101
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Zhou M, Guo B, Wang Y, Yan D, Lin C, Shi Z. The Association Between Obstructive Sleep Apnea and Carotid Intima-Media Thickness: A Systematic Review and Meta-Analysis. Angiology 2016; 68:575-583. [PMID: 27581069 DOI: 10.1177/0003319716665985] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Obstructive sleep apnea (OSA) has been suggested as a risk factor for carotid atherosclerosis. The present meta-analysis aimed to evaluate the association between OSA and carotid intima-media thickness (CIMT). Eighteen studies comparing CIMT of patients with OSA versus non-OSA patients were included. Quantitative data synthesis was used to pool weighted standardized difference in means (SMD) of CIMT in a random-effects model. Compared to healthy controls, patients with OSA had a significantly higher CIMT (SMD: 0.881; 95% confidence interval [CI]: 0.647-1.115; P < .001). Due to the great heterogeneity, a subgroup analysis was conducted based on the study design. The pooled SMD of CIMT between patients with OSA and healthy controls were 0.810 (95% CI: 0.676-0.943; P < .001) and 1.008 (95% CI: 0.506-1.510; P < .001) in matched and unmatched group, respectively. Moreover, the correlation of apnea-hypopnea index and CIMT was moderate ( r = .389; 95% CI: 0.315-0.459; P < .001). After adjustment for several major confounders, OSA is an independent risk factor for CIMT. These findings remind clinicians to screen for cardiovascular diseases in patients with OSA.
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Affiliation(s)
- Min Zhou
- 1 Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Baolei Guo
- 1 Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yonggang Wang
- 1 Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Dong Yan
- 1 Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Changpo Lin
- 1 Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhenyu Shi
- 1 Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
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102
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Abstract
Emerging evidence has assigned an important role to sleep as a modulator of metabolic homeostasis. The impact of variations in sleep duration, sleep-disordered breathing, and chronotype to cardiometabolic function encompasses a wide array of perturbations spanning from obesity, insulin resistance, type 2 diabetes, the metabolic syndrome, and cardiovascular disease risk and mortality in both adults and children. Here, we critically and extensively review the published literature on such important issues and provide a comprehensive overview of the most salient pathophysiologic pathways underlying the links between sleep, sleep disorders, and cardiometabolic functioning.
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Affiliation(s)
- Dorit Koren
- Section of Adult and Pediatric Endocrinology, Diabetes, and Metabolism, Department of Medicine
- Section of Pediatric Sleep Medicine
| | - Magdalena Dumin
- Section of Adult and Pediatric Endocrinology, Diabetes, and Metabolism, Department of Medicine
| | - David Gozal
- Section of Pediatric Sleep Medicine
- Section of Pulmonology, Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division, The University of Chicago, Chicago, IL, USA
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103
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Rotenberg BW, Murariu D, Pang KP. Trends in CPAP adherence over twenty years of data collection: a flattened curve. J Otolaryngol Head Neck Surg 2016; 45:43. [PMID: 27542595 PMCID: PMC4992257 DOI: 10.1186/s40463-016-0156-0] [Citation(s) in RCA: 422] [Impact Index Per Article: 52.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 08/11/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is a common disorder, and continuous airway positive pressure (CPAP) is considered to be the gold standard of therapy. CPAP however is known to have problems with adherence, with many patients eventually abandoning the device. The purpose of this paper is to assess secular trends in CPAP adherence over the long term to see if there have been meaningful improvements in adherence in light of the multiple interventions proposed to do so. METHODS A comprehensive systematic literature review was conducted using the Medline-Ovid, Embase, and Pubmed databases, searching for data regarding CPAP adherence over a twenty year timeframe (1994-2015). Data was assessed for quality and then extracted. The main outcome measure was reported CPAP non-adherence. Secondary outcomes included changes in CPAP non-adherence when comparing short versus long-term, and changes in terms of behavioral counseling. RESULTS Eighty-two papers met study inclusion/exclusion criteria. The overall CPAP non-adherence rate based on a 7-h/night sleep time that was reported in studies conducted over the twenty year time frame was 34.1 %. There was no significant improvement over the time frame. Behavioral intervention improved adherence rates by ~1 h per night on average. CONCLUSIONS The rate of CPAP adherence remains persistently low over twenty years worth of reported data. No clinically significant improvement in CPAP adherence was seen even in recent years despite efforts toward behavioral intervention and patient coaching. This low rate of adherence is problematic, and calls into question the concept of CPAP as gold-standard of therapy for OSA.
