The hypoxic burden of sleep apnoea predicts cardiovascular disease-related mortality: the Osteoporotic Fractures in Men Study and the Sleep Heart Health Study

Clinical Practice Guideline: Clinical Efficacy of Nasal Surgery in the Treatment of Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a common disorder characterized by upper airway obstruction during sleep. To reduce the morbidity of OSA, sleep specialists have explored various methods of managing the condition, including manifold positive airway pressure (PAP) techniques and surgical procedures. Nasal obstruction can cause significant discomfort during sleep, and it is likely that improving nasal obstruction would enhance the quality of life and PAP compliance of OSA patients. Many reliable studies have offered evidence to support this assumption. However, few comprehensive guidelines for managing OSA through nasal surgery encompass all this evidence. In order to address this gap, the Korean Society of Otorhinolaryngology-Head and Neck Surgery (KORL-HNS) and the Korean Society of Sleep and Breathing designated a guideline development group (GDG) to develop recommendations for nasal surgery in OSA patients. Several databases, including OVID Medline, Embase, the Cochrane Library, and KoreaMed, were searched to identify all relevant papers using a predefined search strategy. The types of nasal surgery included septoplasty, turbinate surgery, nasal valve surgery, septorhinoplasty, and endoscopic sinus surgery. When insufficient evidence was found, the GDG sought expert opinions and attempted to fill the evidence gap. Evidence-based recommendations for practice were ranked according to the American College of Physicians' grading system. The GDG developed 10 key action statements with supporting text to support them. Three statements are ranked as strong recommendations, three are only recommendations, and four can be considered options. The GDG hopes that this clinical practice guideline will help physicians make optimal decisions when caring for OSA patients. Conversely, the statements in this guideline are not intended to limit or restrict physicians' care based on their experience and assessment of individual patients.

Obstructive sleep apnoea heterogeneity and cardiovascular disease

Obstructive sleep apnoea (OSA), characterized by recurrent periods of upper airway obstruction and intermittent hypoxaemia, is prevalent in patients with cardiovascular disease (CVD), and is therefore important to consider in the prevention and management of CVD. Observational studies indicate that OSA is a risk factor for incident hypertension, poorly controlled blood pressure, stroke, myocardial infarction, heart failure, cardiac arrhythmias, sudden cardiac death and all-cause death. However, clinical trials have not provided consistent evidence that treatment with continuous positive airway pressure (CPAP) improves cardiovascular outcomes. These overall null findings might be explained by limitations in trial design and low levels of adherence to CPAP. Studies have also been limited by the failure to consider OSA as a heterogeneous disorder that consists of multiple subtypes resulting from variable contributions from anatomical, physiological, inflammatory and obesity-related risk factors, and resulting in different physiological disturbances. Novel markers of sleep apnoea-associated hypoxic burden and cardiac autonomic response have emerged as predictors of OSA-related susceptibility to adverse health outcomes and treatment response. In this Review, we summarize our understanding of the shared risk factors and causal links between OSA and CVD and emerging knowledge on the heterogeneity of OSA. We discuss the varied mechanistic pathways that result in CVD that also vary across subgroups of OSA, as well as the potential role of new biomarkers for CVD risk stratification.

OSA Is Associated With the Human Gut Microbiota Composition and Functional Potential in the Population-Based Swedish CardioPulmonary bioImage Study

BACKGROUND

OSA is a common sleep-breathing disorder linked to increased risk of cardiovascular disease. Intermittent upper airway obstruction and hypoxia, hallmarks of OSA, have been shown in animal models to induce substantial changes to the gut microbiota composition, and subsequent transplantation of fecal matter to other animals induced changes in BP and glucose metabolism.

RESEARCH QUESTION

Does OSA in adults associate with the composition and functional potential of the human gut microbiota?

STUDY DESIGN AND METHODS

We used respiratory polygraphy data from up to 3,570 individuals 50 to 64 years of age from the population-based Swedish Cardiopulmonary bioimage Study combined with deep shotgun metagenomics of fecal samples to identify cross-sectional associations between three OSA parameters covering apneas and hypopneas, cumulative sleep time in hypoxia, and number of oxygen desaturation events with gut microbiota composition. Data collection about potential confounders was based on questionnaires, onsite anthropometric measurements, plasma metabolomics, and linkage with the Swedish Prescribed Drug Register.

RESULTS

We found that all three OSA parameters were associated with lower diversity of species in the gut. Furthermore, in multivariable-adjusted analysis, the OSA-related hypoxia parameters were associated with the relative abundance of 128 gut bacterial species, including higher abundance of Blautia obeum and Collinsella aerofaciens. The latter species was also independently associated with increased systolic BP. Furthermore, the cumulative time in hypoxia during sleep was associated with the abundance of genes involved in nine gut microbiota metabolic pathways, including propionate production from lactate. Finally, we observed two heterogeneous sets of plasma metabolites with opposite association with species positively and negatively associated with hypoxia parameters, respectively.

INTERPRETATION

OSA-related hypoxia, but not the number of apneas/hypopneas, is associated with specific gut microbiota species and functions. Our findings lay the foundation for future research on the gut microbiota-mediated health effects of OSA.

Relevance of cortical arousals for risk stratification in sleep apnea: a 3 cohort analysis

STUDY OBJECTIVES

There is uncertainty on best approaches for defining apnea-hypopnea events. To clarify the contributions of desaturation vs arousal to defining hypopneas, we examined the associations of events with desaturation (≥ 3%) but not arousal (apnea-hypopnea index [AHI]≥3%Only) vs events with arousals but no desaturation (AHIArOnly) with obstructive sleep apnea-related comorbidities and incident cardiovascular disease across multiple cohorts.

METHODS

In the Sleep Heart Health Study (n = 5,473), the Multi-Ethnic Study of Atherosclerosis (n = 1,904), and the Osteoporotic Fractures in Men Study (n = 2,685), we examined the independent associations of AHI≥3%Only and AHIArOnly with hypertension, diabetes, and daytime sleepiness, and incident cardiovascular disease.

RESULTS

After adjusting for covariates and AHI based on events with electroencephalogram arousal (regardless of desaturation), AHI≥3%Only was associated with hypertension in Sleep Heart Health Study (odds ratio: 1.12; 95% confidence interval: 1.04,1.21), per 1 standard deviation increase). Similar associations were observed in the Multi-Ethnic Study of Atherosclerosis and Osteoporotic Fractures in Men Study, as well as for associations with diabetes (odds ratio: 1.30; 1.09,1.54, and 1.25; 1.07,1.47, respectively), sleepiness (odds ratio: 1.19; 1.00,1.41; and 1.17; 1.01-1.35), and incident cardiovascular disease (hazard ratio: 1.37; 1.05,1.77 and 1.14; 1.00,1.29). In contrast, after adjusting for events with desaturation (regardless of arousal), AHIArOnly was unassociated with these outcomes. In Sleep Heart Health Study, greater baseline obstructive sleep apnea severity was associated with a reduction in arousal frequency over 5 years (P < .0001).

CONCLUSIONS

In middle-aged and older individuals, addition of events with arousals does not improve the strength of associations with comorbidities or incident cardiovascular disease. Research is needed to understand generalizability to younger individuals and the mechanistic role of arousals in obstructive sleep apnea.

CITATION

Azarbarzin A, Sands SA, Han S, et al. Relevance of cortical arousals for risk stratification in sleep apnea: a 3 cohort analysis. J Clin Sleep Med. 2023;19(8):1475-1484.

Maxillomandibular advancement for obstructive sleep apnea: a retrospective prognostic factor study for surgical response

PURPOSE

To identify potential predictors of surgical response to maxillomandibular advancement (MMA) in patients with obstructive sleep apnea (OSA) from the most common clinically available data (patient-related, polysomnographic, cephalometric, and surgical variables).

METHODS

This was a retrospective study comprised of consecutive patients who underwent MMA for moderate to severe OSA. Relevant clinical, polysomnographic, cephalometric, and surgical variables were collected as independent variables (predictors). The association of the independent variables with a favorable surgical response to MMA was assessed in univariate and multivariate analyses.

RESULTS

In 100 patients (82% male; mean age 50.5 years), the mean apnea hypopnea index [AHI] was 53.1 events/h. The rate of favorable surgical response was 67%. Based on multivariate analysis, patients with cardiovascular disease (CVD) had 0.140 times lower odds of a favorable response to MMA (OR: 0.140 [0.038, 0.513], P = 0.003). For each 1-unit increase in central apnea index (CAI) and superior posterior airway space (SPAS), there were 0.828 and 0.724 times lower odds to respond favorably to MMA (OR: 0.828 [0.687, 0.997], P = 0.047; and 0.724 [0.576, 0.910], P = 0.006), respectively.

CONCLUSION

The findings of this study suggest that the surgical outcome of MMA may be less favorable when patients with OSA have certain phenotypic characteristics: the presence of CVD, higher CAI and larger SPAS. If confirmed in future studies, these variables may guide patient selection for MMA.

Association of obstructive sleep apnea with cardiometabolic diseases and cardiovascular mortality

BACKGROUND

Obstructive sleep apnea (OSA) is one of the leading respiratory disorders, increasing the risk of cardiometabolic diseases. In the study, we investigated the association between OSA and the risk of cardiometabolic diseases and all-cause and cardiovascular mortality in adults.

METHODS

Participants were enrolled in the National Health and Nutrition Examination Survey. The baseline covariates were compared between participants with and without OSA status. Multivariable logistic regression was performed to explore the association between OSA and cardiometabolic diseases, while Cox proportional regression was performed for all-cause and cardiovascular mortality.

