CI] 1.12-6.90, P = 0.02) and noncompliance with continuous positive airway pressure (CPAP) in patients with moderate-to-severe obstructive sleep apnea (HR 4.50, 95% CI 1.79-11.3, P = 0.0015). CONCLUSIONS Bilateral ODD and noncompliance with CPAP when indicated are associated with increased risk of NAION in the fellow eye. Patients with these risk factors should be counseled on the potentially devastating visual consequences of bilateral NAION, and compliance with CPAP should be stressed when appropriate.
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Münzel T, Kröller-Schön S, Oelze M, Gori T, Schmidt FP, Steven S, Hahad O, Röösli M, Wunderli JM, Daiber A, Sørensen M. Adverse Cardiovascular Effects of Traffic Noise with a Focus on Nighttime Noise and the New WHO Noise Guidelines. Annu Rev Public Health 2020; 41:309-328. [PMID: 31922930 DOI: 10.1146/annurev-publhealth-081519-062400] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Exposure to traffic noise is associated with stress and sleep disturbances. The World Health Organization (WHO) recently concluded that road traffic noise increases the risk for ischemic heart disease and potentially other cardiometabolic diseases, including stroke, obesity, and diabetes. The WHO report focused on whole-day noise exposure, but new epidemiological and translational field noise studies indicate that nighttime noise, in particular,is an important risk factor for cardiovascular disease (CVD) through increased levels of stress hormones and vascular oxidative stress, leading to endothelial dysfunction and subsequent development of various CVDs. Novel experimental studies found noise to be associated with oxidative stress-induced vascular and brain damage, mediated by activation of the NADPH oxidase, uncoupling of endothelial and neuronal nitric oxide synthase, and vascular/brain infiltration with inflammatory cells. Noise-induced pathophysiology was more pronounced in response to nighttime as compared with daytime noise. This review focuses on the consequences of nighttime noise.
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Affiliation(s)
- Thomas Münzel
- Center for Cardiology, University Medical Center Mainz, 55131 Mainz, Germany; .,German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, 55131 Mainz, Germany
| | | | - Matthias Oelze
- Center for Cardiology, University Medical Center Mainz, 55131 Mainz, Germany;
| | - Tommaso Gori
- Center for Cardiology, University Medical Center Mainz, 55131 Mainz, Germany; .,German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, 55131 Mainz, Germany
| | - Frank P Schmidt
- Center for Cardiology, University Medical Center Mainz, 55131 Mainz, Germany;
| | - Sebastian Steven
- Center for Cardiology, University Medical Center Mainz, 55131 Mainz, Germany;
| | - Omar Hahad
- Center for Cardiology, University Medical Center Mainz, 55131 Mainz, Germany;
| | - Martin Röösli
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, 4051 Basel, Switzerland.,University of Basel, 4001 Basel, Switzerland
| | - Jean-Marc Wunderli
- Empa, Swiss Federal Laboratories for Materials Science and Technology, 8600 Dübendorf, Switzerland
| | - Andreas Daiber
- Center for Cardiology, University Medical Center Mainz, 55131 Mainz, Germany; .,German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, 55131 Mainz, Germany
| | - Mette Sørensen
- Diet, Genes and Environment Unit, Danish Cancer Society Research Center, 2100 Copenhagen, Denmark.,Department of Natural Science and Environment, Roskilde University, 4000 Roskilde, Denmark
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Affiliation(s)
| | - Naima Covassin
- Department of Cardiovascular Diseases (N.C., V.K.S.), Mayo Clinic, Rochester, MN
| | - Virend K Somers
- Department of Cardiovascular Diseases (N.C., V.K.S.), Mayo Clinic, Rochester, MN
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Tsuda K. Letter by Tsuda Regarding Article, "High-Sensitivity CRP (C-Reactive Protein) Is Associated With Incident Carotid Artery Plaque in Chinese Aged Adults". Stroke 2019; 50:e323. [PMID: 31623544 DOI: 10.1161/strokeaha.119.027028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kazushi Tsuda
- Cardiovascular and Metabolic Research Center, Kansai University of Health Sciences, Osaka, Japan
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Piovezan RD, Hirotsu C, Moizinho R, de Sá Souza H, D'Almeida V, Tufik S, Poyares D. Associations between sleep conditions and body composition states: results of the EPISONO study. J Cachexia Sarcopenia Muscle 2019; 10:962-973. [PMID: 31125517 PMCID: PMC6818458 DOI: 10.1002/jcsm.12445] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 03/27/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Evidence suggests anthropometric indicators of obesity are associated with changes in sleep quality and quantity, and the presence of obstructive sleep apnoea (OSA). Investigations including diverse and objective evaluations of sleep and body composition are scarce. We aimed to evaluate the associations between indicators of sleep impairment and body composition states in a sample from a population-based study. METHODS Participants of the first follow-up of the EPISONO (São Paulo, Brazil) >50 years were cross-sectionally evaluated. Sleep was assessed through questionnaires, actigraphy, and polysomnography. Body composition was evaluated by bioelectrical impedance analysis. Appendicular skeletal muscle mass adjusted for body mass index defined sarcopenia (men <0.789 and women <0.512). Total body fat defined obesity (men >30% and women >40%). The overlap between both conditions defined sarcopenic obesity (SO). Final results were obtained by multinomial logistic regression analysis. RESULTS Three hundred fifty-nine adults [mean (standard deviation) age, 61 (8.8) years; 212 (59.1%) female] were enrolled. Obesity was detected in 22.6% of the sample, sarcopenia in 5.6%, and SO in 16.2%. After controlling for covariates, OSA was associated with SO [odds ratio = 3.14, 95% confidence interval (CI) = 1.49-6.61]. Additionally, nocturnal hypoxaemia was associated with both obesity (adjusted odds ratio = 2.59, 95% CI = 1.49-4.49) and SO (odds ratio = 2.92, 95% CI = 1.39-6.13). Other indicators of poor sleep/sleep disorders were not associated with body composition states. CONCLUSIONS Sarcopenic obesity but not obesity alone was associated with OSA. Both obesity and SO but not sarcopenia were associated with nocturnal hypoxaemia. The findings suggest a complex pathophysiologic relationship between adverse body composition states and OSA. Upcoming research on risk factors and therapeutic interventions for OSA should target synchronically the lean and adipose body tissues.
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Affiliation(s)
- Ronaldo D Piovezan
- Department of Psychobiology, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Camila Hirotsu
- Department of Psychobiology, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Renato Moizinho
- Department of Psychobiology, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Helton de Sá Souza
- Department of Psychobiology, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Vania D'Almeida
- Department of Psychobiology, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Sergio Tufik
- Department of Psychobiology, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Dalva Poyares
- Department of Psychobiology, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
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Tomita Y, Kasai T, Ishiwata S, Daida H, Narui K. Aortic Knob Width as a Novel Indicator of Atherosclerosis and Obstructive Sleep Apnea. J Atheroscler Thromb 2019; 27:501-508. [PMID: 31564711 PMCID: PMC7355100 DOI: 10.5551/jat.50286] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Aim: Patients with obstructive sleep apnea (OSA) are likely to show increased arterial stiffness and progressive systemic atherosclerosis. Chest radiography reveals atherosclerotic changes in the aorta via measurement of aortic knob width. However, to our knowledge, aortic knob width in patients with OSA has never been evaluated. Methods: We measured the aortic knob width in chest radiographs of 549 patients (age: 52.5 ± 13.2 years; 69 women) who underwent overnight polysomnography. Moreover, we evaluated the association between aortic knob width and other clinical characteristics, including cardio–ankle vascular index (CAVI) and apnea–hypopnea index (AHI). Multivariate linear regression analysis was conducted to identify factors associated with aortic knob width. Results: A significant direct correlation between aortic knob width and CAVI and between aortic knob width and AHI was observed. In multivariate linear regression analysis, either CAVI or AHI was independently associated with aortic knob width (p = 0.004 and p < 0.001, respectively) in addition to age, male gender, body mass index, and systolic blood pressure. Conclusion: A significant independent correlation between aortic knob width and OSA severity was observed. Our findings suggest that an increase in the aortic knob width suggests atherosclerotic changes in the aorta and may be associated with OSA and increased arterial stiffness.
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Affiliation(s)
- Yasuhiro Tomita
- Department of Cardiovascular Center, Toranomon Hospital.,Sleep Center, Toranomon Hospital.,Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine
| | - Takatoshi Kasai
- Sleep Center, Toranomon Hospital.,Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine.,Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine.,Sleep and Sleep-Disordered Breathing Center, Juntendo University Hospital
| | - Sayaki Ishiwata
- Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine.,Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine
| | - Hiroyuki Daida
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine
| | - Koji Narui
- Sleep Center, Toranomon Hospital.,Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine
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Finamore P, Scarlata S, Cardaci V, Incalzi RA. Exhaled Breath Analysis in Obstructive Sleep Apnea Syndrome: A Review of the Literature. MEDICINA (KAUNAS, LITHUANIA) 2019; 55:E538. [PMID: 31461988 PMCID: PMC6780099 DOI: 10.3390/medicina55090538] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 08/14/2019] [Accepted: 08/22/2019] [Indexed: 11/23/2022]
Abstract
Background and Objectives: Obstructive sleep apnea syndrome (OSAS) represents an independent risk factor for cardiovascular, metabolic and neurological events. Polysomnography is the gold-standard for the diagnosis, however is expensive and time-consuming and not suitable for widespread use. Breath analysis is an innovative, non-invasive technique, able to provide clinically relevant information about OSAS. This systematic review was aimed to outline available evidence on the role of exhaled breath analysis in OSAS, taking into account the techniques' level of adherence to the recently proposed technical standards. Materials and Methods: Articles reporting original data on exhaled breath analysis in OSAS were identified through a computerized and manual literature search and screened. Duplicate publications, case reports, case series, conference papers, expert opinions, comments, reviews and meta-analysis were excluded. Results: Fractional exhaled Nitric Oxide (FeNO) is higher in OSAS patients than controls, however its absolute value is within reported normal ranges. FeNO association with AHI is controversial, as well as its change after continuous positive airway pressure (C-PAP) therapy. Exhaled breath condensate (EBC) is acid in OSAS, cytokines and oxidative stress markers are elevated, they positively correlate with AHI and normalize after treatment. The analysis of volatile organic compounds (VOCs) by spectrometry or electronic nose is able to discriminate OSAS from healthy controls. The main technical issues regards the dilution of EBC and the lack of external validation in VOCs studies. Conclusions: Exhaled breath analysis has a promising role in the understanding of mechanisms underpinning OSAS and has demonstrated a clinical relevance in identifying individuals affected by the disease, in assessing the response to treatment and, potentially, to monitor patient's adherence to mechanical ventilation. Albeit the majority of the technical standards proposed by the ERS committee have been followed by existing papers, further work is needed to uniform the methodology.
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Affiliation(s)
- Panaiotis Finamore
- Unit of Geriatrics, Campus Bio-Medico di Roma University, via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Simone Scarlata
- Unit of Geriatrics, Campus Bio-Medico di Roma University, via Alvaro del Portillo 200, 00128 Rome, Italy.
| | - Vittorio Cardaci
- Pulmonary Rehabilitation, IRCCS San Raffaele Pisana, 00166 Rome, Italy
| | - Raffaele Antonelli Incalzi
- Unit of Geriatrics, Campus Bio-Medico di Roma University, via Alvaro del Portillo 200, 00128 Rome, Italy
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Abstract
PURPOSE The purpose of this study was to evaluate the relationship between obstructive sleep apnea syndrome (OSAS) and glaucoma progression, and to examine the correlation between OSAS severity and rate of visual field (VF) loss. METHODS Patients with concurrent diagnoses of open-angle glaucoma and OSAS between 2010 and 2016 were identified. Enrollment criteria consisted of glaucomatous optic neuropathy and VF loss, ≥5 reliable VFs, ≥2 years of follow-up, and polysomnography (PSG) within 12 months of final VF. PSG parameters including apnea-hypopnea index (AHI) and oxygen saturation (SpO2) were collected. Eyes were classified as "progressors" or "nonprogressors" based upon event analysis using Glaucoma Progression Analysis criteria. Two-tailed t test comparisons were performed, and correlations between rates of VF loss and PSG parameters were assessed. RESULTS A total of 141 patients with OSAS and glaucoma were identified. Twenty-five patients (age 67.9±7.6 y) with OSAS (8 mild, 8 moderate, 9 severe) were enrolled. Eleven eyes (44%) were classified as progressors, and had more severe baseline VF loss (P=0.03). Progressors and nonprogressors had nonsignificantly different (P>0.05) age (69.9±8.7 vs. 66.4±6.6 y), follow-up (4.4±0.7 vs. 4.3±1.0 y), intraocular pressure (13.1±2.8 vs. 14.9±2.5 mm Hg), mean ocular perfusion pressure (49.7±5.5 vs. 48.8±9.0 mm Hg), AHI (31.3±18.6 vs. 26.4±24.0), body-mass index (27.8±5.5 vs. 28.8±5.6), and SpO2 (94.1±1.6% vs. 94.0±1.6%). AHI was not correlated with slopes of VF mean deviation (r, -0.271; P, 0.190) or pattern standard deviation (r, 0.211; P, 0.312), and no substantial increase in risk of progression was found with increase in AHI. CONCLUSIONS This study does not support a relationship between OSAS and glaucomatous progression. No correlation was observed between OSAS severity and rate of VF loss.
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Kyotani Y, Takasawa S, Yoshizumi M. Proliferative Pathways of Vascular Smooth Muscle Cells in Response to Intermittent Hypoxia. Int J Mol Sci 2019; 20:ijms20112706. [PMID: 31159449 PMCID: PMC6600262 DOI: 10.3390/ijms20112706] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 05/20/2019] [Accepted: 05/30/2019] [Indexed: 12/13/2022] Open
Abstract
Obstructive sleep apnea (OSA) is characterized by intermittent hypoxia (IH) and is a risk factor for cardiovascular diseases (e.g., atherosclerosis) and chronic inflammatory diseases (CID). The excessive proliferation of vascular smooth muscle cells (VSMCs) plays a pivotal role in the progression of atherosclerosis. Hypoxia-inducible factor-1 and nuclear factor-κB are thought to be the main factors involved in responses to IH and in regulating adaptations or inflammation pathways, however, further evidence is needed to demonstrate the underlying mechanisms of this process in VSMCs. Furthermore, few studies of IH have examined smooth muscle cell responses. Our previous studies demonstrated that increased interleukin (IL)-6, epidermal growth factor family ligands, and erbB2 receptor, some of which amplify inflammation and, consequently, induce CID, were induced by IH and were involved in the proliferation of VSMCs. Since IH increased IL-6 and epiregulin expression in VSMCs, the same phenomenon may also occur in other smooth muscle cells, and, consequently, may be related to the incidence or progression of several diseases. In the present review, we describe how IH can induce the excessive proliferation of VSMCs and we develop the suggestion that other CID may be related to the effects of IH on other smooth muscle cells.
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Affiliation(s)
- Yoji Kyotani
- Department of Pharmacology, Nara Medical University School of Medicine, Kashihara 634-8521, Japan.
| | - Shin Takasawa
- Department of Biochemistry, Nara Medical University School of Medicine, Kashihara 634-8521, Japan.
| | - Masanori Yoshizumi
- Department of Pharmacology, Nara Medical University School of Medicine, Kashihara 634-8521, Japan.