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Affiliation(s)
- Brian W Rotenberg
- Department of Otolaryngology - Head and Neck Surgery, Western University, London, ON, Canada
| | - Dorian Murariu
- Department of Otolaryngology - Head and Neck Surgery, Western University, London, ON, Canada
| | - Kenny P Pang
- Asia Sleep Centre, Paragon, 290, Orchard Road, Unit 18-04, Singapore, 238859, Singapore.
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104
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León Subías E, Gómara de la Cal S, Marin Trigo JM. Red Cell Distribution Width in Obstructive Sleep Apnea. Arch Bronconeumol 2016; 53:114-119. [PMID: 27381970 DOI: 10.1016/j.arbres.2016.05.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 05/12/2016] [Accepted: 05/15/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Red cell distribution width (RDW) describes heterogeneity in the size of red blood cells. An increase in RDW has been associated with excess mortality in heart failure and other chronic diseases. Since there is an increased risk of cardiovascular morbidity and mortality in obstructive sleep apnea (OSA), it is possible that these patients have a high RDW. METHOD We recruited subjects aged 18 to 60 years referred to the sleep-disordered breathing unit for suspected OSA. Subjects with any comorbidity were excluded. Apnea-hypopnea index (AHI) was calculated from the respiratory polygraphy. The RDW was obtained from the complete blood count. Changes in RDW after one year of treatment with continuous positive airway pressure (CPAP) were determined. RESULTS We included 34 healthy subjects and 138 with OSA, aged 40.5±9.8 and 45.6±9.2 (P=.004) years, respectively. The RDW was higher in subjects with OSA compared to healthy subjects: 13.40 (12.40 to 14.40) vs. 13.15 (12.07 to 14.23) (P=.036). AHI showed a positive independent relationship with RDW in both the whole population (r=0.223; P=.002) and the OSA group (r=0.231; P=.005). No significant changes were found in RDW after one year of CPAP therapy. CONCLUSIONS RDW increase in patients with OSA is directly associated with severity, although levels are not modified by the effective treatment of OSA with CPAP.
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Affiliation(s)
- Erica León Subías
- Servicio de Neumología, Hospital Universitario Miguel Servet, Zaragoza, España.
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105
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Iftikhar IH, Bittencourt L, Youngstedt SD, Ayas N, Cistulli P, Schwab R, Durkin MW, Magalang UJ. Comparative efficacy of CPAP, MADs, exercise-training, and dietary weight loss for sleep apnea: a network meta-analysis. Sleep Med 2016; 30:7-14. [PMID: 28215266 DOI: 10.1016/j.sleep.2016.06.001] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 05/30/2016] [Accepted: 06/13/2016] [Indexed: 01/18/2023]
Abstract
STUDY OBJECTIVE To synthesize evidence from available studies on the relative efficacies of continuous positive airway pressure (CPAP), mandibular advancement device (MAD), supervised aerobic exercise training, and dietary weight loss in patients with obstructive sleep apnea (OSA). DESIGN Network meta-analysis of 80 randomized controlled trials (RCTs) short-listed from PubMed, SCOPUS, Web of science, and Cochrane register (inception - September 8, 2015). PATIENTS Individuals with OSA. INTERVENTIONS CPAP, MADs, exercise training, and dietary weight loss. RESULTS CPAP decreased apnea-hypopnea index (AHI) the most [by 25.27 events/hour (22.03-28.52)] followed by exercise training, MADs, and dietary weight loss. While the difference between exercise training and CPAP was non-significant [-8.04 (-17.00 to 0.92), a significant difference was found between CPAP and MADs on AHI and oxygen desaturation index (ODI) [-10.06 (-14.21 to -5.91) and -7.82 (-13.04 to -2.59), respectively]. Exercise training significantly improved Epworth sleepiness scores (ESS) [by 3.08 (0.68-5.48)], albeit with a non-significant difference compared to MADs and CPAP. CONCLUSIONS CPAP is the most efficacious in complete resolution of sleep apnea and in improving the indices of saturation during sleep. While MADs offer a reasonable alternative to CPAP, exercise training which significantly improved daytime sleepiness (ESS) could be used as adjunctive to the former two.