RESULTS

OSA status was positively associated with higher risks of cardiometabolic diseases, including hypertension (odds ratio [OR] 1.28, 95% confidence interval [CI] 1.14-1.45; p < 0.001), diabetes (OR 1.46, 95% CI 1.22-1.76; p < 0.001), and cardiovascular diseases (OR 1.29, 95% CI 1.08-1.54; p = 0.006) after adjusting for numerous covariates. However, no associations of OSA with all-cause or cardiovascular mortality were observed.

CONCLUSION

OSA was associated with a higher risk of hypertension, diabetes, and cardiovascular diseases, but had no significant association with all-cause or cardiovascular mortality in adults.

Peripheral arterial tonometry versus polysomnography in suspected obstructive sleep apnoea

BACKGROUND

Polysomnography (PSG) is the gold standard for the diagnosis of obstructive sleep apnoea (OSA). Home sleep apnoea testing with peripheral arterial tonometry (PAT) is a recommended diagnostic alternative for patients with an increased risk for OSA. In a large clinical cohort, we investigated concordance and predictors for discordance in diagnosing OSA using PAT and PSG, and three-year cardiovascular risk in patients with discordant OSA diagnosis.

METHODS

Retrospective monocentric cohort study. Patients with a PAT AHI ≥ 5/h followed by an in-hospital PSG within three months were included. All patients with a PAT AHI ≥ 5/h but a PSG AHI < 5/h were classified as discordant. Patients with PAT and PSG AHI ≥ 5/h were classified as concordant. To ascertain cardiovascular risk, major adverse cardiovascular events (MACE) were analyzed in discordant patients and sex, age, body mass index (BMI) and cardiovascular disease-matched concordant patients over a follow-up time of 3.1 ± 0.06 years.

RESULTS

A total of 940 patients, 66% male with an average age of 55 ± 0.4 years and BMI of 31 ± 0.2 kg/m² were included. Agreement in OSA diagnosis was observed in 80% of patients (55% in mild and 86% in moderate and severe OSA). Factors significantly associated with a discordant diagnosis were female sex, younger age and lower BMI, but not comorbidities. There was no significant difference in MACE (p = 0.920) between discordant patients (n = 155) and matched concordant patients (n = 274) with or without therapy.

CONCLUSIONS

Concordance between PAT and PSG diagnosis of sleep apnoea is good, particularly in moderate and severe OSA. Predictors for discordant results between PAT and PSG were age, sex and BMI. MACE risk is similar in those with OSA diagnosed by PAT or PSG.

Metabolomic Profiles of Sleep-Disordered Breathing are Associated with Hypertension and Diabetes Mellitus Development: the HCHS/SOL

Sleep-disordered breathing (SDB) is a prevalent disorder characterized by recurrent episodic upper airway obstruction. In a dataset from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL), we applied principal component analysis (PCA) on seven measures characterizing SDB-associated respiratory events. We estimated the association of the top two SDB PCs with serum levels of 617 metabolites, in both single-metabolite analysis, and a joint, penalized regression analysis using the least absolute shrinkage and selection operator (LASSO). Discovery analysis included n = 3,299 HCHS/SOL individuals; associations were validated in a separate dataset of n = 1,522 HCHS/SOL individuals. Seven metabolite associations with SDB PCs were discovered and replicated. Metabolite risk scores (MRSs) developed based on LASSO association results and representing metabolite signatures associated with the two SDB PCs were associated with 6-year incident hypertension and incident diabetes. MRSs have the potential to serve as biomarkers for SDB, guiding risk stratification and treatment decisions.

Sleep-Disordered Breathing and Prognosis after Ischemic Stroke: It Is Not Apnea-Hypopnea Index That Matters

BACKGROUND

Sleep-disordered breathing (SDB) is highly prevalent after stroke and is considered to be a risk factor for poor post-stroke outcomes. The aim of this observational study was to evaluate the effect of nocturnal respiratory-related indices based on nocturnal respiratory polygraphy on clinical outcomes (including mortality and non-fatal events) in patients with ischemic stroke.

METHODS

A total of 328 consecutive patients (181 (55%) males, mean age 65.8 ± 11.2 years old) with confirmed ischemic stroke admitted to a stroke unit within 24 h after stroke onset were included in the analysis. All patients underwent standard diagnostic and treatment procedures, and sleep polygraphy was performed within the clinical routine in the first 72 h after admission. The long-term outcomes were assessed by cumulative endpoint (death of any cause, new non-fatal myocardial infarction, new non-fatal stroke/transient ischemic attack, emergency revascularization, emergency hospitalization due to the worsening of cardiovascular disease). A Cox-regression analysis was applied to evaluate the effects of nocturnal respiratory indices on survival.

RESULTS

The mean follow-up period comprised 12 months (maximal-48 months). Patients with unfavourable outcomes demonstrated a higher obstructive apnea-hypopnea index, a higher hypoxemia burden assessed as a percent of the time with SpO₂ < 90%, a higher average desaturation drop, and a higher respiratory rate at night. Survival time was significantly lower (30.6 (26.5; 34.7) versus 37.9 (34.2; 41.6) months (Log Rank 6.857, p = 0.009)) in patients with higher hypoxemia burden (SpO₂ < 90% during ≥2.1% versus <2.1% of total analyzed time). However, survival time did not differ depending on the SDB presence assessed by AHI thresholds (either ≥5 or ≥15/h). The multivariable Cox proportional hazards regression (backward stepwise analysis) model demonstrated that the parameters of hypoxemia burden were significantly associated with survival time, independent of age, stroke severity, stroke-related medical interventions, comorbidities, and laboratory tests.

CONCLUSION

Our study demonstrates that the indices of hypoxemia burden have additional independent predictive value for long-term outcomes (mortality and non-fatal cardiovascular events) after ischemic stroke.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

A comparison of cardiovascular disease associations of time-domain oximetry parameters in sleep apnoea cases from the Sleep Heart Health Study

Polysomnograms (PSGs) contain a wealth of physiological information that is routinely recorded but not utilised in sleep studies. Intermittent hypoxia arising from obstructive sleep apnoea (OSA) events is an important risk in the later development of cardiovascular disease (CVD). Analysis of oximetry patterns from PSG studies may enable early assessment of CVD risk. The aim of this study was to compare associations of different time-domain oximetry patterns with incident CVD in OSA patients. All participants with OSA and no pre-existing CVD at baseline or within the first two years of follow-up, were selected from the Sleep Heart Health Study data and used for analysis (N=2878). We examined oximetry parameters that are calculated from desaturation events and from time series analysis and compared them to incident CVD outcomes using proportional hazards regression models adjusted for age, race, smoking, BMI, and sex. Our results show that were no associations between OSA oximetry parameters and incident CVD for OSA patients.

Endotyping, phenotyping and personalised therapy in obstructive sleep apnoea: are we there yet?

Obstructive sleep apnoea (OSA) was traditionally thought to be mainly caused by obesity and upper airway crowding, and hence OSA management was not personalised according to particular characteristics, with most symptomatic patients receiving continuous positive airway pressure therapy. Recent advances in our understanding have identified additional potential and distinct causes of OSA (endotypes), and subgroups of patients (phenotypes) with increased risk of cardiovascular complications. In this review, we discuss the evidence to date as to whether there are distinct clinically useful endotypes and phenotypes of OSA, and the challenges to the field in moving towards delivering personalised therapy in OSA.

The combination of atomoxetine and dronabinol for the treatment of obstructive sleep apnea: a dose-escalating, open-label trial

STUDY OBJECTIVES

The potential sedative effect of dronabinol and the high expression of cannabinoid receptors on the hypoglossal motor nuclei makes this agent a good candidate for obstructive sleep apnea (OSA) pharmacotherapy to be tested with atomoxetine, a noradrenergic reuptake inhibitor that reduced OSA severity in combination with oxybutynin. Here we tested the effect of atomoxetine 80 mg plus dronabinol (Ato-Dro) at 2 different doses (5 and 10 mg) vs. baseline and atomoxetine alone in a 2-center, open-label, dose-escalating trial. The primary outcome was the effect of Ato-Dro vs. baseline on OSA severity (apnea-hypopnea index, hypopneas associated with 4% oxygen desaturation). Safety of the combination and self-reported outcomes were also assessed.

METHODS

Fifteen patients with OSA received progressively increasing Ato-Dro doses (dose escalation was performed every week, starting from Ato-Dro 40-2.5 mg, then 80-5 mg and finally 80-10 mg). A clinical, in-lab polysomnography was performed at baseline, on Ato-Dro 80-5 and Ato-Dro 80-10 mg.

RESULTS

Ato-Dro 80-10 mg did not significantly reduce apnea-hypopnea index, hypopneas associated with 4% oxygen desaturation, and hypoxic burden and yielded limited clinical benefit vs. baseline and atomoxetine alone. However, Ato-Dro 80-5 mg did improve OSA severity (Δapnea-hypopnea index = 8.3[0.3, 16.3] events/h; mean [confidence interval]; Δhypoxic burden = 37.7[12.5, 62.7] %min/h) and multiple self-reported outcomes vs. baseline and/or atomoxetine alone. Ato-Dro administration was characterized by several potentially harmful side effects and treatment discontinuation in 1/3 of cases.

CONCLUSIONS

Ato-Dro 80-5 mg might be useful to reduce OSA severity and lead to self-reported improvement in those who could tolerate the combination. However, given the numerous side effects and the exploratory nature of this open-label study, our results warrant further validation in larger trials.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Title: Study for Efficacy and Dose Escalation of AD313 + Atomoxetine (SEED) (SEED); URL: https://clinicaltrials.gov/ct2/show/NCT05101122; Identifier: NCT05101122.