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Coexistence of obstructive sleep apnea and telomerase activity, concentration of selected adipose tissue hormones and vascular endothelial function in patients with arterial hypertension. Respir Med 2019; 153:20-25. [PMID: 31136928 DOI: 10.1016/j.rmed.2019.05.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 05/12/2019] [Accepted: 05/16/2019] [Indexed: 01/21/2023]
Abstract
AIM The aim of the present study was to determine the effect of obstructive sleep apnea (OSA) with hypertension on telomerase activity, visfatin and adipsine concentration in the blood and vascular endothelial function assessed by ultrasound measured flow-mediated dilatation of the brachial artery (FMD). MATERIAL AND METHODS The study involved a group of 106 people (average age: 54.79 years). The determination of telomerase activity and blood visfatin and adipsine concentrations, brachial artery ultrasound examination with endothelium-dependent dilatation evaluation (FMD) and polysomnography were carried out. RESULTS Patients with hypertension without OSA were characterized by significantly greater FMD in comparison to patients with arterial hypertension and OSA (8.13 ± 5.12 %vs. 6.82 ± 5.36%; p < 0.05). Negative linear relationship between apnea-hypopnea index (AHI) and FMD (r = -0.22, p < 0.05) has been demonstrated. Negative linear relationship between adipsine concentration in the blood and length of REM (Rapid Eye Movement) sleep (r = -0.21, p < 0.05) was found. Positive linear relationship between the concentration of visfatin in the blood and the length of REM sleep (r = 0.22, p < 0.05) was also observed. Higher body mass index, higher total cholesterol, triglyceride and glucose levels have been shown to be independent predictors of higher AHI values, while greater telomerase activity, greater FMD and use of angiotensin converting enzyme inhibitors are independent predicators for lower AHI values. CONCLUSION Higher values of AHI index in polysomnography in hypertensive patients can be related to lower telomerase activity in the blood and impaired function of vascular endothelial function assessed using ultrasound.
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Domingues CC, Dore FJ, Cho A, Ahmadi N, Kropotova Y, Kundu N, Younes N, Jain V, Sen S. Reassessing the effects of continuous positive airway pressure (CPAP) on arterial stiffness and peripheral blood derived CD34+ progenitor cells in subjects with sleep apnea. Stem Cell Res Ther 2019; 10:147. [PMID: 31113468 PMCID: PMC6530134 DOI: 10.1186/s13287-019-1251-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 04/22/2019] [Accepted: 04/30/2019] [Indexed: 12/11/2022] Open
Abstract
Background Obstructive sleep apnea (OSA) is an independent risk factor for cardiovascular diseases (CVD) and vascular health. Peripheral blood-derived CD34+ progenitor cells have been used as biomarker for CVD risk and may play a similar role in OSA and CVD risk assessment. Although there are some controversial results in the literature, OSA patients may have a reduction in the number and function of CD34+ cells. The damages promoted by OSA in CD34+ cells may lead to an increase in endothelial oxidative stress and endothelial inflammation which may lead to a reduced endothelial repair capacity. In this study, we explored the effect of continuous positive airway pressure (CPAP) on peripheral blood-derived CD34+ cells and arterial stiffness (another predictor of endothelial health and CVD risk) in OSA patients. Methods and results Nine overweight and obese subjects without prediabetes or diabetes were recruited. Eight out of nine subjects had moderate to severe degree of OSA. CD34+ cells were isolated from peripheral blood. Number and function of these cells were monitored before and after 3 months of treatment with CPAP. No significant changes were observed in the number of CD34+ cells, CFU-Hill’s colony formation unit (CFU) count or migratory response to the chemotactic factor SDF-1a after CPAP use. However, CXCR4 mRNA expression significantly increased by 2.2-fold indicating that CPAP may have a positive effect on SDF1a receptor (CXCR4), thereby improving migration of CD34+ cells mediated by SDF1a after the 3 month period. Interestingly, in clinical arena our results showed a reduction of pulse wave velocity (an established parameter of arterial stiffness) following CPAP therapy. Conclusions Our findings suggest that 3-month CPAP intervention does not show statistical significant increase in CD34+ cell number and function, in mostly moderate to severe OSA subjects; however, it did demonstrate a positive trend. CPAP therapy, did help improve arterial stiffness parameter. Electronic supplementary material The online version of this article (10.1186/s13287-019-1251-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Cleyton C Domingues
- Department of Medicine, School of Medicine and Health Science, The George Washington University, 2300 I Street NW, Washington, DC, 20037, USA
| | - Fiona J Dore
- The GW Medical Faculty Associates, Washington, DC, USA
| | - Alexander Cho
- The GW Medical Faculty Associates, Washington, DC, USA
| | - Neeki Ahmadi
- Department of Medicine, School of Medicine and Health Science, The George Washington University, 2300 I Street NW, Washington, DC, 20037, USA
| | - Yana Kropotova
- Department of Medicine, School of Medicine and Health Science, The George Washington University, 2300 I Street NW, Washington, DC, 20037, USA
| | - Nabanita Kundu
- Department of Medicine, School of Medicine and Health Science, The George Washington University, 2300 I Street NW, Washington, DC, 20037, USA
| | - Naji Younes
- The GW Milken Institute of Public Health, Washington, DC, USA
| | - Vivek Jain
- The GW Medical Faculty Associates, Washington, DC, USA
| | - Sabyasachi Sen
- Department of Medicine, School of Medicine and Health Science, The George Washington University, 2300 I Street NW, Washington, DC, 20037, USA. .,The GW Medical Faculty Associates, Washington, DC, USA.
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Martinez-Garcia MA, Campos-Rodriguez F, Barbé F, Gozal D, Agustí A. Precision medicine in obstructive sleep apnoea. THE LANCET RESPIRATORY MEDICINE 2019; 7:456-464. [DOI: 10.1016/s2213-2600(19)30044-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 01/21/2019] [Accepted: 01/22/2019] [Indexed: 01/13/2023]
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Van der Touw T, Andronicos NM, Smart N. Is C-reactive protein elevated in obstructive sleep apnea? a systematic review and meta-analysis. Biomarkers 2019; 24:429-435. [PMID: 30908094 DOI: 10.1080/1354750x.2019.1600025] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Purpose: This study examined whether circulating C-reactive protein (CRP) is elevated in obstructive sleep apnoea (OSA) independent of the confounding effects of comorbidities, smoking, body mass index (BMI), age and gender. Methods: A systematic review of the literature was performed using PubMed, Embase and Cochrane databases from 1 January 1997 to 1 November 2017 using the key words obstructive sleep apnoea and C-Reactive protein to identify full text English language studies that compared CRP in adult non-smoking OSA participants without comorbidities and adult healthy non-smoking control participants matched for BMI, age and gender. Data from eligible studies were subjected to meta-analysis using RevMan version 5.3. Results: Five studies (219 OSA participants, 116 controls) met the selection criteria. The total standard mean difference for circulating high sensitivity CRP was 0.61 mg/dL higher in OSA participants than in control participants (confidence interval: 0.38 to 0.84, p < 0.00001), with low between-studies heterogeneity (df = 7, p = 0.16, I2 = 33%) and minimal evidence of publication bias. Conclusions: CRP levels in non-smoking OSA participants without comorbidities were increased relative to levels in healthy matched non-smoking control participants, suggesting that pharyngeal or systemic inflammatory effects attributable to OSA may elevate CRP.
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Affiliation(s)
- Tom Van der Touw
- a School of Science and Technology , University of New England , Armidale , Australia
| | | | - Neil Smart
- a School of Science and Technology , University of New England , Armidale , Australia
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Epicardial fat accumulation is an independent marker of impaired heart rate recovery in obese patients with obstructive sleep apnea. Clin Res Cardiol 2019; 108:1226-1233. [PMID: 30887111 DOI: 10.1007/s00392-019-01454-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 03/13/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Sympathetic nervous system activation plays a pivotal role in obese patients with obstructive sleep apnea (OSA), contributing to increased cardiovascular risk. Epicardial adipose tissue (EAT) activates cardiac autonomic nervous system. Our main study objective was to investigate effects of these autonomic dysfunction factors on post-exercise heart rate recovery (HRR). METHODS 36 patients, referred for clinical assessment of obesity (BMI > 30 kg/m2), underwent overnight polysomnography, transthoracic echocardiography and cardiopulmonary exercise testing. RESULTS Compared to non-OSA patients, OSA patients were older and displayed reduced body weight-indexed peak VO2. Cardiac output at peak exercise was similar among groups. Peak exercise arterio-venous oxygen content difference D[a-v]O2 was lower in OSA patients. In univariate linear analysis, age, AHI, EAT thickness, peak VO2 and diabetes were associated with blunted HRR. Multiple linear regression analysis showed that increased EAT thickness, AHI and diabetes were independently associated with lower HRR. For identical AHI value and diabetes status, HRR significantly decreased by 61.7% for every 1 mm increase of EAT volume (p = 0.011). If HRR was treated as a categorical variable, EAT [odds ratio (OR) 1.78 (95% confidence interval [CI] 1.19-2.66); p = 0.005], and type 2 diabetes [OR 8.97 (95% CI 1.16-69.10); p = 0.035] were the only independent predictors of blunted HRR. CONCLUSIONS Aerobic capacity and peak exercise D[a-v]O2 are impaired in obese OSA patients, suggesting abnormal peripheral oxygen extraction. EAT thickness is an independent marker of post-exercise HRR, which is a noninvasive marker of autonomic nerve dysfunction accompanying poor cardiovascular prognosis in obese patients.
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66
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García-Ortega A, Mañas E, Oscullo G. Pulmonary Thromboembolism and Obstructive Sleep Apnea: A Two-way Relationship. Arch Bronconeumol 2019; 55:399-400. [PMID: 30808523 DOI: 10.1016/j.arbres.2019.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 01/22/2019] [Accepted: 01/23/2019] [Indexed: 01/09/2023]
Affiliation(s)
- Alberto García-Ortega
- Servicio de Neumología, Instituto de Investigación Sanitaria La Fe (IISLAFE). Hospital Universitario y Politécnico La Fe, Valencia, España.
| | - Eva Mañas
- Servicio de Neumología, Hospital Ramón y Cajal (IRYCIS), Madrid, España
| | - Grace Oscullo
- Servicio de Neumología, Instituto de Investigación Sanitaria La Fe (IISLAFE). Hospital Universitario y Politécnico La Fe, Valencia, España
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Morales-Loredo H, Jones D, Barrera A, Mendiola PJ, Garcia J, Pace C, Murphy M, Kanagy NL, Gonzalez Bosc LV. A dual blocker of endothelin A/B receptors mitigates hypertension but not renal dysfunction in a rat model of chronic kidney disease and sleep apnea. Am J Physiol Renal Physiol 2019; 316:F1041-F1052. [PMID: 30810064 DOI: 10.1152/ajprenal.00018.2019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Obstructive sleep apnea is characterized by recurrent episodes of pharyngeal collapse during sleep, resulting in intermittent hypoxia (IH), and is associated with a high incidence of hypertension and accelerated renal failure. In rodents, endothelin (ET)-1 contributes to IH-induced hypertension, and ET-1 levels inversely correlate with glomerular filtration rate in patients with end-stage chronic kidney disease (CKD). Therefore, we hypothesized that a dual ET receptor antagonist, macitentan (Actelion Pharmaceuticals), will attenuate and reverse hypertension and renal dysfunction in a rat model of combined IH and CKD. Male Sprague-Dawley rats received one of three diets (control, 0.2% adenine, and 0.2% adenine + 30 mg·kg-1·day-1 macitentan) for 2 wk followed by 2 wk of recovery diet. Rats were then exposed for 4 wk to air or IH (20 short exposures/h to 5% O2-5% CO2 7 h/day during sleep). Macitentan prevented the increases in mean arterial blood pressure caused by CKD, IH, and the combination of CKD + IH. However, macitentan did not improve kidney function, fibrosis, and inflammation. After CKD was established, rats were exposed to air or IH for 2 wk, and macitentan feeding continued for 2 more wk. Macitentan reversed the hypertension in IH, CKD, and CKD + IH groups without improving renal function. Our data suggest that macitentan could be an effective antihypertensive in patients with CKD and irreversible kidney damage as a way to protect the heart, brain, and eyes from elevated arterial pressure, but it does not reverse toxin-induced tubule atrophy.
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Affiliation(s)
- Humberto Morales-Loredo
- Vascular Physiology Group, Department of Cell Biology and Physiology, University of New Mexico Health Sciences Center , Albuquerque, New Mexico
| | - David Jones
- Vascular Physiology Group, Department of Cell Biology and Physiology, University of New Mexico Health Sciences Center , Albuquerque, New Mexico
| | - Adelaeda Barrera
- Vascular Physiology Group, Department of Cell Biology and Physiology, University of New Mexico Health Sciences Center , Albuquerque, New Mexico
| | - Perenkita J Mendiola
- Vascular Physiology Group, Department of Cell Biology and Physiology, University of New Mexico Health Sciences Center , Albuquerque, New Mexico
| | - Joshua Garcia
- Vascular Physiology Group, Department of Cell Biology and Physiology, University of New Mexico Health Sciences Center , Albuquerque, New Mexico
| | - Carolyn Pace
- Vascular Physiology Group, Department of Cell Biology and Physiology, University of New Mexico Health Sciences Center , Albuquerque, New Mexico
| | - Minerva Murphy
- Vascular Physiology Group, Department of Cell Biology and Physiology, University of New Mexico Health Sciences Center , Albuquerque, New Mexico
| | - Nancy L Kanagy
- Vascular Physiology Group, Department of Cell Biology and Physiology, University of New Mexico Health Sciences Center , Albuquerque, New Mexico
| | - Laura V Gonzalez Bosc
- Vascular Physiology Group, Department of Cell Biology and Physiology, University of New Mexico Health Sciences Center , Albuquerque, New Mexico
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García-Ortega A, Mañas E, López-Reyes R, Selma MJ, García-Sánchez A, Oscullo G, Jiménez D, Martínez-García M. Obstructive sleep apnoea and venous thromboembolism: pathophysiological links and clinical implications. Eur Respir J 2019; 53:13993003.00893-2018. [PMID: 30385528 DOI: 10.1183/13993003.00893-2018] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 10/12/2018] [Indexed: 12/13/2022]
Abstract
Obstructive sleep apnoea (OSA) and pulmonary embolism (PE) remain major health issues worldwide. Data from pathophysiological studies suggest that both intermittent hypoxia and sleep fragmentation are associated with increased blood coagulability, endothelial dysfunction and venous stasis. There is growing evidence that OSA is potentially prevalent in and a risk factor for PE. Conversely, patients with acute PE have two to four times greater risk of moderate-to-severe OSA. The role of continuous positive airway pressure (CPAP) treatment in improving clinically meaningful outcomes in PE patients remains unclear, although some authors have suggested that CPAP could improve the hypercoagulability state and normalise circadian alterations in some of the coagulation molecules, as observed in patients with OSA. Emerging research highlights the complex interdependent relationships between OSA and PE, emphasising the need for rigorous, well-powered trials that address the impact of OSA and its treatment on the prevention and management of PE. Undoubtedly, these will require closer collaboration between the sleep medicine and clinical/venous thromboembolism communities.