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Affiliation(s)
- Imran H Iftikhar
- Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, Emory University, Atlanta, GA, USA.
| | - Lia Bittencourt
- Departmento de Psicobiologia, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Shawn D Youngstedt
- College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA
| | - Najib Ayas
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Peter Cistulli
- Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, and Sydney Medical School, University of Sydney, Australia
| | - Richard Schwab
- Department of Medicine, Division of Sleep Medicine, Pulmonary, Allergy and Critical Care, University of Pennsylvania Medical Center, Philadelphia, PA, USA
| | - Martin W Durkin
- Department of Clinical Research, Palmetto Health Richland, Columbia, SC, USA
| | - Ulysses J Magalang
- Division of Pulmonary, Allergy, Critical care & Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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106
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Intermittent Hypoxia-Induced Cardiovascular Remodeling Is Reversed by Normoxia in a Mouse Model of Sleep Apnea. Chest 2016; 149:1400-8. [DOI: 10.1016/j.chest.2015.11.010] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 10/02/2015] [Accepted: 11/02/2015] [Indexed: 11/19/2022] Open
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Sharples LD, Clutterbuck-James AL, Glover MJ, Bennett MS, Chadwick R, Pittman MA, Quinnell TG. Meta-analysis of randomised controlled trials of oral mandibular advancement devices and continuous positive airway pressure for obstructive sleep apnoea-hypopnoea. Sleep Med Rev 2016; 27:108-24. [PMID: 26163056 PMCID: PMC5378304 DOI: 10.1016/j.smrv.2015.05.003] [Citation(s) in RCA: 133] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 04/17/2015] [Accepted: 05/15/2015] [Indexed: 02/01/2023]
Abstract
Obstructive sleep apnoea-hypopnoea (OSAH) causes excessive daytime sleepiness, impairs quality-of-life, and increases cardiovascular disease and road traffic accident risks. Continuous positive airway pressure (CPAP) treatment and mandibular advancement devices (MAD) have been shown to be effective in individual trials but their effectiveness particularly relative to disease severity is unclear. A MEDLINE, Embase and Science Citation Index search updating two systematic reviews to August 2013 identified 77 RCTs in adult OSAH patients comparing: MAD with conservative management (CM); MAD with CPAP; or CPAP with CM. Overall MAD and CPAP significantly improved apnoea-hypopnoea index (AHI) (MAD -9.3/hr (p < 0.001), CPAP -25.4 (p < 0.001)). In direct comparisons mean AHI and Epworth sleepiness scale score were lower (7.0/hr (p < 0.001) and 0.67 (p = 0.093) respectively) for CPAP. There were no CPAP vs. MAD trials in mild OSAH but in comparisons with CM, MAD and CPAP reduced ESS similarly (MAD 2.01 (p < 0.001); CPAP 1.23 (p = 0.012). Both MAD and CPAP are clinically effective in the treatment of OSAH. Although CPAP has a greater treatment effect, MAD is an appropriate treatment for patients who are intolerant of CPAP and may be comparable to CPAP in mild disease.