CITATION

Messineo L, Norman D, Ojile J. The combination of atomoxetine and dronabinol for the treatment of obstructive sleep apnea: a dose-escalating, open-label trial. J Clin Sleep Med. 2023;19(7):1183-1190.

Cardiovascular Outcomes in Adults with Coronary Artery Disease and Obstructive Sleep Apnea with versus without Excessive Daytime Sleepiness in the RICCADSA Cinical Trial

Rationale: Recent randomized controlled trials did not show cardiovascular benefits of continuous positive airway pressure (CPAP) in adults with coronary artery disease (CAD) and obstructive sleep apnea (OSA) in intention-to-treat analyses. It has been argued that exclusion of patients with OSA with excessive daytime sleepiness (EDS), who may be most likely to benefit from CPAP treatment, may be a reason for the null results. Objectives: We addressed 1) the effect of concomitant EDS on adverse outcomes in patients with CAD and OSA; and 2) whether the cardiovascular benefit of CPAP adherence differs between individuals with versus without EDS. Methods: This was a secondary analysis of the RICCADSA (Randomized Intervention with CPAP in CAD and Obstructive Sleep Apnea) trial, conducted in Sweden between 2005 and 2013. Data were analyzed from 155 patients with CAD with OSA (apnea-hypopnea index ⩾ 15/h) and EDS (Epworth Sleepiness Scale score ⩾ 10), who were allocated to CPAP and 244 patients without EDS (ESS < 10), who were randomized to CPAP or no CPAP. Patients who were allocated to no CPAP or were nonadherent (CPAP usage < 4 h/night) were compared with adherent patients (CPAP usage ⩾ 4 h/night) at 1-year follow-up. Inverse probability of treatment weighting was applied to mimic randomization of EDS. The primary endpoint was the first event of repeat revascularization, myocardial infarction, stroke, or cardiovascular mortality. Results: The median follow-up was 52.2 months. The incidence of the primary endpoint did not differ significantly between the EDS versus no-EDS groups in the entire cohort. Within the adherent group, patients without EDS had a significantly decreased risk compared with patients with EDS (adjusted hazard ratio, 0.41; 95% confidence interval, 0.20-0.85; P = 0.02). Conclusions: Adverse cardiovascular outcomes did not differ by degrees of EDS for patients with CAD with OSA who were untreated or nonadherent to treatment. CPAP use, at least 4 h/night, was associated with reduced adverse outcomes in participants without EDS. Clinical trial registered with www.clinicaltrials.gov (NCT00519597).

A comparison of hypoxic burden algorithms using three different methods for calculating baseline oxygen saturation for predicting cardiovascular death in the Sleep Heart Health Study

Respiratory event related oxygen desaturation area measures have recently shown merit as novel predictors of cardiovascular disease (CVD) outcomes. In this study, we investigate one such measure (hypoxic burden (HB)) and investigate how three different ways of calculating the SpO2 baseline of the HB algorithm impact its ability to predict cardiovascular mortality. The three baseline estimation steps include a pre-event baseline, a record-based baseline, and a fixed baseline. Pulse oximetry signals from the Sleep Heart Health Study and the corresponding CVD outcomes were analyzed. The performance of each baseline method was compared using adjusted Cox proportional hazard regression analysis. Results show that HB with the record-based baseline method returned the best performing results with a hazard ratio (HR) of 1.83 (95% CI: 1.03-3.27, p<0.05) in the fully adjusted model, compared to HB with the pre-event baseline method (HR: 1.60, 95%CI: 0.86-3.00, p>0.05) and HB with the fixed baseline method (HR: 1.73, 95%CI: 0.93-3.22, p>0.05).

Time Spent with Saturation below 80% versus 90% in Patients with Obstructive Sleep Apnoea

BACKGROUND

Nocturnal hypoxaemia measured as the percentage of total sleep time spent with saturation below 90% (TST90%) may better predict cardiovascular consequences of obstructive sleep apnoea (OSA) than the number of obstructive respiratory events measured with the apnoea-hypopnea index (AHI). Deeper hypoxaemia may potentially induce more severe pathophysiological consequences. However, the additional value of the percentage of total sleep time spent with saturation below 80% (TST80%) to TST90% is not fully explored.

METHODS

Comprehensive medical history was taken and fasting lipid and C-reactive protein levels were measured in 797 volunteers participating in two cohort studies in Hungary and Romania. Sleep parameters, including AHI, TST90% and TST80%, were recorded following a polysomnography (PSG, n = 598) or an inpatient cardiorespiratory polygraphy (n = 199). The performance of TST80% to predict cardiovascular risk was compared with TST90% using linear and logistic regression analyses as well receiver operating characteristics curves. Sensitivity analyses were performed in patients who had PSG, separately.

RESULTS

Both parameters are significantly related to cardiovascular risk factors; however, TST80% did not show better predictive value for cardiovascular risk than TST90%. On the other hand, patients with more severe hypoxaemia reported more excessive daytime sleepiness.

CONCLUSIONS

TST80% has limited additional clinical value compared to TST90% when evaluating cardiovascular risk in patients with OSA.

Pulse Wave Amplitude Drops Index: A Biomarker of Cardiovascular Risk in Obstructive Sleep Apnea

Rationale: It is currently unclear which patients with obstructive sleep apnea (OSA) are at increased cardiovascular risk. Objective: To investigate the value of pulse wave amplitude drops (PWADs), reflecting sympathetic activations and vasoreactivity, as a biomarker of cardiovascular risk in OSA. Methods: PWADs were derived from pulse oximetry-based photoplethysmography signals in three prospective cohorts: HypnoLaus (N = 1,941), the Pays-de-la-Loire Sleep Cohort (PLSC; N = 6,367), and "Impact of Sleep Apnea syndrome in the evolution of Acute Coronary syndrome. Effect of intervention with CPAP" (ISAACC) (N = 692). The PWAD index was the number of PWADs (>30%) per hour during sleep. All participants were divided into subgroups according to the presence or absence of OSA (defined as ⩾15 or more events per hour or <15/h, respectively, on the apnea-hypopnea index) and the median PWAD index. Primary outcome was the incidence of composite cardiovascular events. Measurements and Main Results: Using Cox models adjusted for cardiovascular risk factors (hazard ratio; HR [95% confidence interval]), patients with a low PWAD index and OSA had a higher incidence of cardiovascular events compared with the high-PWAD and OSA group and those without OSA in the HypnoLaus cohort (HR, 2.16 [1.07-4.34], P = 0.031; and 2.35 [1.12-4.93], P = 0.024) and in the PLSC (1.36 [1.13-1.63], P = 0.001; and 1.44 [1.06-1.94], P = 0.019), respectively. In the ISAACC cohort, the low-PWAD and OSA untreated group had a higher cardiovascular event recurrence rate than that of the no-OSA group (2.03 [1.08-3.81], P = 0.028). In the PLSC and HypnoLaus cohorts, every increase of 10 events per hour in the continuous PWAD index was negatively associated with incident cardiovascular events exclusively in patients with OSA (HR, 0.85 [0.73-0.99], P = 0.031; and HR, 0.91 [0.86-0.96], P < 0.001, respectively). This association was not significant in the no-OSA group and the ISAACC cohort. Conclusions: In patients with OSA, a low PWAD index reflecting poor autonomic and vascular reactivity was independently associated with a higher cardiovascular risk.

Diagnosis and Treatment of Sleep Apnea in Children: A Future Perspective Is Needed

Obstructive sleep apnea (OSA) in children is a prevalent, but still, today, underdiagnosed illness, which consists of repetitive episodes of upper airway obstruction during sleep with important repercussions for sleep quality. OSA has relevant consequences in the pediatric population, mainly in the metabolic, cardiovascular (CV), and neurological spheres. However, contrary to adults, advances in diagnostic and therapeutic management have been scarce in the last few years despite the increasing scientific evidence of the deleterious consequences of pediatric OSA. The problem of underdiagnosis and the lack of response to treatment in some groups make an update to the management of OSA in children necessary. Probably, the heterogeneity of OSA is not well represented by the classical clinical presentation and severity parameters (apnea/hypopnea index (AHI)), and new strategies are required. A specific and consensus definition should be established. Additionally, the role of simplified methods in the diagnosis algorithm should be considered. Finally, the search for new biomarkers for risk stratification is needed in this population. In conclusion, new paradigms based on personalized medicine should be implemented in this population.

High prevalence of sleep-disordered breathing in the intensive care unit - a cross-sectional study

PURPOSE

Sleep-disordered breathing may be induced by, exacerbate, or complicate recovery from critical illness. Disordered breathing during sleep, which itself is often fragmented, can go unrecognized in the intensive care unit (ICU). The objective of this study was to investigate the prevalence, severity, and risk factors of sleep-disordered breathing in ICU patients using a single respiratory belt and oxygen saturation signals.

METHODS

Patients in three ICUs at Massachusetts General Hospital wore a thoracic respiratory effort belt as part of a clinical trial for up to 7 days and nights. Using a previously developed machine learning algorithm, we processed respiratory and oximetry signals to measure the 3% apnea-hypopnea index (AHI) and estimate AH-specific hypoxic burden and periodic breathing. We trained models to predict AHI categories for 12-h segments from risk factors, including admission variables and bio-signals data, available at the start of these segments.

RESULTS

Of 129 patients, 68% had an AHI ≥ 5; 40% an AHI > 15, and 19% had an AHI > 30 while critically ill. Median [interquartile range] hypoxic burden was 2.8 [0.5, 9.8] at night and 4.2 [1.0, 13.7] %min/h during the day. Of patients with AHI ≥ 5, 26% had periodic breathing. Performance of predicting AHI-categories from risk factors was poor.