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Arterial Stiffness in Early Phases of Prehypertension. UPDATES IN HYPERTENSION AND CARDIOVASCULAR PROTECTION 2019. [DOI: 10.1007/978-3-319-75310-2_8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Guidry A, Crutchfield K. Athletes with neurologic disease. HANDBOOK OF CLINICAL NEUROLOGY 2018; 158:445-462. [PMID: 30482372 DOI: 10.1016/b978-0-444-63954-7.00041-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Neurologic disease does not discriminate, even among athletes. Common neurologic diseases among athletes include multiple sclerosis, seizures, headaches, and sleep disorders. Although concrete guidelines for sport participation among athletes with neurologic diseases do not exist, evidence-based and consensus statements can aid healthcare providers in determining whether and to what extent such athletes should participate in sports. Moreover, sport participation is important, since multiple studies indicate that exercise improves disease-specific symptoms, manifestations, and overall quality of life. Although some risk is involved for athletes with neurologic disease, risk is mitigated with proper supervision and neurologic oversight, disease-specific accommodations, and counseling of the athletic staff and the athletes. Neurologic oversight entails an initial comprehensive neurologic assessment by a neurologist followed by regular follow-up. Preparation for environmental conditions encountered by athletes with neurologic disease will further improve safety during their participation in sport. With sound recommendations, neurologic oversight, and proper supervision, most athletes with neurologic disease can participate in athletics. The health benefits that they will gain from participation in athletics outweigh the risks.
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Affiliation(s)
- Andrew Guidry
- Sports Medicine Institute, Sandra and Malcolm Berman Brain and Spine Institute at LifeBridge Health, Baltimore, MD, United States
| | - Kevin Crutchfield
- Sports Medicine Institute, Sandra and Malcolm Berman Brain and Spine Institute at LifeBridge Health, Baltimore, MD, United States.
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71
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Logan JG, Kang H, Lobo JM, Sohn MW, Lin GM, Lima JAC, Punjabi NM, Redline S, Kwon Y. Actigraphy-based sleep characteristics and aortic stiffness: the Multi-Ethnic Study of Atherosclerosis. ACTA ACUST UNITED AC 2018; 12:841-849. [PMID: 30396853 DOI: 10.1016/j.jash.2018.09.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 08/16/2018] [Accepted: 09/19/2018] [Indexed: 12/21/2022]
Abstract
The study aimed to examine the association between objective estimates of sleep duration and quality and aortic stiffness while accounting for the potential confounding effect of sleep-disordered breathing. Participants were part of the Multi-Ethnic Study of Atherosclerosis Sleep study. Sleep duration and quality were assessed by 7-day wrist actigraphy, sleep-disordered breathing by home polysomnography, and aortic stiffness by magnetic resonance imaging-based aortic pulse wave velocity (aPWV), ascending and descending aorta distensibility. Aortic stiffness of participants with "normal" sleep duration (6-8 hours) were compared with those of "short" (<6 hours) and "long" sleep duration (>8 hours) adjusting for common cardiovascular risk factors and apnea-hypopnea index. The sample consisted of 908 participants (mean age 68.4 ± 9.1 years, 55.3% female). There was a significant linear trend of increased aPWV across short (n = 252), normal (n = 552), and long sleep durations (n = 104) (P for trend = .008). Multivariable analysis showed that people with short sleep duration had 0.94 m/s lower aPWV (95% CI: -1.54, -0.35), compared with those with normal sleep duration. In this ethnically diverse community cohort, habitual short sleep duration as estimated by actigraphy was associated with lower aortic stiffness.
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Affiliation(s)
- Jeongok G Logan
- Assistant Professor, University of Virginia School of Nursing, Charlottesville, VA, USA.
| | - Hyojung Kang
- Research Assistant Professor, Systems and Information Engineering, University of Virginia, Charlottesville, VA, USA
| | - Jennifer Mason Lobo
- Assistant Professor, Division of Biomedical Informatics, Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Min-Woong Sohn
- Associate Professor, Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Gen-Min Lin
- Assistant Professor, Department of Medicine, Hualien Armed Forces General Hospital, Hualien, Taiwan
| | - Joao A C Lima
- Professor of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Naresh M Punjabi
- Professor, Johns Hopkins Medicine, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Susan Redline
- Peter C. Farrell Professor of Sleep Medicine, Harvard Medical School, Boston, MA, USA
| | - Younghoon Kwon
- Assistant Professor, University of Virginia, Fontaine Research Park, Charlottesville, VA, USA
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Kinoshita M, Yokote K, Arai H, Iida M, Ishigaki Y, Ishibashi S, Umemoto S, Egusa G, Ohmura H, Okamura T, Kihara S, Koba S, Saito I, Shoji T, Daida H, Tsukamoto K, Deguchi J, Dohi S, Dobashi K, Hamaguchi H, Hara M, Hiro T, Biro S, Fujioka Y, Maruyama C, Miyamoto Y, Murakami Y, Yokode M, Yoshida H, Rakugi H, Wakatsuki A, Yamashita S. Japan Atherosclerosis Society (JAS) Guidelines for Prevention of Atherosclerotic Cardiovascular Diseases 2017. J Atheroscler Thromb 2018; 25:846-984. [PMID: 30135334 PMCID: PMC6143773 DOI: 10.5551/jat.gl2017] [Citation(s) in RCA: 511] [Impact Index Per Article: 85.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 06/11/2018] [Indexed: 11/30/2022] Open
Affiliation(s)
| | - Koutaro Yokote
- Department of Diabetes, Metabolism and Endocrinology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Hidenori Arai
- National Center for Geriatrics and Gerontology, Aichi, Japan
| | - Mami Iida
- Department of Internal Medicine and Cardiology, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Yasushi Ishigaki
- Division of Diabetes and Metabolism, Department of Internal Medicine, Iwate Medical University, Iwate, Japan
| | - Shun Ishibashi
- Division of Endocrinology and Metabolism, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Seiji Umemoto
- Center for Integrated Medical Research, Hiroshima University Hospital, Hiroshima, Japan
| | | | - Hirotoshi Ohmura
- Department of Cardiovascular Medicine, Juntendo University, Tokyo, Japan
| | - Tomonori Okamura
- Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo, Japan
| | - Shinji Kihara
- Biomedical Informatics, Osaka University, Osaka, Japan
| | - Shinji Koba
- Division of Cardiology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Isao Saito
- Department of Community Health Systems Nursing, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Tetsuo Shoji
- Department of Vascular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hiroyuki Daida
- Department of Cardiovascular Medicine, Juntendo University, Tokyo, Japan
| | - Kazuhisa Tsukamoto
- Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Juno Deguchi
- Department of Vascular Surgery, Saitama Medical Center, Saitama, Japan
| | - Seitaro Dohi
- Chief Health Management Department, Mitsui Chemicals Inc., Tokyo, Japan
| | - Kazushige Dobashi
- Department of Pediatrics, Showa University School of Medicine, Tokyo, Japan
| | | | - Masumi Hara
- Department of Internal Medicine, Mizonokuchi Hospital, Teikyo University School of Medicine, Kanagawa, Japan
| | - Takafumi Hiro
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | | | - Yoshio Fujioka
- Faculty of Nutrition, Division of Clinical Nutrition, Kobe Gakuin University, Hyogo, Japan
| | - Chizuko Maruyama
- Department of Food and Nutrition, Faculty of Human Sciences and Design, Japan Women's University, Tokyo, Japan
| | - Yoshihiro Miyamoto
- Department of Preventive Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | | | - Masayuki Yokode
- Department of Clinical Innovative Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hiroshi Yoshida
- Department of Laboratory Medicine, Jikei University Kashiwa Hospital, Chiba, Japan
| | - Hiromi Rakugi
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Akihiko Wakatsuki
- Department of Obstetrics and Gynecology, Aichi Medical University, Aichi, Japan
| | - Shizuya Yamashita
- Department of Community Medicine, Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
- Rinku General Medical Center, Osaka, Japan
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Domagała-Kulawik J, Kwiecień I, Bielicki P, Skirecki T. Fas-positive lymphocytes are associated with systemic inflammation in obstructive sleep apnea syndrome. Sleep Breath 2018; 23:673-678. [PMID: 30171418 PMCID: PMC6529390 DOI: 10.1007/s11325-018-1713-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 08/20/2018] [Accepted: 08/22/2018] [Indexed: 12/28/2022]
Abstract
PURPOSE Obstructive sleep apnea syndrome (OSAS) is associated with alterations in immune system which may lead to serious complications. The aim of this study was to explore lymphocyte populations in OSAS with special attention to the Fas-positive cells. METHODS Fifty-one patients with confirmed OSA and 20 healthy subjects were investigated. The OSA severity indices, data concerning comorbidities, and markers of inflammation and metabolic disorders were collected. Flow cytometry was used to analyze the lymphocyte profile and expression of Fas receptors (CD95). Concentration of adiponectin, IL-1β, TNF-α, and sFas were measured. RESULTS Proportions of Fas-positive cells in the pool of CD4+ and Fas-positive in the pool of CD8+ cells in the blood of patients were significantly increased when compared with healthy subjects (74.5% vs. 65.6% and 78.8% vs.70.9%, respectively, p < 0.05). No correlation with OSA severity was found. However, the proportion and number of Fas+ cells were elevated in obese patients, in non-smokers, and in patients suffering from COPD and hypertension. There were several significant relations of Fas+ cells with inflammatory markers of systemic inflammation. CONCLUSION Lymphocytes with the expression of Fas receptor are associated with systemic inflammation in OSAS.
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Affiliation(s)
- Joanna Domagała-Kulawik
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, ul. Banacha 1a, 02 097, Warsaw, Poland
| | - Iwona Kwiecień
- Laboratory of Flow Cytometry, Department of Internal Medicine and Hematology, Military Medical Institute, ul. Szaserow 128, 04 141, Warsaw, Poland
| | - Piotr Bielicki
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, ul. Banacha 1a, 02 097, Warsaw, Poland
| | - Tomasz Skirecki
- Laboratory of Flow Cytometry, Department of Anesthesiology and Intensive Care, Centre of Postgraduate Medical Education, ul. Marymoncka 99/103, 01 813, Warsaw, Poland.
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Kerns ES, Kim ED, Meoni LA, Sozio SM, Jaar BG, Estrella MM, Parekh RS, Bourjeily G. Obstructive Sleep Apnea Increases Sudden Cardiac Death in Incident Hemodialysis Patients. Am J Nephrol 2018; 48:147-156. [PMID: 30110675 DOI: 10.1159/000489963] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 05/04/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Mortality in end-stage renal disease (ESRD) occurs predominantly from cardiovascular disease (CVD) and sudden cardiac death (SCD). Obstructive sleep apnea (OSA) is characterized by periodic airflow limitation associated with sleep arousal and oxygen desaturation and is prevalent in patients with ESRD. Whether OSA increases the risk for SCD, cardiovascular and all-cause mortality among hemodialysis patients remains unknown. METHODS In a prospective cohort of 558 incident hemodialysis patients, we examined the association of OSA with all-cause mortality, cardiovascular mortality, and SCD using Cox proportional hazards models controlling for traditional CVD risk factors. RESULTS Sixty-six incident hemodialysis patients (12%) had OSA. Mean age (56 years) and percentage of males (56%) were identical in OSA and no-OSA groups. Fewer African Americans had OSA than non-African Americans (9 vs. 18%, respectively). Participants with OSA had higher body-mass index, Charlson comorbidity score, and left ventricular mass index and greater prevalence of diabetes and coronary artery disease. During 1,080 person-years of follow-up, 104 deaths occurred, 29% of which were cardiovascular. OSA was associated with a higher risk of all-cause mortality (HR 1.90 [95% CI 1.04-3.46]) and cardiovascular mortality (HR 3.62 [95% CI 1.36-9.66]) after adjusting for demographics and body-mass index. OSA was associated with a higher risk of SCD after adjusting for demographics (HR 3.28 [95% CI 1.12-9.57]) and multiple cardiovascular risk factors. CONCLUSIONS Incident hemodialysis patients with OSA are at increased risk of all-cause and cardiovascular mortality and SCD. Future studies should assess the impact of screening for OSA and OSA-targeted interventions on mortality in ESRD.
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Affiliation(s)
- Eric S Kerns
- Department of Medicine, Division of Nephrology, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Esther D Kim
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lucy A Meoni
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Stephen M Sozio
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Bernard G Jaar
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
- Nephrology Center of Maryland, Baltimore, Maryland, USA
| | - Michelle M Estrella
- University of California San Francisco, Kidney Health Research Collaborative, San Francisco, California, USA
- San Francisco VA Health Care System, San Francisco, California, USA
| | - Rulan S Parekh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pediatrics and Medicine, School of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ghada Bourjeily
- Department of Medicine, Divisions of Pulmonary, Critical Care and Sleep Medicine, and Obstetric Medicine, The Miriam Hospital and Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Abdullah A, Eigbire G, Salama A, Wahab A, Nadkarni N, Alweis R. Relation of Obstructive Sleep Apnea to Risk of Hospitalization in Patients With Heart Failure and Preserved Ejection Fraction from the National Inpatient Sample. Am J Cardiol 2018; 122:612-615. [PMID: 30205888 DOI: 10.1016/j.amjcard.2018.04.052] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 04/19/2018] [Accepted: 04/24/2018] [Indexed: 12/27/2022]
Abstract
Obstructive Sleep Apnea (OSA) increases the risk of diastolic dysfunction and heart failure. The impact of OSA on hospitalization for heart failure with preserved ejection fraction (HFpEF) is not well elucidated. We used data from the National Inpatient Sample for the years 2012 to 2014. We identified discharges (age ≥18 years) associated with OSA and HFpEF using the International Classification of Diseases, Ninth Revision, Clinical Modification codes (327.23 and 428.3x), respectively. Propensity score analysis, adjusting for age, gender, race, and comorbidities, compared the rates of admission for HFpEF in patients with OSA to those without OSA. Out of 12,608,637 discharges included, there were 147,463 patients with HFpEF, and 653,762 or 5.2% of all discharges had OSA. The prevalence of OSA in patients with HFpEF was 16.8%. Patients with OSA were older, more likely to be men, more likely to have diabetes, hypertension, history of coronary artery disease, chronic kidney disease, obesity, atrial fibrillation, African-American race, and smoking status. In patients with OSA, HFpEF occurred in 3.8% versus 1.0%, with adjusted odds ratio: 2.2 (95% confidence interval 2.16 to 2.23), p <0.001. Subgroup analysis showed similar results in men and women. After propensity score matching, OSA was associated with increased risk of admission with HFpEF, relative risk = 2.2 (95% confidence interval 2.12 to 2.21). In conclusion, OSA was associated with increased risk of hospitalization for HFpEF.