CONCLUSIONS

Sleep-disordered breathing and sleep apnea events while in the ICU are common and are associated with substantial burden of hypoxia and periodic breathing. Detection is feasible using limited bio-signals, such as respiratory effort and SpO2 signals, while risk factors were insufficient to predict AHI severity.

Analysis of the Ischemia-Modified Albumin as a Potential Biomarker for Cardiovascular Damage in Obstructive Sleep Apnea Patients with Acute Coronary Syndrome

Obstructive sleep apnea (OSA) has been identified as a cardiovascular (CV) risk factor. The potential of OSA promoting the synthesis of CV biomarkers in acute coronary syndrome (ACS) is unknown. Ischemia-modified albumin (IMA) has been identified as a specific CV biomarker. The aim of this study was to evaluate the role of IMA as a potential biomarker for determining the impact of OSA in ACS patients. A total of 925 patients (15.5% women, age: 59 years, body mass index: 28.8 kg/m²) from the ISAACC study (NCT01335087) were included. During hospitalization for ACS, a sleep study for OSA diagnosis was performed and blood samples extraction for IMA determination were obtained. IMA values were significantly higher in severe OSA (median (IQR), 33.7 (17.2-60.3) U/L) and moderate (32.8 (16.9-58.8) U/L) than in mild/no OSA (27.7 (11.8-48.6) U/L) (p = 0.002). IMA levels were very weakly related to apnea-hypopnea index (AHI) as well as hospital and intensive care unit stay, although they only maintained a significant relationship with days of hospital stay after adjusting for sex, age and BMI (ß = 0.410, p = 0.013). The results of the present study would suggest a potentially weaker role of OSA in the synthesis of the CV risk biomarker IMA in patients with ACS than in primary prevention.

Utilizing Envelope Analysis of a Nasal Pressure Signal for Sleep Apnea Severity Estimation

Obstructive sleep apnea (OSA) severity assessment is based on manually scored respiratory events and their arbitrary definitions. Thus, we present an alternative method to objectively evaluate OSA severity independently of the manual scorings and scoring rules. A retrospective envelope analysis was conducted on 847 suspected OSA patients. Four parameters were calculated from the difference between the nasal pressure signal's upper and lower envelopes: average (AV), median (MD), standard deviation (SD), and coefficient of variation (CoV). We computed the parameters from the entirety of the recorded signals to perform binary classifications of patients using three different apnea-hypopnea index (AHI) thresholds (5-15-30). Additionally, the calculations were undertaken in 30-second epochs to estimate the ability of the parameters to detect manually scored respiratory events. Classification performances were assessed with areas under the curves (AUCs). As a result, the SD (AUCs ≥ 0.86) and CoV (AUCs ≥ 0.82) were the best classifiers for all AHI thresholds. Furthermore, non-OSA and severe OSA patients were separated well with SD (AUC = 0.97) and CoV (AUC = 0.95). Respiratory events within the epochs were identified moderately with MD (AUC = 0.76) and CoV (AUC = 0.82). In conclusion, envelope analysis is a promising alternative method by which to assess OSA severity without relying on manual scoring or the scoring rules of respiratory events.

Severity, comorbidities, and adherence to therapy in Native Hawaiians/Pacific Islanders with obstructive sleep apnea

STUDY OBJECTIVES

Considerable disparities in the prevalence, diagnosis, and management of obstructive sleep apnea (OSA) exist for minority groups in the United States. However, the impact of OSA on Native Hawaiian/Pacific Islanders (NHPIs) has not been evaluated.

METHODS

We performed a retrospective review of patient records of NHPIs who underwent sleep apnea testing between 2014 and 2021 at a single center in Utah to characterize the distribution of comorbidities, disease severity, and treatment adherence.

RESULTS

140 of 141 NHPI patients who underwent sleep testing had OSA. High rates of obesity (94%) and other relevant comorbidities were found. OSA was mostly severe (57%), particularly in males with higher obesity. Adherence to continuous positive airway pressure was low (41% using for 4 or more hours on 70% of nights), and medical factors predicted whether adherence targets were met with modest accuracy (area under the curve 0.699).

CONCLUSIONS

NHPIs at a single sleep center had a high prevalence of comorbidities in association with OSA, a skewed distribution toward severe disease suggestive of barriers to care or unique disease characteristics, and low adherence to continuous positive airway pressure. These findings suggest a high burden of OSA in this population, and further work to characterize barriers to identifying and treating OSA in NHPIs can improve chronic disease outcomes in NHPIs.

CITATION

Locke BW, Sundar DJ, Ryujin D. Severity, comorbidities, and adherence to therapy in Native Hawaiians/Pacific Islanders with obstructive sleep apnea. J Clin Sleep Med. 2023;19(5):967-974.

Obstructive Sleep Apnea and Longitudinal Changes in Interstitial Lung Imaging and Lung Function: The MESA Study

Rationale: Obstructive sleep apnea (OSA) has been hypothesized to be a risk factor in interstitial lung disease (ILD) and is associated with radiological markers that may represent the earlier stages of ILD. Prior studies have been limited by their cross-sectional design and potential confounding by body habitus. Objectives: To test the hypothesis that OSA severity is associated with more high-attenuation areas (HAAs) on computed tomography and worse lung function over time among older community-dwelling adults. Methods: We used data from participants in the MESA (Multi-Ethnic Study of Atherosclerosis) who had apnea-hypopnea index (AHI) measured from polysomnography (2010-2013), high attenuation areas (HAAs, -600 to -250 Hounsfield units, n = 784), assessments from exams 5 (2010-2012) and 6 (2016-2018) full-lung computed tomography scans, and spirometry assessments (n = 677). Linear mixed-effects models with random intercept were used to examine associations of OSA severity (i.e., AHI and hypoxic burden) with changes in HAAs, total lung volumes, and forced vital capacity (FVC) between exams 5 and 6. Potential confounders were adjusted for in the model, including age, sex, smoking history, height, and weight. Results: Among those with a higher AHI there were more men and a higher body mass index. Participants with AHI ⩾ 15 events/h and in the highest hypoxic burden quartile each had increases in HAAs of 11.30% (95% confidence interval [CI], 3.74-19.35%) and 9.85% (95% CI, 1.40-19.01%) per 10 years, respectively. There was a more rapid decline in total lung volumes imaged and FVC among those with AHI ⩾ 15 events/h of 220.2 ml (95% CI, 47.8-392.5 ml) and 3.63% (95% CI, 0.43-6.83%) per 10 years, respectively. Conclusions: A greater burden of hypoxia related to obstructive events during sleep was associated with increased lung densities over time and a more rapid decline in lung volumes regardless of body habitus. Our findings suggest OSA may be a contributing factor in the early stages of ILD.

Transvenous phrenic nerve stimulation for the treatment of central sleep apnea reduces episodic hypoxemic burden

STUDY OBJECTIVES

To determine the effect of transvenous phrenic nerve stimulation (TPNS) on the composition of the nocturnal hypoxemic burden in patients with CSA.

METHODS

We analysed oximetry data from baseline and follow-up overnight polysomnograms (PSG) in 134 CSA patients with implanted TPNS randomised (1:1) to neurostimulation (treatment group; TPNS on) or no stimulation (control group; TPNS off) from the remedē System Pivotal Trial. The hypoxemic burden was quantified using a battery of metrics, including the oxygen desaturation index (ODI), the relative sleep time spent below 90% SpO2 (T90) due to acute episodic desaturations (T90_desat) and due to non-specific and non-cyclic drifts of SpO2 (T90_non-specific). Mean change from baseline is provided.

RESULTS

TPNS titrated to reduce respiratory events significantly reduced the ODI in the treatment group by -15.85 h^-1 ± 1.99 compared to the control group, which increased 1.32 h^-1 ± 1.85 (p 〈0001) and shortened the relative T90 duration by -3.81 percentage points ± 1.23 vs. 0.49 percentage points ± 1.14 increase (p = 0.012). This shortening of T90 was primarily accomplished by reducing the brief cyclic desaturations (T90_desaturation: -4.32 percentage points ± 0.98 vs. 0.52 percentage points ± 0.91, p = 0.0004) while notable non-specific drifts in SpO₂ remained unchanged (T90_non-specific: 0.18 percentage points ± 0.62 vs. -0.13 percentage points ± 0.57, p = 0.72).

CONCLUSIONS

TPNS appears to significantly reduce the nocturnal hypoxemic burden due to sleep-disordered breathing, but a considerable nocturnal hypoxemic burden from other sources remains. Further investigations are warranted to identify the best strategy to reduce the nocturnal hypoxemic burden beyond preventing respiratory events.

Comorbidity Profile and Predictors of Obstructive Sleep Apnea Severity and Mortality in Non-Obese Obstructive Sleep Apnea Patients

Backgrounds and Objectives: Obstructive sleep apnea (OSA) is associated with increased morbidity and mortality. OSA is an independent risk factor for many different conditions, especially cardiovascular diseases. The purpose of this study was to ascertain the comorbidity profile of non-obese patients with newly diagnosed OSA and evaluate the risk for cardiovascular disease and mortality. The present study also aimed to establish predictors for OSA severity. Materials and Methods: This study included 138 newly diagnosed patients who underwent polysomnographic analysis. The 10-year risk for cardiovascular disease was assessed using a newly validated prediction model: Systematic Coronary Risk Evaluation (SCORE-2). In addition, the Charlson Comorbidity Index (CCI) was assessed as a widely-used example of a mortality comorbidity index. Results: The study population included 138 patients: 86 males and 52 females. Patients were stratified, according to AHI (apnea/hypopnea index), into four groups: 33 patients had mild OSA (5 ≤ AHI < 15), 33 patients had moderate OSA (15 ≤ AHI < 30), 31 patients had severe OSA (AHI ≥ 30), and 41 individuals had AHI < 5, which were a part of the control group. SCORE-2 increased in line with OSA severity and was higher in OSA groups compared to the control group (H = 29.913; DF = 3; p < 0.001). Charlson Index was significantly higher in OSA patients compared to controls (p = 0.001), with a higher prevalence of total comorbidities in the OSA group of patients. Furthermore, CCI 10-year survival score was significantly lower in the OSA group, suggesting a shorter survival of those patients with a more severe form of OSA. We also examined the prediction model for OSA severity. Conclusions: Determining the comorbidity profile and estimation of the 10-year risk score of OSA patients could be used to classify these patients into various mortality risk categories and, according to that, provide them with adequate treatment.