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Kwon Y, Jacobs DR, Lutsey PL, Brumback L, Chirinos JA, Mariani S, Redline S, Duprez DA. "Sleep disordered breathing and ECG R-wave to radial artery pulse delay, The Multi-Ethnic Study of Atherosclerosis". Sleep Med 2018; 48:172-179. [PMID: 29960211 PMCID: PMC6051731 DOI: 10.1016/j.sleep.2018.05.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 03/14/2018] [Accepted: 05/08/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Electrocardiography R-wave to radial artery pulse delay (RRD) represents pulse transit time inclusive of pre-ejection period (PEP) and arterial pulse propagation time. RRD is proposed to largely reflect arterial stiffness when PEP is accounted for (shorter RRD = higher arterial stiffness). Sleep disordered breathing (SDB) causes intermittent hypoxemia and sympathetic activation, which negatively influences vascular function. We aimed to examine the association of measures of SDB with RRD. METHODS Our sample consisted of participants in the Multi-Ethnic Study of Atherosclerosis without prevalent cardiovascular disease who underwent a daytime arterial elasticity exam, cardiac magnetic resonance imaging (MRI), and overnight polysomnography. SDB measures of interest included apnea hypopnea index (AHI) and oxygen desaturation index (ODI) (N = 1173). RRD was regressed on each measure of SDB separately, with adjustment for other cardiovascular risk factors as well as for correlates of the PEP, another component of RRD, by including cardiac MRI measures of contractility and preload. RESULTS In multivariate analysis, among measures of SDB, ODI, a marker of intermittent hypoxemia, was inversely associated with RRD (β = -60.2 msec per SD [15.5/hr], p = 0.04). No significant association was found with AHI. In gender stratified analyses, ODI and AHI were predictive of RRD in men only (β = -111.3 msec per SD [15.5/hr], p = 0.01 and β = -100.3 msec per SD [16.1/hr], p = 0.02 respectively). CONCLUSION Severity of SDB as measured by ODI was associated with RRD, a marker of arterial stiffness. Thus, association of RRD with measures of SDB appears to be gender-dependent.
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Affiliation(s)
- Younghoon Kwon
- Department of Medicine, University of Virginia, Charlottesville, VA, USA.
| | - David R. Jacobs
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Pamela L. Lutsey
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Lyndia Brumback
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | | | - Sara Mariani
- Departments of Medicine, Brigham and Women’s Hospital and Beth Israel Deaconess Medical Center; Harvard Medical School, Boston, MA, USA
| | - Susan Redline
- Departments of Medicine, Brigham and Women’s Hospital and Beth Israel Deaconess Medical Center; Harvard Medical School, Boston, MA, USA
| | - Daniel A. Duprez
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
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Joyeux-Faure M, Tamisier R, Borel JC, Millasseau S, Galerneau LM, Destors M, Bailly S, Pepin JL. Contribution of obstructive sleep apnoea to arterial stiffness: a meta-analysis using individual patient data. Thorax 2018; 73:1146-1151. [PMID: 30032122 DOI: 10.1136/thoraxjnl-2018-211513] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 07/08/2018] [Accepted: 07/09/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Arterial stiffness, measured by pulse wave velocity (PWV), is a strong independent predictor of late cardiovascular events and mortality. It is recognised that obstructive sleep apnoea (OSA) is associated with cardiovascular comorbidities and mortality. Although previous meta-analyses concluded that PWV is elevated in OSA, we feel that an individual patient data analysis from nine relatively homogeneous studies could help answer: to what extent does OSA drive arterial stiffness? METHODS Individual data from well-characterised patients referred for suspicion of OSA, included in nine studies in which carotid-femoral PWV was measured using a Complior device, were merged for an individual patient data meta-analysis. RESULTS 893 subjects were included (age: 56±11 (mean±SD), 72% men, 84% with confirmed OSA). Body Mass Index varied from 15 to 81 kg/m2 (30±7 kg/m2). PWV ranged from 5.3 to 20.5 m/s (10.4±2.3 m/s). In univariate analysis, log(PWV) was strongly related to age, gender, systolic blood pressure, presence of type 2 diabetes (all p<0.01) as well as to dyslipidaemia (p=0.03) and an Epworth Sleepiness Scale score ≥9 (p=0.04), whereas it was not related to obesity (p=0.54), a severe Apnoea-Hypopnoea Index (p=0.14), mean nocturnal saturation (p=0.33) or sleep time with oxygen saturation below 90% (p=0.47). In multivariable analysis, PWV was independently associated with age, systolic blood pressure and diabetes (all p<0.01), whereas severe OSA was not significantly associated with PWV. CONCLUSION Our individual patient meta-analysis showed that elevated arterial stiffness in patients with OSA is driven by conventional cardiovascular risk factors rather than apnoea parameters.
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Affiliation(s)
- Marie Joyeux-Faure
- Laboratoire HP2, INSERM U1042, Univ. Grenoble Alpes, Grenoble, France.,Laboratoire EFCR, Grenoble Alpes University Hospital, Grenoble, France
| | - Renaud Tamisier
- Laboratoire HP2, INSERM U1042, Univ. Grenoble Alpes, Grenoble, France.,Laboratoire EFCR, Grenoble Alpes University Hospital, Grenoble, France
| | - Jean-Christian Borel
- Laboratoire HP2, INSERM U1042, Univ. Grenoble Alpes, Grenoble, France.,Laboratoire EFCR, Grenoble Alpes University Hospital, Grenoble, France
| | | | - Louis-Marie Galerneau
- Laboratoire HP2, INSERM U1042, Univ. Grenoble Alpes, Grenoble, France.,Laboratoire EFCR, Grenoble Alpes University Hospital, Grenoble, France
| | - Marie Destors
- Laboratoire HP2, INSERM U1042, Univ. Grenoble Alpes, Grenoble, France.,Laboratoire EFCR, Grenoble Alpes University Hospital, Grenoble, France
| | - Sébastien Bailly
- Laboratoire HP2, INSERM U1042, Univ. Grenoble Alpes, Grenoble, France.,Laboratoire EFCR, Grenoble Alpes University Hospital, Grenoble, France
| | - Jean Louis Pepin
- Laboratoire HP2, INSERM U1042, Univ. Grenoble Alpes, Grenoble, France.,Laboratoire EFCR, Grenoble Alpes University Hospital, Grenoble, France
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Arterial stiffness alteration and obstructive sleep apnea in an elderly cohort free of cardiovascular event history: the PROOF cohort study. Sleep Breath 2018; 23:201-208. [PMID: 29946946 DOI: 10.1007/s11325-018-1683-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Revised: 06/05/2018] [Accepted: 06/08/2018] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Several studies suggest in middle-aged subjects a relationship between arterial stiffness, a cardiovascular risk marker, and moderate to severe obstructive sleep apnea (OSA). No extensive data are present in older subjects. This study explores this association in a sample of healthy older subjects suffering OSA. METHODS A total of 101 volunteers aged 75.3 ± 0.7 years were examined at the hospital sleep center. Each subject was assessed for medical history, body mass index and 24-h blood pressure measures, biological blood samples, and home polygraphy in 2002-2003 (P2) as well as in 2009-2010 (P4). Arterial stiffness was also assessed using carotid-femoral and carotid-radial pulse wave velocity (cfPWV and crPWV) during P4 examination. RESULTS The total group consisted of 59 women and 42 men with a mean apnea-hypopnea index (AHI) of 17.8 ± 12.1 and a mean oxygen desaturation index (ODI) of 9.8 ± 8.9. No-OSA (AHI < 15) represented 50% of the sample, and severe cases (AHI > 30) 17%. No significant differences had been founded between men and women for blood pressure, cfPWV, and crPWV. Considering the severity of the AHI, no significant differences between groups were present for PWV and blood pressure values. No difference for PWV was present for subjects with and without hypertension. No correlation was found between PWV value and AHI and ODI values at P2 or between P2 and P4 visits. cfPWV was higher in patients demonstrating incident hypertension during the follow-up. CONCLUSIONS In this sample of older subjects, PWV is not affected by AHI and ODI but was associated with incident hypertension. These results may suggest potential protective and adaptive mechanisms in older sleep apnea patients. CLINICAL TRIAL REGISTRATIONS NCT 00759304 and NCT 00766584 .
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79
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Bhattacharjee R, Khalyfa A, Khalyfa AA, Mokhlesi B, Kheirandish-Gozal L, Almendros I, Peris E, Malhotra A, Gozal D. Exosomal Cargo Properties, Endothelial Function and Treatment of Obesity Hypoventilation Syndrome: A Proof of Concept Study. J Clin Sleep Med 2018; 14:797-807. [PMID: 29734990 DOI: 10.5664/jcsm.7110] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 02/09/2018] [Indexed: 01/19/2023]
Abstract
STUDY OBJECTIVES Longitudinal studies support the usage of positive airway pressure (PAP) therapy in treating obstructive sleep apnea (OSA) to improve cardiovascular disease. However, the anticipated benefit is not ubiquitous. In this study, we elucidate whether PAP therapy leads to immediate improvements on endothelial function, a subclinical marker of cardiovascular status, by examining the effect of circulating exosomes, isolated from patients before and after PAP therapy, on naive endothelial cells. METHODS We isolated plasma-derived circulating exosomes from 12 patients with severe OSA and obesity hypoventilation syndrome (OHS) before and after 6 weeks of PAP therapy, and examined their effect on cultured endothelial cells using several in vitro reporter assays. RESULTS We found that circulating exosomes contributed to the induction and propagation of OSA/OHS-related endothelial dysfunction (ie, increased permeability and disruption of tight junctions along with increased adhesion molecule expression, and reduced endothelial nitric oxide synthase expression), and promoted increased monocyte adherence. Further, when comparing exosomes isolated before and after PAP therapy, the disturbances in endothelial cell function were attenuated with treatment, including an overall cumulative decrease in endothelial permeability in all 12 subjects by 10.8% (P = .035), as well as detection of a subset of 4 differentially expressed exosomal miRNAs, even in the absence of parallel changes in systemic blood pressure or metabolic function. CONCLUSIONS Circulating exosomes facilitate important intercellular signals that modify endothelial phenotype, and thus emerge as potential fundamental contributors in the context of OSA/OHS-related endothelial dysfunction. Exosomes may not only provide candidate biomarkers, but are also a likely and plausible mechanism toward OSA/OHS-induced cardiovascular disease. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov, Title: AVAPS-AE Efficacy Study, URL: https://clinicaltrials.gov/ct2/show/NCT01368614, Identifier: NCT01368614.
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Affiliation(s)
- Rakesh Bhattacharjee
- Division of Respiratory Medicine, Department of Pediatrics, Rady Children's Hospital, The University of California San Diego, San Diego, California
| | - Abdelnaby Khalyfa
- Section of Sleep Medicine, Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division University of Chicago, Chicago, Illinois
| | - Ahamed A Khalyfa
- Section of Sleep Medicine, Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division University of Chicago, Chicago, Illinois
| | - Babak Mokhlesi
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Leila Kheirandish-Gozal
- Section of Sleep Medicine, Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division University of Chicago, Chicago, Illinois
| | | | - Eduard Peris
- Section of Sleep Medicine, Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division University of Chicago, Chicago, Illinois
| | - Atul Malhotra
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California San Diego, San Diego, California
| | - David Gozal
- Section of Sleep Medicine, Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division University of Chicago, Chicago, Illinois
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Impairment of vascular strain in patients with obstructive sleep apnea. PLoS One 2018; 13:e0193397. [PMID: 29489881 PMCID: PMC5831412 DOI: 10.1371/journal.pone.0193397] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 02/10/2018] [Indexed: 11/18/2022] Open
Abstract
Background Obstructive sleep apnea (OSA) is an independent risk factor for the development of cardiovascular diseases. Aim of this present study was to evaluate and extend recent research on the influence of obstructive sleep apnea on vascular strain. Methods A total number of 98 patients were integrated in the study. Patients were grouped according to the Apnea-Hypopnea-Index (AHI) in patients with mild-to-moderate OSA (5/h ≤ AHI < 30/h), severe OSA (AHI ≥ 30/h) and controls (AHI < 5/h). Groups were matched in age, body-mass-index and cardiovascular risks. Vascular strain of common carotid arteries was assessed by ultrasound speckle-tracking. A minor group of 30 patients and controls further underwent assessment of vascular strain of brachial and femoral arteries. Additionally, all patients underwent blood testing to reveal potential influences of inflammatory markers on arterial stiffness. In additional analysis we examined the effect of statin therapy on vascular strain. Results Patients with OSA showed significantly reduced values of vascular strain of common carotid arteries. Radial and circumferential strains were significantly lower in both patients with mild-to-moderate (p = .05) and patients with severe OSA (p = .001) compared to control. Vascular strain parameters of brachial and femoral arteries showed no consistent results. There were no significant correlations of inflammatory markers with vascular strain parameters. No significant differences in vascular strain were detected between statin and non-statin groups. Conclusion Patients with OSA show significantly reduced vascular strain assessed by ultrasound-based speckle-tracking. Vascular stiffness increases with the severity of the disease. Target vessels to assess vascular strain in patients with OSA are common carotid arteries, whereas other sites of the arterial tree are not reliable. No significant impact of current statin therapy on vascular strain was found. Further studies are needed to evaluate potential benefit of statins in secondary prevention of atherosclerosis in OSA.
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81
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Aydin Ş, Özdemir C, Küçükali CI, Sökücü SN, Giriş M, Akcan U, Tüzün E. Reduced Peripheral Blood Mononuclear Cell ROCK1 and ROCK2 Levels in Obstructive Sleep Apnea Syndrome. ACTA ACUST UNITED AC 2018; 32:319-325. [PMID: 29475915 DOI: 10.21873/invivo.11240] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 01/03/2018] [Accepted: 01/04/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND/AIM Obstructive sleep apnea syndrome (OSAS) is associated with intermittent episodes of hypoxia, endothelial dysfunction and associated cardiovascular problems. Our aim was to investigate whether OSAS-related hypoxia alters the expression of rho-associated protein kinase (ROCK), a marker of chronic hypoxia and endothelial dysfunction. MATERIALS AND METHODS ROCK1 and ROCK2 levels were measured by immunoblotting in peripheral blood mononuclear cells (PBMC) of 47 OSAS patients and 17 healthy controls. RESULTS OSAS patients showed significantly lower PBMC ROCK1 and ROCK2 levels than healthy controls in the morning, but not in the evening. ROCK1/2 levels were correlated with blood triglyceride, visceral adiposity index, minimum oxygen saturation, C-reactive protein concentration, lymphocyte levels and sleep efficiency. CONCLUSION Intermittent hypoxia induced by OSAS does not permanently alter ROCK protein expression levels. OSAS appears to be associated with endothelial dysfunction through inflammation and lipid metabolism pathways.
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Affiliation(s)
- Şenay Aydin
- Department of Neurology, Yedikule Chest Diseases and Chest Surgery Training and Research Hospital, Istanbul, Turkey
| | - Cengiz Özdemir
- Department of Chest Diseases, Yedikule Chest Diseases and Chest Surgery Training and Research Hospital, Istanbul, Turkey
| | - Cem Ismail Küçükali
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medical Research, Istanbul University, Istanbul, Turkey
| | - Sinem Nedime Sökücü
- Department of Chest Diseases, Yedikule Chest Diseases and Chest Surgery Training and Research Hospital, Istanbul, Turkey
| | - Murat Giriş
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medical Research, Istanbul University, Istanbul, Turkey
| | - Uğur Akcan
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medical Research, Istanbul University, Istanbul, Turkey
| | - Erdem Tüzün
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medical Research, Istanbul University, Istanbul, Turkey
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Fernandez RC, Moore VM, Van Ryswyk EM, Varcoe TJ, Rodgers RJ, March WA, Moran LJ, Avery JC, McEvoy RD, Davies MJ. Sleep disturbances in women with polycystic ovary syndrome: prevalence, pathophysiology, impact and management strategies. Nat Sci Sleep 2018; 10:45-64. [PMID: 29440941 PMCID: PMC5799701 DOI: 10.2147/nss.s127475] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Polycystic ovary syndrome (PCOS) is a complex endocrine disorder affecting the reproductive, metabolic and psychological health of women. Clinic-based studies indicate that sleep disturbances and disorders including obstructive sleep apnea and excessive daytime sleepiness occur more frequently among women with PCOS compared to comparison groups without the syndrome. Evidence from the few available population-based studies is supportive. Women with PCOS tend to be overweight/obese, but this only partly accounts for their sleep problems as associations are generally upheld after adjustment for body mass index; sleep problems also occur in women with PCOS of normal weight. There are several, possibly bidirectional, pathways through which PCOS is associated with sleep disturbances. The pathophysiology of PCOS involves hyperandrogenemia, a form of insulin resistance unique to affected women, and possible changes in cortisol and melatonin secretion, arguably reflecting altered hypothalamic-pituitary-adrenal function. Psychological and behavioral pathways are also likely to play a role, as anxiety and depression, smoking, alcohol use and lack of physical activity are also common among women with PCOS, partly in response to the distressing symptoms they experience. The specific impact of sleep disturbances on the health of women with PCOS is not yet clear; however, both PCOS and sleep disturbances are associated with deterioration in cardiometabolic health in the longer term and increased risk of type 2 diabetes. Both immediate quality of life and longer-term health of women with PCOS are likely to benefit from diagnosis and management of sleep disorders as part of interdisciplinary health care.
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Affiliation(s)
- Renae C Fernandez
- The University of Adelaide, Robinson Research Institute, Adelaide, SA, Australia
- The University of Adelaide, Adelaide Medical School, Adelaide, SA, Australia
- The University of Adelaide, School of Public Health, Adelaide, SA, Australia
| | - Vivienne M Moore
- The University of Adelaide, Robinson Research Institute, Adelaide, SA, Australia
- The University of Adelaide, School of Public Health, Adelaide, SA, Australia
- The University of Adelaide, Fay Gale Centre for Research on Gender, Adelaide, SA, Australia
| | - Emer M Van Ryswyk
- Adelaide Institute for Sleep Health, Flinders Centre for Research Excellence, Flinders University of South Australia, Bedford Park, SA, Australia
| | - Tamara J Varcoe
- The University of Adelaide, Robinson Research Institute, Adelaide, SA, Australia
- The University of Adelaide, Adelaide Medical School, Adelaide, SA, Australia
| | - Raymond J Rodgers
- The University of Adelaide, Robinson Research Institute, Adelaide, SA, Australia
- The University of Adelaide, Adelaide Medical School, Adelaide, SA, Australia
| | - Wendy A March
- The University of Adelaide, Robinson Research Institute, Adelaide, SA, Australia
- The University of Adelaide, School of Public Health, Adelaide, SA, Australia
| | - Lisa J Moran
- The University of Adelaide, Robinson Research Institute, Adelaide, SA, Australia
- Monash Centre for Health Research Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Jodie C Avery
- The University of Adelaide, Robinson Research Institute, Adelaide, SA, Australia
- The University of Adelaide, Adelaide Medical School, Adelaide, SA, Australia
| | - R Doug McEvoy
- Adelaide Institute for Sleep Health, Flinders Centre for Research Excellence, Flinders University of South Australia, Bedford Park, SA, Australia
- Adelaide Sleep Health, Southern Adelaide Local Health Network, Repatriation General Hospital, Daw Park, SA, Australia
| | - Michael J Davies
- The University of Adelaide, Robinson Research Institute, Adelaide, SA, Australia
- The University of Adelaide, Adelaide Medical School, Adelaide, SA, Australia
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Koo DL, Nam H, Thomas RJ, Yun CH. Sleep Disturbances as a Risk Factor for Stroke. J Stroke 2018; 20:12-32. [PMID: 29402071 PMCID: PMC5836576 DOI: 10.5853/jos.2017.02887] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 01/07/2018] [Accepted: 01/15/2018] [Indexed: 12/30/2022] Open
Abstract
Sleep, a vital process of human being, is carefully orchestrated by the brain and consists of cyclic transitions between rapid eye movement (REM) and non-REM (NREM) sleep. Autonomic tranquility during NREM sleep is characterized by vagal dominance and stable breathing, providing an opportunity for the cardiovascular-neural axis to restore homeostasis, in response to use, distress or fatigue inflicted during wakefulness. Abrupt irregular swings in sympathovagal balance during REM sleep act as phasic loads on the resting cardiovascular system. Any causes of sleep curtailment or fragmentation such as sleep restriction, sleep apnea, insomnia, periodic limb movements during sleep, and shift work, not only impair cardiovascular restoration but also impose a stress on the cardiovascular system. Sleep disturbances have been reported to play a role in the development of stroke and other cardiovascular disorders. This review aims to provide updated information on the role of abnormal sleep in the development of stroke, to discuss the implications of recent research findings, and to help both stroke clinicians and researchers understand the importance of identification and management of sleep pathology for stroke prevention and care.
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Affiliation(s)
- Dae Lim Koo
- Department of Neurology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Hyunwoo Nam
- Department of Neurology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Robert J Thomas
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Chang-Ho Yun
- Department of Neurology, Bundang Clinical Neuroscience Institute, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Jain S, Gurubhagavatula I, Townsend R, Kuna ST, Teff K, Wadden TA, Chittams J, Hanlon AL, Maislin G, Saif H, Broderick P, Ahmad Z, Pack AI, Chirinos JA. Effect of CPAP, Weight Loss, or CPAP Plus Weight Loss on Central Hemodynamics and Arterial Stiffness. Hypertension 2017; 70:1283-1290. [PMID: 29038203 PMCID: PMC5726418 DOI: 10.1161/hypertensionaha.117.09392] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 04/03/2017] [Accepted: 08/14/2017] [Indexed: 01/02/2023]
Abstract
Obesity and obstructive sleep apnea tend to coexist. Little is known about the effects of obstructive sleep apnea, obesity, or their treatment on central aortic pressures and large artery stiffness. We randomized 139 adults with obesity (body mass index >30 kg/m2) and moderate-to-severe obstructive sleep apnea to (1) continuous positive airway pressure (CPAP) therapy (n=45), (2) weight loss (WL) therapy (n=48), or (3) combined CPAP and WL (n=46) for 24 weeks. We assessed the effect of these interventions on central pressures and carotid-femoral pulse wave velocity (a measure of large artery stiffness), measured with arterial tonometry. Central systolic pressure was reduced significantly only in the combination arm (-7.4 mm Hg; 95% confidence interval, -12.5 to -2.4 mm Hg; P=0.004), without significant reductions detected in either the WL-only (-2.3 mm Hg; 95% confidence interval, -7.5 to 3.0; P=0.39) or the CPAP-only (-3.1 mm Hg; 95% confidence interval, -8.3 to 2.0; P=0.23) arms. However, none of these interventions significantly changed central pulse pressure, pulse pressure amplification, or the central augmentation index. The change in mean arterial pressure (P=0.008) and heart rate (P=0.027) induced by the interventions was significant predictors of the change in carotid-femoral pulse wave velocity. However, after adjustment for mean arterial pressure and heart rate, no significant changes in carotid-femoral pulse wave velocity were observed in any group. In obese subjects with obstructive sleep apnea, combination therapy with WL and CPAP is effective in reducing central systolic pressure. However, this effect is largely mediated by changes in mean, rather than central pulse pressure. WL and CPAP, alone or in combination, did not reduce large artery stiffness in this population. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00371293.
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Affiliation(s)
- Snigdha Jain
- From the Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX (S.J.); Divisions of Sleep Medicine (I.G., G.M., S.T.K, A.I.P.), Nephrology (R.T) and Cardiovascular Medicine (J.A.C., Z.A.), Department of Medicine and Center for Weight and Eating Disorders, Department of Psychiatry (T.A.W), University of Pennsylvania Perelman School of Medicine, Philadelphia; Hospital of University of Pennsylvania, Philadelphia (R.T., S.T.K., T.A.W., A.I.P., J.A.C.); Corporal Michael Crescenz VA Medical Center, Philadelphia, PA (I.G.); Division of Diabetes, National Institutes of Health, Bethesda, MD (K.T.); Departments of Biostatistics Consulting Unit (J.C.) and Family and Community Health, (A.L.H.), School of Nursing, University of Pennsylvania, Philadelphia; Department of Cardiology, Lehigh Valley Health Network, Allentown, PA (H.S.); and Johns Hopkins University Technology and Innovation Center, Johns Hopkins University, Baltimore, MD (P.B.)
| | - Indira Gurubhagavatula
- From the Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX (S.J.); Divisions of Sleep Medicine (I.G., G.M., S.T.K, A.I.P.), Nephrology (R.T) and Cardiovascular Medicine (J.A.C., Z.A.), Department of Medicine and Center for Weight and Eating Disorders, Department of Psychiatry (T.A.W), University of Pennsylvania Perelman School of Medicine, Philadelphia; Hospital of University of Pennsylvania, Philadelphia (R.T., S.T.K., T.A.W., A.I.P., J.A.C.); Corporal Michael Crescenz VA Medical Center, Philadelphia, PA (I.G.); Division of Diabetes, National Institutes of Health, Bethesda, MD (K.T.); Departments of Biostatistics Consulting Unit (J.C.) and Family and Community Health, (A.L.H.), School of Nursing, University of Pennsylvania, Philadelphia; Department of Cardiology, Lehigh Valley Health Network, Allentown, PA (H.S.); and Johns Hopkins University Technology and Innovation Center, Johns Hopkins University, Baltimore, MD (P.B.)
| | - Raymond Townsend
- From the Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX (S.J.); Divisions of Sleep Medicine (I.G., G.M., S.T.K, A.I.P.), Nephrology (R.T) and Cardiovascular Medicine (J.A.C., Z.A.), Department of Medicine and Center for Weight and Eating Disorders, Department of Psychiatry (T.A.W), University of Pennsylvania Perelman School of Medicine, Philadelphia; Hospital of University of Pennsylvania, Philadelphia (R.T., S.T.K., T.A.W., A.I.P., J.A.C.); Corporal Michael Crescenz VA Medical Center, Philadelphia, PA (I.G.); Division of Diabetes, National Institutes of Health, Bethesda, MD (K.T.); Departments of Biostatistics Consulting Unit (J.C.) and Family and Community Health, (A.L.H.), School of Nursing, University of Pennsylvania, Philadelphia; Department of Cardiology, Lehigh Valley Health Network, Allentown, PA (H.S.); and Johns Hopkins University Technology and Innovation Center, Johns Hopkins University, Baltimore, MD (P.B.)
| | - Samuel T Kuna
- From the Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX (S.J.); Divisions of Sleep Medicine (I.G., G.M., S.T.K, A.I.P.), Nephrology (R.T) and Cardiovascular Medicine (J.A.C., Z.A.), Department of Medicine and Center for Weight and Eating Disorders, Department of Psychiatry (T.A.W), University of Pennsylvania Perelman School of Medicine, Philadelphia; Hospital of University of Pennsylvania, Philadelphia (R.T., S.T.K., T.A.W., A.I.P., J.A.C.); Corporal Michael Crescenz VA Medical Center, Philadelphia, PA (I.G.); Division of Diabetes, National Institutes of Health, Bethesda, MD (K.T.); Departments of Biostatistics Consulting Unit (J.C.) and Family and Community Health, (A.L.H.), School of Nursing, University of Pennsylvania, Philadelphia; Department of Cardiology, Lehigh Valley Health Network, Allentown, PA (H.S.); and Johns Hopkins University Technology and Innovation Center, Johns Hopkins University, Baltimore, MD (P.B.)
| | - Karen Teff
- From the Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX (S.J.); Divisions of Sleep Medicine (I.G., G.M., S.T.K, A.I.P.), Nephrology (R.T) and Cardiovascular Medicine (J.A.C., Z.A.), Department of Medicine and Center for Weight and Eating Disorders, Department of Psychiatry (T.A.W), University of Pennsylvania Perelman School of Medicine, Philadelphia; Hospital of University of Pennsylvania, Philadelphia (R.T., S.T.K., T.A.W., A.I.P., J.A.C.); Corporal Michael Crescenz VA Medical Center, Philadelphia, PA (I.G.); Division of Diabetes, National Institutes of Health, Bethesda, MD (K.T.); Departments of Biostatistics Consulting Unit (J.C.) and Family and Community Health, (A.L.H.), School of Nursing, University of Pennsylvania, Philadelphia; Department of Cardiology, Lehigh Valley Health Network, Allentown, PA (H.S.); and Johns Hopkins University Technology and Innovation Center, Johns Hopkins University, Baltimore, MD (P.B.)
| | - Thomas A Wadden
- From the Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX (S.J.); Divisions of Sleep Medicine (I.G., G.M., S.T.K, A.I.P.), Nephrology (R.T) and Cardiovascular Medicine (J.A.C., Z.A.), Department of Medicine and Center for Weight and Eating Disorders, Department of Psychiatry (T.A.W), University of Pennsylvania Perelman School of Medicine, Philadelphia; Hospital of University of Pennsylvania, Philadelphia (R.T., S.T.K., T.A.W., A.I.P., J.A.C.); Corporal Michael Crescenz VA Medical Center, Philadelphia, PA (I.G.); Division of Diabetes, National Institutes of Health, Bethesda, MD (K.T.); Departments of Biostatistics Consulting Unit (J.C.) and Family and Community Health, (A.L.H.), School of Nursing, University of Pennsylvania, Philadelphia; Department of Cardiology, Lehigh Valley Health Network, Allentown, PA (H.S.); and Johns Hopkins University Technology and Innovation Center, Johns Hopkins University, Baltimore, MD (P.B.)
| | - Jesse Chittams
- From the Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX (S.J.); Divisions of Sleep Medicine (I.G., G.M., S.T.K, A.I.P.), Nephrology (R.T) and Cardiovascular Medicine (J.A.C., Z.A.), Department of Medicine and Center for Weight and Eating Disorders, Department of Psychiatry (T.A.W), University of Pennsylvania Perelman School of Medicine, Philadelphia; Hospital of University of Pennsylvania, Philadelphia (R.T., S.T.K., T.A.W., A.I.P., J.A.C.); Corporal Michael Crescenz VA Medical Center, Philadelphia, PA (I.G.); Division of Diabetes, National Institutes of Health, Bethesda, MD (K.T.); Departments of Biostatistics Consulting Unit (J.C.) and Family and Community Health, (A.L.H.), School of Nursing, University of Pennsylvania, Philadelphia; Department of Cardiology, Lehigh Valley Health Network, Allentown, PA (H.S.); and Johns Hopkins University Technology and Innovation Center, Johns Hopkins University, Baltimore, MD (P.B.)