High night-to-night variability in sleep apnea severity is associated with uncontrolled hypertension

Obstructive sleep apnea (OSA) severity can vary markedly from night-to-night. However, the impact of night-to-night variability in OSA severity on key cardiovascular outcomes such as hypertension is unknown. Thus, the primary aim of this study is to determine the effects of night-to-night variability in OSA severity on hypertension likelihood. This study uses in-home monitoring of 15,526 adults with ~180 nights per participant with an under-mattress sleep sensor device, plus ~30 repeat blood pressure measures. OSA severity is defined from the mean estimated apnea-hypopnoea index (AHI) over the ~6-month recording period for each participant. Night-to-night variability in severity is determined from the standard deviation of the estimated AHI across recording nights. Uncontrolled hypertension is defined as mean systolic blood pressure ≥140 mmHg and/or mean diastolic blood pressure ≥90 mmHg. Regression analyses are performed adjusted for age, sex, and body mass index. A total of 12,287 participants (12% female) are included in the analyses. Participants in the highest night-to-night variability quartile within each OSA severity category, have a 50-70% increase in uncontrolled hypertension likelihood versus the lowest variability quartile, independent of OSA severity. This study demonstrates that high night-to-night variability in OSA severity is a predictor of uncontrolled hypertension, independent of OSA severity. These findings have important implications for the identification of which OSA patients are most at risk of cardiovascular harm.

Obstructive sleep apnea is not associated with diabetic retinopathy in diabetes: a prospective case-control study

PURPOSE

Diabetic retinopathy (DR) is the most common ocular complication of type 2 diabetes mellitus (T2D) and is associated with diabetes duration, glycemic control, and hypertension (HTN). Obstructive sleep apnea (OSA) is frequent in T2D and is associated with poor glycemic control. However, it is unclear if there is an association between OSA and DR. This study aimed to assess whether or not the presence of OSA in patients with T2D was associated with DR.

METHODS

In this prospective case-control study, consecutive patients with DM attending the ophthalmology clinics were recruited to include patients with DR (cases) and without DR (controls). OSA was diagnosed by attended polysomnography (PSG). Blood pressure and a fasting morning blood sample, including glycosylated hemoglobin (HbA1c), were recorded. Patients were matched for age, body mass index (BMI), gender, and T2D duration.

RESULTS

Thirty diabetic patients with DR were matched with 30 controls. In all patients, the prevalence of moderate-to-severe OSA was 57%. In the logistic regression analysis, DR was associated with increased HbA1c (OR 2.63, 95% CI 1.35-5.16, p = 0.004) but not with any PSG parameter. In the DR group, PSG parameters were not associated with the severity of ocular disease (non-proliferative, proliferative, presence/absence of macular edema). The proliferative aspect of DR was correlated with age (p = 0.017). DR occurred more frequently in uncontrolled diabetes compared to well-controlled diabetes (80% vs 38%, p = 0.029).

CONCLUSIONS

In patients with T2D, the presence of DR is not associated with OSA, but with poorly controlled T2D.

Respiratory effort during sleep and prevalent hypertension in obstructive sleep apnoea

BACKGROUND

Mechanisms underlying blood pressure changes in obstructive sleep apnoea (OSA) are incompletely understood. Increased respiratory effort is one of the main features of OSA and is associated with sympathetic overactivity, leading to increased vascular wall stiffness and remodelling. This study investigated associations between a new measure of respiratory effort (percentage of total sleep time spent with increased respiratory effort based on measurement of mandibular jaw movements (MJM): REMOV, %TST) and prevalent hypertension in adults referred for evaluation of suspected OSA.

METHODS

A machine learning model was built to predict hypertension from clinical data, conventional polysomnography (PSG) indices and MJM-derived parameters (including REMOV). The model was evaluated in a training subset and a test subset.

RESULTS

The analysis included 1127 patients: 901 (80%) in the training subset and 226 (20%) in the test subset. The prevalence of hypertension was 31% and 30%, respectively, in the training and test subsets. A risk stratification model based on 18 input features including REMOV had good accuracy for predicting prevalent hypertension (sensitivity 0.75 and specificity 0.83). Using the Shapley additive explanation method, REMOV was the best predictor of hypertension after clinical risk factors (age, sex, body mass index and neck circumference) and time with oxygen saturation <90%, ahead of standard PSG metrics (including the apnoea-hypopnoea index and oxygen desaturation index).

CONCLUSION

The proportion of sleep time spent with increased respiratory effort automatically derived from MJM was identified as a potential new reliable metric to predict prevalent hypertension in patients with OSA.

Nocturnal hypoxia indexes are associated with left ventricular remodeling and diastolic dysfunction in obstructive sleep apnea patients

BACKGROUND AND OBJECTIVE

Obstructive sleep apnea (OSA) is associated with heart derangements detected at echocardiography as higher left ventricular mass index (LVMI), higher left ventricular end-diastolic diameter, lower left ventricular ejection fraction (LVEF), and impaired diastolic function. However, the currently used parameter to define OSA diagnosis and severity, the apnea/hypopnea index (AHI), poorly predicts cardiovascular damage, cardiovascular events, and mortality. Our study aimed to assess if other polygraphic indices of OSA presence and severity, in addition to AHI, might better predict echocardiographic cardiac remodeling.

METHODS AND RESULTS

We enrolled two cohorts of individuals referred for suspected OSA to the outpatient facilities of the IRCCS Istituto Auxologico Italiano, Milano, and of the Clinica Medica 3, Padova. All patients underwent home sleep apnea testing and echocardiography. Based on the AHI the cohort was divided into no-OSA (AHI<15 events/hour) and moderate-severe OSA (AHI≥15 events/hour). We recruited 162 patients and found that compared to patients with no-OSA, those with moderate-severe OSA showed higher LV remodeling [left ventricular end-diastolic volume (LVEDV) 48.4 ± 11.5 ml/m2 vs. 54.1 ± 14.0 ml/m2, respectively, p = 0.005] and lower LVEF (65.3 ± 5.8% vs. 61.6 ± 7.8%, respectively, p = 0.002), whereas we could not find any difference in LVMI and early and late ventricular filling velocity ratio (E/A). At multivariate linear regression analysis two polygraphic hypoxic burden-related markers were independent predictors of LVEDV and E/A, i.e., the percentage of time with O2 saturation below 90% (β = 0.222) and ODI (β = -0.422), respectively.

CONCLUSIONS

Our study shows that nocturnal hypoxia-related indexes were associated with left ventricular remodeling and diastolic dysfunction in OSA patients.

Effects of the combination of atomoxetine and oxybutynin in Japanese patients with obstructive sleep apnoea: A randomized controlled crossover trial

BACKGROUND AND OBJECTIVE

The possibility of combination therapy with atomoxetine (ATO) and oxybutynin (OXY) has been suggested for obstructive sleep apnoea (OSA). However, the effectiveness of this treatment remains uninvestigated in Japanese OSA patients. Therefore, we performed a randomized, crossover, phase II, single-centre prospective trial to examine the effects of ATO-OXY therapy in Japanese OSA patients.

METHODS

In total, 17 OSA patients participated in this study. The effects of one night of 80-mg ATO plus 5-mg OXY administration were compared with those of no medication administered before sleep. The primary and secondary outcomes comprised the apnoea-hypopnoea index (AHI) and nadir SpO₂ , SpO₂ drop time and sleep architecture, respectively. The safety endpoints included drug side effects and adverse events.

RESULTS

The values of AHI, nadir SpO₂ , 3% oxygen desaturation index (ODI), 4% ODI, and SpO₂ drop time of <90% did not significantly differ between patients receiving ATO-OXY administration and no medication. Sleep architecture exhibited a significant change: ATO-OXY increased sleep stage N1 (p < 0.0001) and decreased stage N2 (p = 0.03), rapid eye movement (p < 0.0001) and sleep efficiency (p = 0.02). However, the subanalysis demonstrated an obvious decrease in AHI in five responder patients. Total sleep time and basal sleep efficiency tended to be lower in the responders compared with nonresponders (p = 0.065). No patients experienced severe adverse events or side effects.

CONCLUSION

Overall, ATO-OXY therapy does not reduce AHI in Japanese OSA patients, although AHI was decreased in a proportion of patients. Future studies for identifying treatment response group characteristics are warranted.

Implication of a novel measure of obstructive sleep apnea severity for cardiovascular morbidity

OBJECTIVE

To evaluate the association between cardiovascular morbidity and obstructive sleep apnea (OSA) severity quantified using the sleep breathing impairment index (SBII), a novel measure that captures both respiratory events and event-associated hypoxia.

PATIENTS AND METHODS

This retrospective follow-up study included 737 participants with OSA who were diagnosed based on an apnea-hypopnea index of >5/h in polysomnography from January 1, 2012 to December 31, 2015. Data on baseline clinical characteristics and polysomnography parameters were collected. SBII was determined as the sum of products of respiratory events and event-related desaturation areas, and was categorized based on its quintiles. The outcomes were any hospital admission for cardiovascular diseases, including coronary heart disease, stroke, peripheral vascular disease, or heart failure after the diagnosis of OSA. Logistic regression models were constructed to estimate the potential association between SBII and cardiovascular morbidity after adjusting for confounders.