| | - Alexandra L Hanlon
- From the Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX (S.J.); Divisions of Sleep Medicine (I.G., G.M., S.T.K, A.I.P.), Nephrology (R.T) and Cardiovascular Medicine (J.A.C., Z.A.), Department of Medicine and Center for Weight and Eating Disorders, Department of Psychiatry (T.A.W), University of Pennsylvania Perelman School of Medicine, Philadelphia; Hospital of University of Pennsylvania, Philadelphia (R.T., S.T.K., T.A.W., A.I.P., J.A.C.); Corporal Michael Crescenz VA Medical Center, Philadelphia, PA (I.G.); Division of Diabetes, National Institutes of Health, Bethesda, MD (K.T.); Departments of Biostatistics Consulting Unit (J.C.) and Family and Community Health, (A.L.H.), School of Nursing, University of Pennsylvania, Philadelphia; Department of Cardiology, Lehigh Valley Health Network, Allentown, PA (H.S.); and Johns Hopkins University Technology and Innovation Center, Johns Hopkins University, Baltimore, MD (P.B.)
| | - Greg Maislin
- From the Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX (S.J.); Divisions of Sleep Medicine (I.G., G.M., S.T.K, A.I.P.), Nephrology (R.T) and Cardiovascular Medicine (J.A.C., Z.A.), Department of Medicine and Center for Weight and Eating Disorders, Department of Psychiatry (T.A.W), University of Pennsylvania Perelman School of Medicine, Philadelphia; Hospital of University of Pennsylvania, Philadelphia (R.T., S.T.K., T.A.W., A.I.P., J.A.C.); Corporal Michael Crescenz VA Medical Center, Philadelphia, PA (I.G.); Division of Diabetes, National Institutes of Health, Bethesda, MD (K.T.); Departments of Biostatistics Consulting Unit (J.C.) and Family and Community Health, (A.L.H.), School of Nursing, University of Pennsylvania, Philadelphia; Department of Cardiology, Lehigh Valley Health Network, Allentown, PA (H.S.); and Johns Hopkins University Technology and Innovation Center, Johns Hopkins University, Baltimore, MD (P.B.)
| | - Hassam Saif
- From the Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX (S.J.); Divisions of Sleep Medicine (I.G., G.M., S.T.K, A.I.P.), Nephrology (R.T) and Cardiovascular Medicine (J.A.C., Z.A.), Department of Medicine and Center for Weight and Eating Disorders, Department of Psychiatry (T.A.W), University of Pennsylvania Perelman School of Medicine, Philadelphia; Hospital of University of Pennsylvania, Philadelphia (R.T., S.T.K., T.A.W., A.I.P., J.A.C.); Corporal Michael Crescenz VA Medical Center, Philadelphia, PA (I.G.); Division of Diabetes, National Institutes of Health, Bethesda, MD (K.T.); Departments of Biostatistics Consulting Unit (J.C.) and Family and Community Health, (A.L.H.), School of Nursing, University of Pennsylvania, Philadelphia; Department of Cardiology, Lehigh Valley Health Network, Allentown, PA (H.S.); and Johns Hopkins University Technology and Innovation Center, Johns Hopkins University, Baltimore, MD (P.B.)
| | - Preston Broderick
- From the Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX (S.J.); Divisions of Sleep Medicine (I.G., G.M., S.T.K, A.I.P.), Nephrology (R.T) and Cardiovascular Medicine (J.A.C., Z.A.), Department of Medicine and Center for Weight and Eating Disorders, Department of Psychiatry (T.A.W), University of Pennsylvania Perelman School of Medicine, Philadelphia; Hospital of University of Pennsylvania, Philadelphia (R.T., S.T.K., T.A.W., A.I.P., J.A.C.); Corporal Michael Crescenz VA Medical Center, Philadelphia, PA (I.G.); Division of Diabetes, National Institutes of Health, Bethesda, MD (K.T.); Departments of Biostatistics Consulting Unit (J.C.) and Family and Community Health, (A.L.H.), School of Nursing, University of Pennsylvania, Philadelphia; Department of Cardiology, Lehigh Valley Health Network, Allentown, PA (H.S.); and Johns Hopkins University Technology and Innovation Center, Johns Hopkins University, Baltimore, MD (P.B.)
| | - Zeshan Ahmad
- From the Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX (S.J.); Divisions of Sleep Medicine (I.G., G.M., S.T.K, A.I.P.), Nephrology (R.T) and Cardiovascular Medicine (J.A.C., Z.A.), Department of Medicine and Center for Weight and Eating Disorders, Department of Psychiatry (T.A.W), University of Pennsylvania Perelman School of Medicine, Philadelphia; Hospital of University of Pennsylvania, Philadelphia (R.T., S.T.K., T.A.W., A.I.P., J.A.C.); Corporal Michael Crescenz VA Medical Center, Philadelphia, PA (I.G.); Division of Diabetes, National Institutes of Health, Bethesda, MD (K.T.); Departments of Biostatistics Consulting Unit (J.C.) and Family and Community Health, (A.L.H.), School of Nursing, University of Pennsylvania, Philadelphia; Department of Cardiology, Lehigh Valley Health Network, Allentown, PA (H.S.); and Johns Hopkins University Technology and Innovation Center, Johns Hopkins University, Baltimore, MD (P.B.)
| | - Allan I Pack
- From the Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX (S.J.); Divisions of Sleep Medicine (I.G., G.M., S.T.K, A.I.P.), Nephrology (R.T) and Cardiovascular Medicine (J.A.C., Z.A.), Department of Medicine and Center for Weight and Eating Disorders, Department of Psychiatry (T.A.W), University of Pennsylvania Perelman School of Medicine, Philadelphia; Hospital of University of Pennsylvania, Philadelphia (R.T., S.T.K., T.A.W., A.I.P., J.A.C.); Corporal Michael Crescenz VA Medical Center, Philadelphia, PA (I.G.); Division of Diabetes, National Institutes of Health, Bethesda, MD (K.T.); Departments of Biostatistics Consulting Unit (J.C.) and Family and Community Health, (A.L.H.), School of Nursing, University of Pennsylvania, Philadelphia; Department of Cardiology, Lehigh Valley Health Network, Allentown, PA (H.S.); and Johns Hopkins University Technology and Innovation Center, Johns Hopkins University, Baltimore, MD (P.B.)
| | - Julio A Chirinos
- From the Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX (S.J.); Divisions of Sleep Medicine (I.G., G.M., S.T.K, A.I.P.), Nephrology (R.T) and Cardiovascular Medicine (J.A.C., Z.A.), Department of Medicine and Center for Weight and Eating Disorders, Department of Psychiatry (T.A.W), University of Pennsylvania Perelman School of Medicine, Philadelphia; Hospital of University of Pennsylvania, Philadelphia (R.T., S.T.K., T.A.W., A.I.P., J.A.C.); Corporal Michael Crescenz VA Medical Center, Philadelphia, PA (I.G.); Division of Diabetes, National Institutes of Health, Bethesda, MD (K.T.); Departments of Biostatistics Consulting Unit (J.C.) and Family and Community Health, (A.L.H.), School of Nursing, University of Pennsylvania, Philadelphia; Department of Cardiology, Lehigh Valley Health Network, Allentown, PA (H.S.); and Johns Hopkins University Technology and Innovation Center, Johns Hopkins University, Baltimore, MD (P.B.).
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Drager LF, McEvoy RD, Barbe F, Lorenzi-Filho G, Redline S. Sleep Apnea and Cardiovascular Disease: Lessons From Recent Trials and Need for Team Science. Circulation 2017; 136:1840-1850. [PMID: 29109195 DOI: 10.1161/circulationaha.117.029400] [Citation(s) in RCA: 308] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Emerging research highlights the complex interrelationships between sleep-disordered breathing and cardiovascular disease, presenting clinical and research opportunities as well as challenges. Patients presenting to cardiology clinics have a high prevalence of obstructive and central sleep apnea associated with Cheyne-Stokes respiration. Multiple mechanisms have been identified by which sleep disturbances adversely affect cardiovascular structure and function. Epidemiological research indicates that obstructive sleep apnea is associated with increases in the incidence and progression of coronary heart disease, heart failure, stroke, and atrial fibrillation. Central sleep apnea associated with Cheyne-Stokes respiration predicts incident heart failure and atrial fibrillation; among patients with heart failure, it strongly predicts mortality. Thus, a strong literature provides the mechanistic and empirical bases for considering obstructive sleep apnea and central sleep apnea associated with Cheyne-Stokes respiration as potentially modifiable risk factors for cardiovascular disease. Data from small trials provide evidence that treatment of obstructive sleep apnea with continuous positive airway pressure improves not only patient-reported outcomes such as sleepiness, quality of life, and mood but also intermediate cardiovascular end points such as blood pressure, cardiac ejection fraction, vascular parameters, and arrhythmias. However, data from large-scale randomized controlled trials do not currently support a role for positive pressure therapies for reducing cardiovascular mortality. The results of 2 recent large randomized controlled trials, published in 2015 and 2016, raise questions about the effectiveness of pressure therapies in reducing clinical end points, although 1 trial supported the beneficial effect of continuous positive airway pressure on quality of life, mood, and work absenteeism. This review provides a contextual framework for interpreting the results of recent studies, key clinical messages, and suggestions for future sleep and cardiovascular research, which include further consideration of individual risk factors, use of existing and new multimodality therapies that also address adherence, and implementation of trials that are sufficiently powered to target end points and to support subgroup analyses. These goals may best be addressed through strengthening collaboration among the cardiology, sleep medicine, and clinical trial communities.
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Affiliation(s)
- Luciano F Drager
- From Hypertension Unit (L.F.D.) and Sleep Laboratory, Pulmonary Division (G.L.-F.), Instituto do Coracao, and Hypertension Unit, Renal Division (L.F.D.), University of São Paulo Medical School, Brazil; Adelaide Institute for Sleep Health, College of Medicine and Public Health, and School of Medicine, Faculty of Medicine, Nursing, and Health Sciences, Flinders University, Australia (R.D.M.); Sleep Health Service, Respiratory and Sleep Services, Southern Adelaide Local Health Network, Australia (R.D.M.); Respiratory Department, Institut de Recerca Biomèdica de Lleida, Lleida and Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias, Madrid, Spain (F.B.); and Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (S.R.).
| | - R Doug McEvoy
- From Hypertension Unit (L.F.D.) and Sleep Laboratory, Pulmonary Division (G.L.-F.), Instituto do Coracao, and Hypertension Unit, Renal Division (L.F.D.), University of São Paulo Medical School, Brazil; Adelaide Institute for Sleep Health, College of Medicine and Public Health, and School of Medicine, Faculty of Medicine, Nursing, and Health Sciences, Flinders University, Australia (R.D.M.); Sleep Health Service, Respiratory and Sleep Services, Southern Adelaide Local Health Network, Australia (R.D.M.); Respiratory Department, Institut de Recerca Biomèdica de Lleida, Lleida and Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias, Madrid, Spain (F.B.); and Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (S.R.)
| | - Ferran Barbe
- From Hypertension Unit (L.F.D.) and Sleep Laboratory, Pulmonary Division (G.L.-F.), Instituto do Coracao, and Hypertension Unit, Renal Division (L.F.D.), University of São Paulo Medical School, Brazil; Adelaide Institute for Sleep Health, College of Medicine and Public Health, and School of Medicine, Faculty of Medicine, Nursing, and Health Sciences, Flinders University, Australia (R.D.M.); Sleep Health Service, Respiratory and Sleep Services, Southern Adelaide Local Health Network, Australia (R.D.M.); Respiratory Department, Institut de Recerca Biomèdica de Lleida, Lleida and Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias, Madrid, Spain (F.B.); and Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (S.R.)
| | - Geraldo Lorenzi-Filho
- From Hypertension Unit (L.F.D.) and Sleep Laboratory, Pulmonary Division (G.L.-F.), Instituto do Coracao, and Hypertension Unit, Renal Division (L.F.D.), University of São Paulo Medical School, Brazil; Adelaide Institute for Sleep Health, College of Medicine and Public Health, and School of Medicine, Faculty of Medicine, Nursing, and Health Sciences, Flinders University, Australia (R.D.M.); Sleep Health Service, Respiratory and Sleep Services, Southern Adelaide Local Health Network, Australia (R.D.M.); Respiratory Department, Institut de Recerca Biomèdica de Lleida, Lleida and Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias, Madrid, Spain (F.B.); and Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (S.R.)
| | - Susan Redline
- From Hypertension Unit (L.F.D.) and Sleep Laboratory, Pulmonary Division (G.L.-F.), Instituto do Coracao, and Hypertension Unit, Renal Division (L.F.D.), University of São Paulo Medical School, Brazil; Adelaide Institute for Sleep Health, College of Medicine and Public Health, and School of Medicine, Faculty of Medicine, Nursing, and Health Sciences, Flinders University, Australia (R.D.M.); Sleep Health Service, Respiratory and Sleep Services, Southern Adelaide Local Health Network, Australia (R.D.M.); Respiratory Department, Institut de Recerca Biomèdica de Lleida, Lleida and Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias, Madrid, Spain (F.B.); and Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (S.R.).
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Scherbakov N, Sandek A, Ebner N, Valentova M, Nave AH, Jankowska EA, Schefold JC, von Haehling S, Anker SD, Fietze I, Fiebach JB, Haeusler KG, Doehner W. Sleep-Disordered Breathing in Acute Ischemic Stroke: A Mechanistic Link to Peripheral Endothelial Dysfunction. J Am Heart Assoc 2017; 6:JAHA.117.006010. [PMID: 28893762 PMCID: PMC5634268 DOI: 10.1161/jaha.117.006010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Sleep-disordered breathing (SDB) after acute ischemic stroke is frequent and may be linked to stroke-induced autonomic imbalance. In the present study, the interaction between SDB and peripheral endothelial dysfunction (ED) was investigated in patients with acute ischemic stroke and at 1-year follow-up. METHODS AND RESULTS SDB was assessed by transthoracic impedance records in 101 patients with acute ischemic stroke (mean age, 69 years; 61% men; median National Institutes of Health Stroke Scale, 4) while being on the stroke unit. SDB was defined by apnea-hypopnea index ≥5 episodes per hour. Peripheral endothelial function was assessed using peripheral arterial tonometry (EndoPAT-2000). ED was defined by reactive hyperemia index ≤1.8. Forty-one stroke patients underwent 1-year follow-up (390±24 days) after stroke. SDB was observed in 57% patients with acute ischemic stroke. Compared with patients without SDB, ED was more prevalent in patients with SDB (32% versus 64%; P<0.01). After adjustment for multiple confounders, presence of SDB remained independently associated with ED (odds ratio, 3.1; [95% confidence interval, 1.2-7.9]; P<0.05). After 1 year, the prevalence of SDB decreased from 59% to 15% (P<0.001). Interestingly, peripheral endothelial function improved in stroke patients with normalized SDB, compared with patients with persisting SDB (P<0.05). CONCLUSIONS SDB was present in more than half of all patients with acute ischemic stroke and was independently associated with peripheral ED. Normalized ED in patients with normalized breathing pattern 1 year after stroke suggests a mechanistic link between SDB and ED. CLINICAL TRIAL REGISTRATION URL: https://drks-neu.uniklinik-freiburg.de. Unique identifier: DRKS00000514.
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Affiliation(s)
- Nadja Scherbakov
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Anja Sandek
- Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medicine Goettingen (UMG), Goettingen, Germany
| | - Nicole Ebner
- Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medicine Goettingen (UMG), Goettingen, Germany
| | - Miroslava Valentova
- Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medicine Goettingen (UMG), Goettingen, Germany
| | - Alexander Heinrich Nave
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Ewa A Jankowska
- Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland.,Cardiology Department, Military Hospital, Wroclaw, Poland
| | - Jörg C Schefold
- Department of Intensive Care Medicine, Inselspital, University Hospital of Bern, Switzerland
| | - Stephan von Haehling
- Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medicine Goettingen (UMG), Goettingen, Germany
| | - Stefan D Anker
- Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medicine Goettingen (UMG), Goettingen, Germany
| | - Ingo Fietze
- Interdisciplinary Center of Sleep Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jochen B Fiebach
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Karl Georg Haeusler
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Wolfram Doehner
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Cardiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
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87
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Borsini E, Blanco M, Bosio M, Schrappe M, Ernst G, Nosetto D, Gaggioli N, Salvado A, Manuale O, Schiavone M. Prevalence of sleep apnea and cardiovascular risk factors in patients with hypertension in a day hospital model. Clin Exp Hypertens 2017; 40:231-237. [PMID: 28872361 DOI: 10.1080/10641963.2017.1356841] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION To identify patients at risk for obstructive sleep apnea (OSA) syndrome at a specialized hypertension center, we administered questionnaires and used respiratory polygraphy (RP). RESULTS We studied 168 patients (64.8% men and 35.2% women). Patients' body mass index (BMI) was 34.7 ± 6.79 and Epworth Sleepiness Scale (ESS) scores were 8.01 for male and 8.92 for women (p = 0.69). RP recordings revealed AHI (Apnea-Hypopnea Index) of 18.03 ± 15.7, an ODI (Oxygen Desaturation Index) of 18.6 ± 15.2, and a time oxygen saturation <90% (%) of 20.8 ± 24.3. Around 44% of patients had an AHI of >15 events/h, and continuous positive airway pressure (CPAP) was recommended to 69 patients (41.07%). Pulse wave velocity (PWV) showed high values in AHI > 15/h (p = 0.050), and carotid intima-media thickness (IMT) did not correlate with AHI > 15; right IMT: 0.83 ± 1.3 versus 0.78 ± 0.13 mm (p = 0.41) and 0.82 ± 0.16 versus 0.78 ± 0.19 mm (p = 0.40). However, we find correlation with carotid plaque (p = 0.046). The ACC/AHA calculator revealed a gradual increase in the risk of cardiovascular events: 8.7% with AHI < 5/h, and 30.3% in severe OSA. CONCLUSIONS In hypertension (HT) patients, RP revealed a high prevalence of OSA associated with carotid artery disease, high PWV, and increased cardiovascular risk.
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Affiliation(s)
- Eduardo Borsini
- a Respiratory Medicine Service , Hospital Británico , Buenos Aires , Argentina.,b Argentine Research Group for Sleep Apnea (GAIAS) , Buenos Aires , Argentina
| | - Magalí Blanco
- a Respiratory Medicine Service , Hospital Británico , Buenos Aires , Argentina
| | - Martín Bosio
- c Hypertension Section, Cardiology Service , Hospital Británico , Buenos Aires , Argentina
| | - Marcela Schrappe
- c Hypertension Section, Cardiology Service , Hospital Británico , Buenos Aires , Argentina
| | - Glenda Ernst
- a Respiratory Medicine Service , Hospital Británico , Buenos Aires , Argentina.,b Argentine Research Group for Sleep Apnea (GAIAS) , Buenos Aires , Argentina
| | - Daniela Nosetto
- c Hypertension Section, Cardiology Service , Hospital Británico , Buenos Aires , Argentina
| | - Nazarena Gaggioli
- a Respiratory Medicine Service , Hospital Británico , Buenos Aires , Argentina
| | - Alejandro Salvado
- a Respiratory Medicine Service , Hospital Británico , Buenos Aires , Argentina
| | - Osvaldo Manuale
- c Hypertension Section, Cardiology Service , Hospital Británico , Buenos Aires , Argentina
| | - Miguel Schiavone
- c Hypertension Section, Cardiology Service , Hospital Británico , Buenos Aires , Argentina
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88
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Mokros Ł, Kuczyński W, Franczak Ł, Białasiewicz P. Morning Diastolic Blood Pressure May Be Independently Associated With Severity of Obstructive Sleep Apnea in Non-Hypertensive Patients: A Cross-Sectional Study. J Clin Sleep Med 2017; 13:905-910. [PMID: 28502282 PMCID: PMC5482582 DOI: 10.5664/jcsm.6664] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 04/03/2017] [Accepted: 04/24/2017] [Indexed: 12/23/2022]
Abstract
STUDY OBJECTIVES The aim of the study is to verify a possible association between arterial blood pressure and obstructive sleep apnea (OSA) severity in a group of non-hypertensive patients. METHODS This is a retrospective study of 1,171 consecutive patients referred to the sleep laboratory with complaints suggestive of OSA who underwent standard diagnostic polysomnography. In total, 454 patients with no History of arterial hypertension nor had received any such treatment were selected from this group. RESULTS Patients with severe OSA (apnea-hypopnea index [AHI] ≥ 30 events/h) presented with higher diastolic blood pressure (DBP) in the morning than healthy subjects (AHI < 5 events/h) or those suffering from mild (15 < AHI ≥ 5 events/h) or moderate OSA (30 < AHI ≥ 15 events/h): 86.2 ± 11.3 versus 79.2 ± 8.5, 80.3 ± 10.2 and 81.4 ± 9.6 mmHg, P < .01, respectively. In a linear regression model, a rise in morning DBP was predicted by AHI (ß = 0.14, P < .001) and body mass index (BMI) (ß = 0.22, P < .01), but not by age (ß = 0.01, P = .92), male sex (ß = -0.06, P = .19), or smoking (ß = 0.01, P = .86). In contrast, no association existed between morning systolic blood pressure (SBP) and AHI independently of BMI, sex, age, or smoking. High blood pressure (ie, SBP ≥ 140 mmHg or DBP ≥ 90 mmHg on each of three measurements on different occasions) was predicted by age of 42 years or older, BMI of at least 29 kg/m2, and severe OSA. CONCLUSIONS High AHI, independent of obesity, age and sex, was associated with elevated DBP in the morning. Thus, elevated morning DBP may be one of the symptoms related to OSA that warrants specific diagnostics. COMMENTARY A commentary on this article appears in this issue on page 861.
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Affiliation(s)
- Łukasz Mokros
- Department of Clinical Pharmacology, Medical University of Łódź, Łódź, Poland
| | - Wojciech Kuczyński
- Department of Sleep and Metabolic Disorders, Medical University of Łódź, Łódź, Poland
| | - Łukasz Franczak
- Department of Sleep and Metabolic Disorders, Medical University of Łódź, Łódź, Poland
| | - Piotr Białasiewicz
- Department of Sleep and Metabolic Disorders, Medical University of Łódź, Łódź, Poland
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Ehsan Z, Ishman SL, Kimball TR, Zhang N, Zou Y, Amin RS. Longitudinal Cardiovascular Outcomes of Sleep Disordered Breathing in Children: A Meta-Analysis and Systematic Review. Sleep 2017; 40:2962446. [PMID: 28329042 DOI: 10.1093/sleep/zsx015] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objectives The presence of sleep disordered breathing (SDB) is known to impact long-term cardiovascular morbidity in adults; however, the long-term effects in children are poorly understood. We aimed to systematically review and synthesize studies published to date on the long-term effects of SDB in children. Study Design Meta-analysis and systematic review using PubMed, CINAHL, Embase, and Scopus (all indexed years). Methods We searched for English-language articles containing original human data from prospective studies, with ≥7 participants, in children ≤18 years of age. Data regarding study design, demographics, clinical characteristics, outcomes, level of evidence, and risk of bias were obtained. Articles were independently reviewed by three investigators. Retrospective and cross-sectional studies were excluded. Results Of 1701 identified abstracts, 25 articles (combined n = 1418) were ultimately included. All studies reported longitudinal outcomes following treatment of SDB, 21 studies exclusively reporting outcomes after adenotonsillectomy. Therefore, studies were combined to objectively assess the effect of SDB treatment on cardiovascular outcomes. Although all cardiovascular parameters were within the normal range at baseline, at follow-up there was a significant decrease in mean pulmonary artery pressure, right ventricular end diastolic diameter, heart rate, mitral Em/Am ratio, and C-reactive protein. There was no significant change in interventricular septum thickness, left ventricular parameters (shortening fraction, systolic and end diastolic diameters, ejection fraction, posterior wall thickness, isovolumetric relaxation time), left atrial diameter, and aortic and pulmonary valve peak velocities. Conclusions Studies assessing the long-term cardiovascular effects of SDB in children are limited. The available literature indicates effects on autonomic function, right, and left heart function following treatment for SDB. However, well-designed, large-scale, prospective cohort studies (using standardized outcomes) are needed to better understand the relationship of cardiovascular morbidity in the context of pediatric SDB.
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Affiliation(s)
- Zarmina Ehsan
- Division of Pulmonary and Sleep Medicine, Children's Mercy Hospital, Kansas City, MO
| | - Stacey L Ishman
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.,Division of Pulmonary and Sleep Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Thomas R Kimball
- Division of Cardiology, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Nanhua Zhang
- Department of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Yuanshu Zou
- Department of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Raouf S Amin
- Division of Pulmonary and Sleep Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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90
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Zoccali C, Vanholder R, Massy ZA, Ortiz A, Sarafidis P, Dekker FW, Fliser D, Fouque D, Heine GH, Jager KJ, Kanbay M, Mallamaci F, Parati G, Rossignol P, Wiecek A, London G. The systemic nature of CKD. Nat Rev Nephrol 2017; 13:344-358. [PMID: 28435157 DOI: 10.1038/nrneph.2017.52] [Citation(s) in RCA: 239] [Impact Index Per Article: 34.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The accurate definition and staging of chronic kidney disease (CKD) is one of the major achievements of modern nephrology. Intensive research is now being undertaken to unravel the risk factors and pathophysiologic underpinnings of this disease. In particular, the relationships between the kidney and other organs have been comprehensively investigated in experimental and clinical studies in the last two decades. Owing to technological and analytical limitations, these links have been studied with a reductionist approach focusing on two organs at a time, such as the heart and the kidney or the bone and the kidney. Here, we discuss studies that highlight the complex and systemic nature of CKD. Energy balance, innate immunity and neuroendocrine signalling are highly integrated biological phenomena. The diseased kidney disrupts such integration and generates a high-risk phenotype with a clinical profile encompassing inflammation, protein-energy wasting, altered function of the autonomic and central nervous systems and cardiopulmonary, vascular and bone diseases. A systems biology approach to CKD using omics techniques will hopefully enable in-depth study of the pathophysiology of this systemic disease, and has the potential to unravel critical pathways that can be targeted for CKD prevention and therapy.
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Affiliation(s)
- Carmine Zoccali
- CNR-IFC Clinical Epidemiology and Pathophysiology of Renal Diseases and Hypertension Unit, Ospedali Riuniti 89124 Reggio Calabria, Italy
| | - Raymond Vanholder
- Ghent University Hospital, Department of Nephrology, Department of Internal Medicine, University Hospital Gent, De Pintelaan 185, B9000 Ghent, Belgium
| | - Ziad A Massy
- Division of Nephrology, Ambroise Paré Hospital, Assistance Publique Hôpitaux de Paris, 9 Avenue Charles de Gaulle, 92100 Boulogne-Billancourt, Paris.,University of Paris Ouest-Versailles-Saint-Quentin-en-Yvelines (UVSQ), 55 Avenue de Paris, 78000 Versailles, France.,Inserm U-1018, Centre de recherche en épidémiologie et santé des populations (CESP), Equipe 5, Hôpital Paul-Brousse, 16 avenue Paul Vaillant-Couturier, 94807 Villejuif Cedex, France.,Paris-Sud University (PSU), 15 Rue Georges Clemenceau, 91400 Orsay, France.,French-Clinical Research Infrastructure Network (F-CRIN), Pavillon Leriche 2è étage CHU de Toulouse, Place Dr Baylac TSA40031, 31059 TOULOUSE Cedex 3, France
| | - Alberto Ortiz
- Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Fundación Renal Iñigo Alvarez de Toledo, Madrid, Av. Reyes Católicos, 2, 28040 Madrid, Spain
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Thessaloniki, Konstantinoupoleos 49, Thessaloniki 546 42, Greece
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Danilo Fliser
- Department Internal Medicine IV-Renal and Hypertensive Disease-Saarland University Medical Centre Kirrberger Straß 66421 Homburg, Saar, Germany
| | - Denis Fouque
- Université de Lyon, UCBL, Carmen, Department of Nephrology, Centre Hospitalier Lyon-Sud, F-69495 Pierre Bénite, France
| | - Gunnar H Heine
- Department Internal Medicine IV-Renal and Hypertensive Disease-Saarland University Medical Centre Kirrberger Straß 66421 Homburg, Saar, Germany
| | - Kitty J Jager
- European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry, Department of Medical Informatics, Meibergdreef 9, 1105 AZ Amsterdam-Zuidoost, The Netherlands
| | - Mehmet Kanbay
- Division of Nephrology, Department of Medicine,Koç University, Rumelifeneri Yolu 34450 Sarıyer Istanbul, Turkey
| | - Francesca Mallamaci
- CNR-IFC Clinical Epidemiology and Pathophysiology of Renal Diseases and Hypertension Unit, Ospedali Riuniti 89124 Reggio Calabria, Italy.,Nephrology, Dialysis and Transplantation Unit Ospedali Riuniti, 89124 Reggio Calabria Italy
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences, S. Luca Hospital, Istituto Auxologico Italiano &Department of Medicine and Surgery, University of Milan-Bicocca, Piazzale Brescia 20, Milan 20149, Italy
| | - Patrick Rossignol
- French-Clinical Research Infrastructure Network (F-CRIN), Pavillon Leriche 2è étage CHU de Toulouse, Place Dr Baylac TSA40031, 31059 TOULOUSE Cedex 3, France.,Inserm, Centre d'Investigations Cliniques-Plurithématique 1433, Cardiovascular and Renal Clinical Trialists (INI-CRCT), Institut Lorrain du Cœur et des Vaisseaux Louis Mathieu, 4 rue Morvan, 54500 Vandoeuvre-les-Nancy, France.,Inserm U1116, Faculté de Médecine, Bâtiment D 1er étage, 9 avenue de la forêt de Haye - BP 184, 54500 Vandœuvre-lès-Nancy Cedex, France.,CHU Nancy, Département de Cardiologie, Institut Lorrain du Cœur et des Vaisseaux, 5 Rue du Morvan, 54500 Vandœuvre-lès-Nancy, France.,Université de Lorraine, 34 Cours Léopold, 54000 Nancy, France
| | - Andrzej Wiecek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Francuska 20/24 Street, Pl-40-027 Katowice, Poland
| | - Gerard London
- INSERM U970, Hopital Européen Georges Pompidou, 20 Rue Leblanc, 75015 Paris, France
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91
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Crinion SJ, Ryan S, McNicholas WT. Obstructive sleep apnoea as a cause of nocturnal nondipping blood pressure: recent evidence regarding clinical importance and underlying mechanisms. Eur Respir J 2017; 49:49/1/1601818. [DOI: 10.1183/13993003.01818-2016] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 10/02/2016] [Indexed: 12/19/2022]
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92
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The relationship between sleep apnea, metabolic dysfunction and inflammation: The gender influence. Brain Behav Immun 2017; 59:211-218. [PMID: 27621224 DOI: 10.1016/j.bbi.2016.09.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 09/06/2016] [Accepted: 09/07/2016] [Indexed: 02/08/2023] Open
Abstract
Obstructive sleep apnea (OSA) has been associated with increased risk of cardiovascular morbidity and mortality. Although inflammatory markers may mediate this association, it is unknown the influence of gender in this mechanism. Thus, we aimed to evaluate the interaction effects between OSA and gender on metabolic and inflammatory profile in a population sample. This study is part of EPISONO cohort, in which 1042 participants underwent polysomnography, answered questionnaires, and had their blood collected for analysis of fasting glucose, total cholesterol and fractions, leptin, ghrelin, liver transaminases, tumor necrosis factor (TNF)-α, interleukin (IL)-6, and C-reactive protein. The results showed that men with OSA had higher leptin levels, shorter sleep latency and lower N3 sleep stage compared to men control (CTRL). They also presented higher apnea index and number of central apneas compared to both CTRL men and OSA women. In women, OSA was related to longer REM sleep latency, higher apnea-hypopnea index (AHI) during REM sleep and increased TNF-α levels compared to CTRL women. A multivariate model showed that male gender, ghrelin and total cholesterol were negatively associated with TNF-α, while IL-6, triglycerides and hypopnea index were positively associated (R2=0.21). Additionally, gender (men), body mass index, ghrelin, apnea index and smoking were positive predictors of leptin levels (R2=0.55). Of note, postmenopause was associated with changes observed in both TNF-α and AHI during REM sleep in women with OSA. Taken together, our study suggests that OSA consequences may differ between genders and this could indicate a need for different OSA management in women according to their reproductive life's stage.