RESULTS

A total of 60 cardiovascular events were recorded. Compared with the first quintile of SBII, the odds ratio (95% confidence interval [CI]) of cardiovascular morbidity for the second, third, and fourth quintiles were 4.01 (95% CI, 1.22-13.24), 3.91 (95% CI, 1.05-14.53), and 7.57 (95% CI, 1.70-33.68) after adjusting for covariables, including anthropometric variables, medical conditions, and sleep parameters.

CONCLUSION

In patients with OSA, higher SBII was associated with an increased cardiovascular risk. These findings suggest that a more comprehensive measure, such as SBII incorporating the respiratory event and related hypoxia during sleep, may better capture the disease burden and reflect the OSA-associated adverse outcomes.

[Effect of Objective Daytime Sleepiness on Heart Rate Variability in Patients With Obstructive Sleep Apnea]

Objective

Excessive daytime sleepiness (EDS) is associated with cardiovascular events in patients with obstructive sleep apnea (OSA). Our study explored the correlation between objective daytime sleepiness assessed with daytime multiple sleep latency tests (MSLT) and heart rate variability (HRV) in OSA patients. The results may provide insight into possible mechanisms underlying increased risk of cardiovascular events in patients with OSA.

Methods

A retrospective analysis was conducted with the data of 139 patients with OSA and 35 patients with primary snoring. All subjects underwent polysomnography (PSG) and MSLT at West China Hospital between January 2019 and May 2022. We used mean sleep latency (MSL) to measure the severity of EDS and to categorize OSA patients into three groups, severe EDS, light EDS, and non-EDS, with MSL of less than 5 minutes, 5 to 10 minutes, and greater than 10 minutes as the respective defining criteria for classification. A comparison of sleep structure, clinical characteristics, and HRV parameters was performed in order to evaluate the difference between OSA subgroups with varying levels of objective EDS and the primary snoring group. In addition, we also analyzed the correlation between MSL and HRV parameters.

Results

Severe EDS patients had higher values of standard deviation of all N-N intervals (SDNN), total spectral power (TOT), and low-frequency power (LF) as compared to non-EDS patients, which was indicative of sympathetic stimulation ( P<0.05). Additionally, high-frequency power (HF) was also higher in severe EDS patients, which indicated decreased parasympathetic drive. A significantly positive correlation was found between MSL and the values of SDNN, TOT, LF, and HF in OSA patients.

Conclusion

OSA patients with objective EDS have elevated sympathetic drive and decreased parasympathetic drive. A positive correlation was found between this change in neural activity and the shortening of MSL.

Exercise capacity remains supernormal, though mildly reduced in middle-aged military personnel with Moderate to Severe Obstructive Sleep Apnea

INTRODUCTION

The relationship between moderate to severe OSA and exercise capacity remains unclear. Prior studies showing a reduction in VO₂ max in this population have mostly involved middle-aged, overweight patients. We aimed to study this relationship in a similarly aged population of military personnel with previously undiagnosed moderate to severe OSA.

METHODS

We studied late-career male military personnel who underwent CPET and polysomnography (PSG). Patients were categorized either into an OSA group (apnea-hypopnea index (AHI) ≥ 15 events/h) or a control group (AHI < 15 events/h). VO₂ max was compared between groups.

RESULTS

170 male military personnel met criteria for the study. Mean AHI was 29.0/h in the OSA group (n = 58) versus 7.4/h in the controls (n = 112) while SpO₂ nadir was slightly lower (86.0% vs. 89.0%). Patients were of similar age (53.1 vs. 53.7 years), and BMI was slightly higher in the OSA group (27.5 kg/m² vs. 26.3 kg/m²). Percent-predicted VO₂ max was supernormal in both groups, though it was comparatively lower in the OSA group (117% vs. 125%; p < 0.001).

CONCLUSIONS

Military personnel with moderate to severe OSA were able to achieve supernormal VO₂ max values, yet had an 8% decrement in exercise capacity compared to controls. These findings suggest that OSA without significant hypoxemia may not significantly influence exercise capacity. It remains likely that the effects of untreated OSA on exercise capacity are complex and are affected by several variables including BMI, degree of associated hypoxemia, and regularity of exercise. Statistically lower VO₂ max noted in this study may suggest that untreated OSA in less fit populations may lead to significant decrements in exercise capacity.

Impact of reboxetine plus oxybutynin treatment for obstructive sleep apnea on cardiovascular autonomic modulation

The combination of noradrenergic (reboxetine) plus antimuscarinic (oxybutynin) drugs (reb-oxy) reduced obstructive sleep apnea (OSA) severity but no data are available on its effects on cardiac autonomic modulation. We sought to evaluate the impact of 1-week reb-oxy treatment on cardiovascular autonomic control in OSA patients. OSA patients were randomized to a double-blind, crossover trial comparing 4 mg reboxetine plus 5 mg oxybutynin to a placebo for OSA treatment. Heart rate (HR) variability (HRV), ambulatory blood pressure (BP) monitoring (ABPM) over 24 h baseline and after treatment were performed. Baroreflex sensitivity was tested over beat-to-beat BP recordings. 16 subjects with (median [interquartile range]) age 57 [51-61] years and body mass index 30 [26-36]kg/m² completed the study. The median nocturnal HR was 65 [60-69] bpm at baseline and increased to 69 [64-77] bpm on reb-oxy vs 66 [59-70] bpm on placebo (p = 0.02). The mean 24 h HR from ABPM was not different among treatment groups. Reb-oxy administration was not associated with any modification in HRV or BP. Reb-oxy increased the baroreflex sensitivity and did not induce orthostatic hypotension. In conclusion, administration of reb-oxy did not induce clinically relevant sympathetic overactivity over 1-week and, together with a reduction in OSA severity, it improved the baroreflex function.

Sleep Irregularity and Subclinical Markers of Cardiovascular Disease: The Multi-Ethnic Study of Atherosclerosis

Background Sleep irregularity has been linked to incident cardiovascular disease. Less is known about associations of sleep regularity with atherosclerosis. We examined cross-sectional associations of actigraphy-assessed sleep duration and sleep timing regularity with subclinical atherosclerosis in the community-based MESA (Multi-Ethnic Study of Atherosclerosis). Methods and Results MESA Sleep Ancillary Study participants (N=2032; mean age, 68.6±9.2 years; 37.9% White) completed 7-day wrist actigraphy. Participants underwent assessments of coronary artery calcium, carotid plaque presence, carotid intima-media thickness, and the ankle-brachial index. Sleep regularity was quantified by the 7-day with-in person SD of sleep duration and sleep onset timing. Relative risk regression models were used to calculate prevalence ratios and 95% CIs. Models are adjusted for demographics, cardiovascular disease risk factors, and other objectively assessed sleep characteristics including obstructive sleep apnea, sleep duration, and sleep fragmentation. After adjustment, compared with participants with more regular sleep durations (SD ≤60 minutes), participants with greater sleep duration irregularity (SD >120 minutes) were more likely to have high coronary artery calcium burden (>300; prevalence ratio, 1.33 [95% CI, 1.03-1.71]) and abnormal ankle-brachial index (<0.9; prevalence ratio, 1.75 [95% CI, 1.03-2.95]). Compared with participants with more regular sleep timing (SD ≤30 minutes), participants with irregular sleep timing (SD >90 minutes) were more likely to have high coronary artery calcium burden (prevalence ratio, 1.39 [95% CI, 1.07-1.82]). Associations persisted after adjustment for cardiovascular disease risk factors and average sleep duration, obstructive sleep apnea, and sleep fragmentation. Conclusions Sleep irregularity, particularly sleep duration irregularity, was associated with several measures of subclinical atherosclerosis. Sleep regularity may be a modifiable target for reducing atherosclerosis risk. Future investigation into cardiovascular risk reduction interventions targeting sleep irregularity may be warranted.

Prevalence of sleep apnoea in patients with type 1 diabetes and its association with comorbidities and diabetic complications: A French nationwide prospective study

AIM

To investigate sleep apnoea prevalence, factors influencing severity, and associations between sleep apnoea severity and micro-/macrovascular complications in a large population of patients with type 1 diabetes.

MATERIALS AND METHODS

This French multicentre prospective cohort study was conducted between July 2016 and June 2020. Adults with type 1 diabetes using an insulin pump were eligible. Home care provider nurses collected demographic and clinical data and set up oximetry to determine the oxygen desaturation index (ODI). No, mild-moderate and severe sleep apnoea were defined as ODI <15 events/h, 15 to <30 events/h and ≥30 events/h, respectively. Univariate and multivariate analyses were performed to identify factors associated with sleep apnoea, and associations between sleep apnoea severity and micro-/macrovascular complications were determined using logistic regression.

RESULTS

Of 769 participants, 12.4% and 3.4% had mild-to-moderate or severe sleep apnoea, respectively. Factors significantly associated with sleep apnoea on multivariate analysis were age, sex, body mass index (BMI) and hypertension. After adjustment for age, sex and BMI, presence of severe sleep apnoea was significantly associated with macrovascular complications (odds ratio vs. no sleep apnoea: 3.96 [95% confidence interval 1.43-11.11]; P < 0.01), while mild-to-moderate sleep apnoea was significantly associated with presence of diabetic retinopathy (odds ratio 2.09 [95% confidence interval 1.10-3.74]; P < 0.01).

CONCLUSION

Sleep apnoea is a significant comorbidity in patients with type 1 diabetes, especially with respect to diabetic complications. This highlights the need for sleep apnoea screening and management in these individuals.

Prognostic Implications of OSA in Acute Coronary Syndrome by Obesity Status

BACKGROUND

A close relationship exists between OSA and obesity. The impact of obesity on the prognostic significance of OSA in patients with acute coronary syndrome (ACS) remains unclear.

RESEARCH QUESTION

Do the effects of OSA on subsequent cardiovascular events in patients with ACS vary with obesity status?

STUDY DESIGN AND METHODS

This is a prospective cohort study. Patients 18 to 85 years of age and hospitalized for ACS were consecutively enrolled and underwent portable sleep monitoring after clinical stabilization. OSA was defined as an apnea hypopnea index ≥ 15 events/h. The primary end point was major adverse cardiovascular and cerebrovascular event (MACCE), including cardiovascular death, hospitalization for ACS, stroke, ischemia-driven revascularization, or hospitalization for heart failure.

RESULTS

Among 1,920 patients enrolled (84.5% men; mean age ± SD, 56.4 ± 10.5 years), 1,013 (52.8%) had OSA, and 718 (37.4%) were obese (BMI ≥ 28 kg/m²). During 2.9 years (1.5, 3.6) follow up, the incidence of MACCE was significantly higher in patients with obesity than in patients without obesity (hazard ratio [HR], 1.29; 95% CI, 1.06-1.58; P = .013). Although the prevalence of OSA was lower in patients without obesity than in those with obesity (43.9% vs 67.5%, P < .001), OSA independently predicted the incidence of MACCE only in patients without obesity (adjusted HR, 1.34; 95% CI, 1.03-1.75; P = .03), but not in patients with obesity (adjusted HR, 1.10; 95% CI, 0.78-1.55; P = .58). No significant interaction between obesity and OSA was noted (P for interaction = .35). The incremental risk associated with OSA in patients without obesity might be explained by more hospitalization for ACS and ischemia-driven revascularization.

INTERPRETATION

For patients with ACS, OSA was independently associated with an increased risk of subsequent events, particularly among patients without obesity. These findings highlight the importance of identifying OSA in nonobese patients with ACS.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; No.: NCT03362385; URL: www.

CLINICALTRIALS

gov.

Depression with obstructive sleep apnea lead to high cardiovascular disease morbidity/all-cause mortality: Findings from the SHHS cohort

The aim of this study is to explore the association between depression and obstructive sleep apnea, and cardiovascular disease morbidity/all-cause mortality using Sleep Heart Health Study data. This post hoc analysis of a prospective study used patient data from the Sleep Heart Health Study conducted between 1995 and 1998. The association between depression and obstructive sleep apnea, and cardiovascular disease morbidity/all-cause mortality was explored using multivariable Cox proportional hazard models. A total of 4918 participants, 656 (13.3%) with obstructive sleep apnea (obstructive sleep apnea group), 1614 (32.8%) with depression (depression group), 482 (9.8%) with depression and obstructive sleep apnea (depression and obstructive sleep apnea group), and 2166 (44%) with neither obstructive sleep apnea nor depression (health group), were included. The incidence of cardiovascular disease was 24.5%, 31.0%, 31.6% and 41.7% for healthy, depression, obstructive sleep apnea, and depression and obstructive sleep apnea groups, respectively. The risk of cardiovascular disease in depression and obstructive sleep apnea participants was increased compared with that in healthy participants, which was consistent across various definitions of obstructive sleep apnea (hazard ratio [95% confidence interval]: 1.24 [1.06-1.47]; 1.25 [1.05-1.49]; 1.28 [1.06-1.54]; 1.55 [1.22-1.96] for apnea-hypopnea index ≥ 10 per hr, 15 per hr, 20 per hr, 30 per hr, respectively). The risk of all-cause mortality was increased in the depression and obstructive sleep apnea participants (hazard ratio: 1.46; 95% confidence interval: 1.07-1.99) compared with that in healthy participants when the definition of obstructive sleep apnea was apnea-hypopnea index ≥ 30. Participants with depression and obstructive sleep apnea might be at a greater risk of cardiovascular disease, and those with higher apnea-hypopnea index might be at a greater risk of all-cause mortality.

Influence of obstructive sleep apnea syndrome on the contralateral optic nerve in patients with unilateral nonarteritic anterior ischemic optic neuropathy

STUDY OBJECTIVES

The aim was to quantitatively evaluate the influence of obstructive sleep apnea syndrome (OSAS) on the morphology and function of the contralateral optic nerve in patients with unilateral nonarteritic anterior ischemic optic neuropathy (NAION).

METHODS

Fifty patients with unilateral NAION were divided into non-OSAS (n = 16), mild OSAS (n = 15), and moderate-severe OSAS (n = 19) groups based on their apnea-hypopnea index (AHI) scores. Systemic and ocular characteristics were compared between these groups. Spearman correlation and multiple linear regression analyses were used to determine the independent factors that most influenced the thickness of the peripapillary retinal nerve fiber layer (pRNFL).

RESULTS

Body mass index and hypertension occurrence were higher in the moderate-severe OSAS group than in the non-OSAS group. Temporal pRNFL was thinner in the moderate-severe group than in the mild and non-OSAS groups, whereas no difference was found between the mild and non-OSAS groups. Spearman correlation showed that the AHI (r = -.469, P = .001) and the percentage of total sleep time with oxygen saturation < 90% (T90%; r = -.477, P = .001) correlated with temporal pRNFL thickness. Multiple linear regression showed that the AHI was negatively associated with temporal pRNFL thickness (β = -0.573, P = .003).

CONCLUSIONS

OSAS may cause subclinical temporal pRNFL thinning in the contralateral optic nerve among patients with unilateral NAION without any significant change in visual function. Advanced optic nerve observation and intervention may be warranted in patients with moderate-severe OSAS.

CITATION

Li X, Zhang Y, Guo T, et al. Influence of obstructive sleep apnea syndrome on the contralateral optic nerve in patients with unilateral nonarteritic anterior ischemic optic neuropathy. J Clin Sleep Med. 2023;19(2):347-353.

Effects of the combination of novel eye mask sleep position therapy device and oral appliance on positional OSA: A multi-arm, parallel-group randomized controlled trial

OBJECTIVES

We explored whether a new combination of eye mask sleep position therapy (SPT) and oral appliance therapy (OAT) was more effective at treating positional obstructive sleep apnea (POSA) than was the use of either device alone.

METHODS

In this randomized controlled trial, 60 POSA subjects diagnosed by standard polysomnography (PSG) were divided into three groups (ratio 1:1:1): SPT, OAT, and SPT combined with OAT (SOT). Participants underwent hospital-based follow-ups during months 1 and 6 after beginning treatment. The primary outcome was the decline in the apnea hypopnea index (AHI) at month 6. The secondary outcomes were changes in oxygen-derived parameters and the curative effect at month 6.

RESULTS

After 6 months of treatment, PSG showed that SPT, OAT, and SOT all improved the AHI and oxygen-derived parameters. The AHI decline was significantly better in the SOT group than in the OAT or SPT group (71.58% [50.56-84.84%] for SOT, 44.42% [21.23-67.52%] for OAT, and 33.24% [19.03-54.62%] for SPT at 6 months) (P = 0.018 and P < 0.001 for the comparisons of SOT with OAT and SOT with SPT, respectively). In terms of oxygen-derived parameters, only the sleep apnea-specific hypoxic burden (SASHB) improved more in the SOT group (76.89% [57.43-85.91%]) than in the other groups (44.73% [32.38-72.69%] for OAT and 41.82% [15.40-65.24%] for SPT, P = 0.002 and P < 0.001 for the comparisons of SOT with OAT and SOT with SPT, respectively). The efficacies of SPT, OAT, and SOT were 36.84%, 50%, and 80% at 6 months; the SOT group evidenced the highest value (rate ratio [95% confidence interval] 1.78 (1.05-3.03), P = 0.048 and 2.17 (1.16-4.07), P = 0.010, for the comparisons of SOT with OAT and SOT with SPT, respectively).

CONCLUSION

The combination of SPT and OAT was better than either treatment alone and may represent a good option for the treatment of POSA.

TRIAL REGISTRATION

Chinese Clinical Trial Registry; URL: http://www.chictr.org.cn/showproj.aspx?proj=42,852; No. ChiCTR1900025584.

Implication of prolonged nocturnal hypoxemia and obstructive sleep apnea for pulmonary hemodynamics in patients being evaluated for pulmonary hypertension: a retrospective study

STUDY OBJECTIVES

The unique pathophysiologic contributions of obstructive sleep apnea (OSA) toward pulmonary hypertension and right ventricular (RV) dysfunction still represent an understudied area. We aimed to investigate the impacts of various respiratory parameters on pulmonary hemodynamics and RV performance in OSA.

METHODS

Data of consecutive patients with OSA who completed right heart catheterization for evaluation of pulmonary hemodynamics were retrospectively reviewed and analyzed. Univariable and multivariable regression analyses were used to determine the significant respiratory parameter associated with right heart catheterization metrics.

RESULTS

Of 205 patients with OSA (43.4% male), 134 (65.4%) had pulmonary hypertension. Among various sleep parameters, the time percentage spent with SpO2 below 90% (T90) was the sole and the strongest independent factor associated with mean pulmonary artery pressure (mPAP) (β = 0.467, P < .001), pulmonary vascular resistance (PVR) (β = 0.433, P < .001), and RV stroke work index (RVSWI) (β = 0.338, P < .001). For every 5-unit increase in T90, there was approximately 36% greater risk of mPAP ≥ 25 mmHg (odds ratio [OR] 1.36, 95% confidence interval [CI] 1.16-1.59, P < .001), and 45% greater risk of PVR > 3 Woods units (OR 1.45, 95% CI 1.21-1.74, P < .001), respectively. T90 per 5-unit increment was also related to a nearly 1.2-fold higher risk of RVSWI ≥ 12 g/m2/beat (OR 1.19, 95% CI 1.11-1.28, P < .001). These associations remained significant even after multivariable adjustment for confounding factors (all P < .05).