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93
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Benhamou D, Brouquet A. Postoperative cerebral dysfunction in the elderly: Diagnosis and prophylaxis. J Visc Surg 2016; 153:S27-S32. [DOI: 10.1016/j.jviscsurg.2016.09.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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94
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Abstract
Sleep is important for regulating many physiologic functions that relate to metabolism. Because of this, there is substantial evidence to suggest that sleep habits and sleep disorders are related to diabetes risk. In specific, insufficient sleep duration and/or sleep restriction in the laboratory, poor sleep quality, and sleep disorders such as insomnia and sleep apnea have all been associated with diabetes risk. This research spans epidemiologic and laboratory studies. Both physiologic mechanisms such as insulin resistance, decreased leptin, and increased ghrelin and inflammation and behavioral mechanisms such as increased food intake, impaired decision-making, and increased likelihood of other behavioral risk factors such as smoking, sedentary behavior, and alcohol use predispose to both diabetes and obesity, which itself is an important diabetes risk factor. This review describes the evidence linking sleep and diabetes risk at the population and laboratory levels.
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Affiliation(s)
- Michael A Grandner
- Sleep and Health Research Program, Department of Psychiatry, University of Arizona College of Medicine, 1501 N Campbell Ave, PO Box 245002, Tucson, AZ, 85724-5002, USA.
- Sarver Heart Center, University of Arizona College of Medicine, Tucson, AZ, USA.
- Department of Medicine, University of Arizona College of Medicine, Tucson, AZ, USA.
| | - Azizi Seixas
- Center for Healthful Behavior Change, Department of Population Health, New York University Langone Medical Center, New York, NY, USA
| | - Safal Shetty
- Department of Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Sundeep Shenoy
- Department of Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
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95
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Restless legs syndrome and cardiovascular disease: a research roadmap. Sleep Med 2016; 31:10-17. [PMID: 28065687 DOI: 10.1016/j.sleep.2016.08.008] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 08/30/2016] [Accepted: 08/31/2016] [Indexed: 12/14/2022]
Abstract
In this paper, we first critically appraise the epidemiologic literature examining the association of restless legs syndrome (RLS) with cardiovascular disease (CVD) and then consider whether lessons learned from the study of cardiovascular consequences of other sleep disorders might inform a research agenda to examine the potential mechanisms of cardiovascular morbidity of RLS. Cross-sectional and longitudinal studies are both mixed as to whether there is a meaningful association of RLS and CVD. On the other hand, numerous cross-sectional and longitudinal observational studies have shown a strong association of obstructive sleep apnea (OSA) with CVD risk. Each of the potential mediating mechanisms in OSA may also be assessed in RLS, including 1) neural mechanisms such as increased central sympathetic outflow, impaired baroreflex function, diminished heart rate and blood pressure variability, and increased chemoreflex sensitivity, 2) metabolic mechanisms such as glucose intolerance and reduced insulin sensitivity/diabetes as a result of sleep disturbance in RLS, 3) oxidative stress, 4) systemic or vascular inflammatory mechanisms, and 5) vascular mechanisms including impaired endothelial functioning, increased aortic stiffness, hypothalamic-pituitary axis activation or renin-angiotensin-aldosterone activation. Three known characteristics of RLS may contribute to these specific mechanisms of increased cardiovascular risk: 1) periodic limb movements of sleep, which are associated with large increases in heart rate and blood pressure, 2) sleep fragmentation and sleep deprivation, which are known to produce adverse consequences for neural, metabolic, oxidative, inflammatory, and vascular systems, and 3) iron deficiency, which is an emerging risk for cardiovascular disease. Future research priorities include additional epidemiologic studies which characterize multiple CVD risk factors, case-control studies which examine known markers of cardiovascular risk, and small clinical trials which assess the effects of RLS treatment on intermediate physiological markers such as sympathetic activity or baroreflex control, measures of vascular stiffness and reactivity, or measures of insulin sensitivity and glucose tolerance.
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96
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Micheu MM, Rosca AM, Deleanu OC. Stem/progenitor cells and obstructive sleep apnea syndrome - new insights for clinical applications. World J Stem Cells 2016; 8:332-341. [PMID: 27822340 PMCID: PMC5080640 DOI: 10.4252/wjsc.v8.i10.332] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 06/25/2016] [Accepted: 08/16/2016] [Indexed: 02/06/2023] Open
Abstract
Obstructive sleep apnea syndrome (OSAS) is a widespread disorder, characterized by recurrent upper airway obstruction during sleep, mostly as a result of complete or partial pharyngeal obstruction. Due to the occurrence of frequent and regular hypoxic events, patients with OSAS are at increased risk of cardiovascular disease, stroke, metabolic disorders, occupational errors, motor vehicle accidents and even death. Thus, OSAS has severe consequences and represents a significant economic burden. However, some of the consequences, as well as their costs can be reduced with appropriate detection and treatment. In this context, the recent advances that were made in stem cell biology knowledge and stem cell - based technologies hold a great promise for various medical conditions, including respiratory diseases. However, the investigation of the role of stem cells in OSAS is still recent and rather limited, requiring further studies, both in animal models and humans. The goal of this review is to summarize the current state of knowledge regarding both lung resident as well as circulating stem/progenitor cells and discuss existing controversies in the field in order to identify future research directions for clinical applications in OSAS. Also, the paper highlights the requisite for inter-institutional, multi-disciplinary research collaborations in order to achieve breakthrough results in the field.
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97
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Nagayoshi M, Lutsey PL, Benkeser D, Wassel CL, Folsom AR, Shahar E, Iso H, Allison MA, Criqui MH, Redline S. Association of sleep apnea and sleep duration with peripheral artery disease: The Multi-Ethnic Study of Atherosclerosis (MESA). Atherosclerosis 2016; 251:467-475. [PMID: 27423537 PMCID: PMC4983210 DOI: 10.1016/j.atherosclerosis.2016.06.040] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 06/04/2016] [Accepted: 06/22/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS Numerous biological pathways linking sleep disturbances to atherosclerosis have been identified, such as insulin resistance, inflammation, hypertension, and endothelial dysfunction. Yet, the association of sleep apnea and sleep duration with peripheral artery disease (PAD) is not well characterized. METHODS We evaluated the cross-sectional association between objectively measured sleep and prevalent PAD in 1844 participants (mean age 68 years) who in 2010-2013 had in-home polysomnography, 7-day wrist actigraphy and ankle-brachial index (ABI) measurements. We also evaluated the relation between self-reported diagnosed sleep apnea and PAD incidence in 5365 participants followed from 2000 to 2012. PAD was defined as ABI < 0.90. RESULTS In cross-sectional analyses, severe sleep apnea [apnea-hypopnea index (AHI) ≥30 vs. AHI <5] was associated with greater prevalent PAD only among black participants [multivariate adjusted prevalence ratio (95% CI): 2.29 (1.07-4.89); p-interaction = 0.05]. Short and long sleep duration was also associated with a 2-fold higher prevalence of PAD as compared with those who slept 7 h/night, in the full sample. In longitudinal analyses, participants with self-reported diagnosed sleep apnea were at higher risk of incident PAD [multivariable adjusted hazard ratio (95% CI): 1.93 (1.05-3.53)], with no evidence of interaction by race/ethnicity. CONCLUSIONS These findings support a significant association between sleep apnea and prevalent and incident PAD, with evidence for stronger associations with objectively measured sleep apnea and cross sectional PAD in blacks. In addition, short and long sleep duration was associated with PAD. These results identify sleep disturbances as a potential risk factor for PAD.
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Affiliation(s)
- Mako Nagayoshi
- Division of Epidemiology & Community Health, University of Minnesota, Minneapolis, MN, USA; Department of Community Medicine, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan.
| | - Pamela L Lutsey
- Division of Epidemiology & Community Health, University of Minnesota, Minneapolis, MN, USA
| | - David Benkeser
- Division of Biostatistics, University of California, Berkeley, CA, USA
| | - Christina L Wassel
- Department of Pathology and Laboratory Medicine, College of Medicine, University of Vermont, Colchester, VT, USA
| | - Aaron R Folsom
- Division of Epidemiology & Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Eyal Shahar
- Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA
| | - Hiroyasu Iso
- Public Health, Department of Social Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Matthew A Allison
- Department of Family Medicine and Public Health, University of California, San Diego, CA, USA
| | - Michael H Criqui
- Department of Family Medicine and Public Health, University of California, San Diego, CA, USA
| | - Susan Redline
- Brigham and Women's Hospital and Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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98
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Daulatzai MA. Fundamental role of pan-inflammation and oxidative-nitrosative pathways in neuropathogenesis of Alzheimer's disease in focal cerebral ischemic rats. AMERICAN JOURNAL OF NEURODEGENERATIVE DISEASE 2016; 5:102-30. [PMID: 27335702 PMCID: PMC4913220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Accepted: 02/09/2016] [Indexed: 06/06/2023]
Abstract
Alzheimer's disease (AD) is a chronic progressive neurodegenerative condition of the brain, and it is the most common cause of dementia. Several neurobiological etiologies of AD are described in the literature. These include vascular, infectious, toxic, nutritional, metabolic, and inflammatory. However, these heterogeneous etiologies have a common denominator - viz. Inflammation and oxidative stress. Lipopolysaccharide (LPS) elevates the synthesis of proinflammatory cytokines and chemokines; chronically, together they trigger various pathological responses in the periphery and the CNS including dysfunctional memory consolidation and memory decline. Aging - the main risk factor for AD is inherently associated with inflammation. There are several age-related comorbidities that are also associated with inflammation and oxidative stress. Such co-prevailing aggravating factors, therefore, persist against a background of underlying aging-related pathology. They may converge, and their synergistic propagation may modify the disease course. A critical balance exists between homeostasis/repair and inflammatory factors; chronic, unrelenting inflammatory milieu succeeds in promoting a neuroinflammatory and neurodegenerative outcome. Extensive evidence is available that CNS inflammation is associated with neurodegeneration. LPS, proinflammatory cytokines, several mediators secreted by microglia, and oxidative-nitrosative stress in concert play a pivotal role in triggering neuroinflammatory processes and neurodegeneration. The persistent uncontrolled activity of the above factors can potentiate cognitive decline in tandem enhancing vulnerability to AD. Despite significant progress during the past twenty years, the prevention and treatment of AD have been tantalizingly elusive. Current studies strongly suggest that amelioration/prevention of the deleterious effects of inflammation may prove beneficial in preventing AD onset and retarding cognitive dysfunction in aging and AD. A concerted multi-focal therapeutic effort around the inflammation-oxidative-nitrosative stress paradigm may be crucial in preventing and treating AD. This paper informs on such relevant polypharmacy approach.
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Affiliation(s)
- Mak Adam Daulatzai
- Sleep Disorders Group, EEE/Melbourne School of Engineering, The University of Melbourne Parkville, Victoria 3010, Australia
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99
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Daulatzai MA. Fundamental role of pan-inflammation and oxidative-nitrosative pathways in neuropathogenesis of Alzheimer's disease. AMERICAN JOURNAL OF NEURODEGENERATIVE DISEASE 2016; 5:1-28. [PMID: 27073740 PMCID: PMC4788729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 02/09/2016] [Indexed: 06/05/2023]
Abstract
Alzheimer's disease (AD) is a chronic progressive neurodegenerative condition of the brain, and it is the most common cause of dementia. Several neurobiological etiologies of AD are described in the literature. These include vascular, infectious, toxic, nutritional, metabolic, and inflammatory. However, these heterogeneous etiologies have a common denominator - viz. Inflammation and oxidative stress. Lipopolysaccharide (LPS) elevates the synthesis of proinflammatory cytokines and chemokines; chronically, together they trigger various pathological responses in the periphery and the CNS including dysfunctional memory consolidation and memory decline. Aging - the main risk factor for AD is inherently associated with inflammation. There are several age-related comorbidities that are also associated with inflammation and oxidative stress. Such co-prevailing aggravating factors, therefore, persist against a background of underlying aging-related pathology. They may converge, and their synergistic propagation may modify the disease course. A critical balance exists between homeostasis/repair and inflammatory factors; chronic, unrelenting inflammatory milieu succeeds in promoting a neuroinflammatory and neurodegenerative outcome. Extensive evidence is available that CNS inflammation is associated with neurodegeneration. LPS, proinflammatory cytokines, several mediators secreted by microglia, and oxidative-nitrosative stress in concert play a pivotal role in triggering neuroinflammatory processes and neurodegeneration. The persistent uncontrolled activity of the above factors can potentiate cognitive decline in tandem enhancing vulnerability to AD. Despite significant progress during the past twenty years, the prevention and treatment of AD have been tantalizingly elusive. Current studies strongly suggest that amelioration/prevention of the deleterious effects of inflammation may prove beneficial in preventing AD onset and retarding cognitive dysfunction in aging and AD. A concerted multi-focal therapeutic effort around the inflammation-oxidative-nitrosative stress paradigm may be crucial in preventing and treating AD. This paper informs on such relevant polypharmacy approach.
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Affiliation(s)
- Mak Adam Daulatzai
- Sleep Disorders Group, EEE/Melbourne School of Engineering, The University of Melbourne Parkville, Victoria 3010, Australia
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