CONCLUSIONS

Increased mPAP, PVR, and RVSWI were associated with prolonged T90 in patients with OSA. Assessment of OSA with insights into hypoxemic duration may aid in early recognition of impaired pulmonary hemodynamics and RV dysfunction.

CITATION

Huang Z, Duan A, Hu M, et al. Implication of prolonged nocturnal hypoxemia and obstructive sleep apnea for pulmonary hemodynamics in patients being evaluated for pulmonary hypertension: a retrospective study. J Clin Sleep Med. 2023;19(2):213-223.

The effectiveness of sleep breathing impairment index in assessing obstructive sleep apnea severity

STUDY OBJECTIVES

Using the apnea-hypopnea index (AHI) and the sleep breathing impairment index (SBII) to assess the severity of obstructive sleep apnea (OSA) to study how effective SBII is in assessing the severity and cardiovascular disease (CVD) prognosis.

METHODS

This study comprised a total of 147 patients with diagnosed OSA. The AHI and SBII were calculated from the polysomnography. Patients were enrolled in the cluster analysis using 20 symptoms and the SBII. The prognostic indicator was determined as the moderate-to-high Framingham 10-year CVD risk.

RESULTS

Cluster analysis revealed 3 separate groups: cluster 1 (n = 45, 30.61%) had the lowest symptoms complaints yet the highest PSQI score; cluster 2 (n = 70, 47.62%) had considerably increased symptom complaints but the lowest Epworth Sleepiness Scale score, intermediate PSG indices, a higher low arousal threshold possibility, and a lower SBII quantile; cluster 3 (n = 32, 21.77%) had the largest percentage of smokers, a predominant symptom of restless sleep, severe PSG characteristics, a lower low arousal threshold likelihood, a greater SBII quantile and a higher Framingham CVD risk. There were no differences in severity indicated by AHI between groups. Higher SBII rather than AHI is associated with an increased 10-year CVD risk.

CONCLUSIONS

SBII provides higher sensitivity when evaluating OSA severity and better predictive capabilities for CVD outcomes. SBII may be a more effective substitute for AHI in the future.

CITATION

Dai L, Cao W, Luo J, Huang R, Xiao Y. The effectiveness of sleep breathing impairment index in assessing obstructive sleep apnea severity. J Clin Sleep Med. 2023;19(2):267-274.

Sleep Arousal-Related Ventricular Repolarization Lability Is Associated With Cardiovascular Mortality in Older Community-Dwelling Men

BACKGROUND

Sleep is fragmented by brief arousals, and excessive arousal burden has been linked to increased cardiovascular (CV) risk, but mechanisms are poorly understood.

RESEARCH QUESTION

Do arousals trigger cardiac ventricular repolarization lability that may predispose people to long-term cardiovascular mortality?

STUDY DESIGN AND METHODS

This study analyzed 407,541 arousals in the overnight polysomnograms of 2,558 older men in the Osteoporotic Fractures in Men sleep study. QT and RR intervals were measured beat-to-beat starting 15 s prior to arousal onset until 15 s past onset. Ventricular repolarization lability was quantified by using the QT variability index (QTVi).

RESULTS

During 10.1 ± 2.5 years of follow-up, 1,000 men died of any cause, including 348 CV deaths. During arousals, QT and RR variability increased on average by 5 and 55 ms, respectively, resulting in a paradoxical transient decrease in QTVi from 0.07 ± 1.68 to -1.00 ± 1.68. Multivariable Cox proportional hazards analysis adjusted for age, BMI, cardiovascular and respiratory risk factors, sleep-disordered breathing and arousal, diabetes, and Parkinson disease indicated that excessive QTVi during arousal was independently associated with all-cause and CV mortality (all-cause hazard ratio, 1.20 [95% CI, 1.04-1.38; P = .012]; CV hazard ratio, 1.29 [95% CI, 1.01 -1.65; P = .043]).

INTERPRETATION

Arousals affect ventricular repolarization. A disproportionate increase in QT variability during arousal is associated with an increased all-cause and CV mortality and may reflect ventricular repolarization maladaptation to the arousal stimulus. Whether arousal-related QTVi can be used for more tailored risk stratification warrants further study, including evaluating whether arousal suppression attenuates ventricular repolarization lability and reduces subsequent mortality.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; No.: NCT00070681; URL: www.

CLINICALTRIALS

gov.

Association of alternative polysomnographic features with patient outcomes in obstructive sleep apnea: a systematic review

STUDY OBJECTIVES

Polysomnograms (PSGs) collect a plethora of physiologic signals across the night. However, few of these PSG data are incorporated into standard reports, and hence, ultimately, under-utilized in clinical decision making. Recently, there has been substantial interest regarding novel alternative PSG metrics that may help to predict obstructive sleep apnea (OSA)-related outcomes better than standard PSG metrics such as the apnea-hypopnea index. We systematically review the recent literature for studies that examined the use of alternative PSG metrics in the context of OSA and their association with health outcomes.

METHODS

We systematically searched EMBASE, MEDLINE, and the Cochrane Database of Systematic Reviews for studies published between 2000 and 2022 for those that reported alternative metrics derived from PSG in adults and related them to OSA-related outcomes.

RESULTS

Of the 186 initial studies identified by the original search, data from 31 studies were ultimately included in the final analysis. Numerous metrics were identified that were significantly related to a broad range of outcomes. We categorized the outcomes into 2 main subgroups: (1) cardiovascular/metabolic outcomes and mortality and (2) cognitive function- and vigilance-related outcomes. Four general categories of alternative metrics were identified based on signals analyzed: autonomic/hemodynamic metrics, electroencephalographic metrics, oximetric metrics, and respiratory event-related metrics.

CONCLUSIONS

We have summarized the current landscape of literature for alternative PSG metrics relating to risk prediction in OSA. Although promising, further prospective observational studies are needed to verify findings from other cohorts, and to assess the clinical utility of these metrics.

CITATION

Hajipour M, Baumann B, Azarbarzin A, et al. Association of alternative polysomnographic features with patient outcomes in obstructive sleep apnea: a systematic review. J Clin Sleep Med. 2023;19(2):225-242.

Personalized multimodal management for severe obstructive sleep apnea in a patient intolerant of positive airway pressure with hypoglossal nerve stimulator and mandibular advancement device

Treatment of moderate to severe obstructive sleep apnea poses clinical challenges in persons with intolerance or inadequate response to traditional treatment modalities, including positive airway pressure and mandibular advancement devices. Hypoglossal nerve stimulation is a new treatment option, but few management guidelines exist when it is intolerable or ineffective. Combining several treatment modalities has been an effective strategy for improving symptoms, tolerance, and efficacy. We describe a patient intolerant to positive airway pressure therapy who had continued sleepiness, morning headaches, and snoring with a mandibular advancement device. He underwent hypoglossal nerve stimulation implantation but was intolerant of the voltages required to adequately control his obstructive sleep apnea. Multimodal management with hypoglossal nerve stimulation, mandibular advancement device, and positional therapy was successfully implemented to improve sleepiness, nocturnal symptoms, and the apnea-hypopnea index. This case highlights the personalization and adaptability of combination therapy to suit patient needs while effectively controlling obstructive sleep apnea.

CITATION

Lowery MM, Rundo JV, Walia HK, Shah V. Personalized multimodal management for severe obstructive sleep apnea in a patient intolerant of positive airway pressure with hypoglossal nerve stimulator and mandibular advancement device. J Clin Sleep Med. 2023;19(2):403-408.

Single-Night Diagnosis of Sleep Apnea Contributes to Inconsistent Cardiovascular Outcome Findings

BACKGROUND

Single-night disease misclassification of OSA due to night-to-night variability may contribute to inconsistent findings in OSA trials.

RESEARCH QUESTION

Does multinight quantification of OSA severity provide more precise estimates of associations with incident hypertension?

STUDY DESIGN AND METHODS

A total of 3,831 participants without hypertension at baseline were included in simulation analyses. Included participants had ≥ 28 days of nightly apnea-hypopnea index (AHI) recordings via an under-mattress sensor and ≥ 3 separate BP measurements over a 3-month baseline period followed by ≥ 3 separate BP measurements 6 to 9 months postbaseline. Incident hypertension was defined as a mean systolic BP ≥ 140 mm Hg or a mean diastolic BP ≥ 90 mm Hg. Simulated trials (1,000) were performed, using bootstrap methods to investigate the effect of variable numbers of nights (x = 1-56 per participant) to quantify AHI and the ability to detect associations between OSA and incident hypertension via logistic regression adjusted for age, sex, and BMI.

RESULTS

Participants were middle-aged (mean ± SD, 52 ± 12 y), mostly men (91%), and overweight (BMI, 28 ± 5 kg/m²). Single-night quantification of OSA failed to detect an association with hypertension risk in 42% of simulated trials (α = 0.05). Conversely, 100% of trials detected an association when AHI was quantified over ≥ 28 nights. Point estimates of hypertension risk were also 50% higher and uncertainty was 5 times lower during multinight vs single-night simulation trials.

INTERPRETATION

Multinight monitoring of OSA allows for better estimates of hypertension risk and potentially other adverse health outcomes associated with OSA. These findings have important implications for clinical care and OSA trial design.