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Affiliation(s)
- Linda D Sharples
- University of Leeds Clinical Trials Research Unit, Leeds, United Kingdom; Medical Research Council Biostatistics Unit, Cambridge, United Kingdom.
| | | | - Matthew J Glover
- Health Economics Research Unit, Brunel University, Uxbridge, Middlesex, United Kingdom
| | - Maxine S Bennett
- Medical Research Council Biostatistics Unit, Cambridge, United Kingdom
| | - Rebecca Chadwick
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Marcus A Pittman
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, United Kingdom
| | - Timothy G Quinnell
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, United Kingdom
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108
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Lorenzi-Filho G, Drager LF. Are the Effects of OSA on the Cardiovascular System Reversible? Chest 2016; 149:1360-1. [DOI: 10.1016/j.chest.2016.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 01/07/2016] [Accepted: 01/07/2016] [Indexed: 10/21/2022] Open
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Effects of Continuous Positive Airway Pressure on Lipidaemia and High-sensitivity C-reactive Protein Levels in Non-obese Patients with Coronary Artery Disease and Obstructive Sleep Apnoea. Heart Lung Circ 2016; 25:576-83. [DOI: 10.1016/j.hlc.2015.10.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 10/07/2015] [Accepted: 10/10/2015] [Indexed: 11/30/2022]
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110
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Feldstein CA. Blood pressure effects of CPAP in nonresistant and resistant hypertension associated with OSA: A systematic review of randomized clinical trials. Clin Exp Hypertens 2016; 38:337-46. [PMID: 27159803 DOI: 10.3109/10641963.2016.1148156] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Obstructive sleep apnea (OSA) is a rather common chronic disorder, associated with increased prevalence of hypertension. The pathophysiological mechanisms for hypertension in OSA are at least in part linked to intermittent hypoxia developed during nightly hypopneas and apneas. Hypoxemia stimulates sympathetic overactivity, systemic inflammation, oxidative stress, and endothelial dysfunction. However, it appears that intermittent hypoxemia is not the only factor in the development of hypertension in OSA. Supplemental oxygen therapy that improved oxyhemoglobin saturation to similar levels to those achieved with CPAP treatment did not reduce BP. In this scenario, it could be proposed that hypoxemia acts as a trigger of sympathetic overdrive, which when set is the main factor in the development of hypertension in OSA. This review appraises evidence provided by randomized controlled trials on the BP-lowering effectiveness of continuous positive airway pressure (CPAP) treatment of OSA patients with nonresistant and resistant hypertension. It suggests that CPAP treatment is more effective in treating resistant hypertension than nonresistant hypertension. A possible explanation is that sympathetic overactivity and altered vascular reactivity in OSA could be more severe in resistant hypertension than in nonresistant hypertension. An intricate interaction among compliance, adherence, and their interaction with demographic characteristics, genetic factors, and comorbidities of the population included might explain the differences found between trials on their influence over the antihypertensive effectiveness of CPAP. Further long-term trials are needed in hypertensive OSA patients to assess whether CPAP treatment in OSA patients consistently restores physiological nocturnal BP fall and adjusts resting and circadian heart rate.
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Affiliation(s)
- Carlos A Feldstein
- a Hospital de Clínicas José de San Martín, Department of Internal Medicine , Hypertension Program, University of Buenos Aires, Ciudad Autónoma de Buenos Aires , Argentina
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111
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Rotenberg BW, Vicini C, Pang EB, Pang KP. Reconsidering first-line treatment for obstructive sleep apnea: a systematic review of the literature. J Otolaryngol Head Neck Surg 2016; 45:23. [PMID: 27048606 PMCID: PMC4822285 DOI: 10.1186/s40463-016-0136-4] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 03/30/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Continuous positive airway pressure (CPAP) is typically recommended as first line therapy for obstructive sleep apnea, but the adherence rate of CPAP is problematic. This study's objective was to systematically review the literature relating to CPAP as first line therapy for OSA and compare it to surgical literature on the same topic. METHODS A systematic review was conducted according to PRISMA guidelines, examining Medline-Ovid, Embase, and Pubmed databases. The primary search objective was to identify all papers reporting the results of (1) randomized clinical trials (RCT) of CPAP for the treatment of adults with OSA; and (2) both randomized and non-randomized clinical trials and case series on the surgical treatment of OSA in adults. A PhD-level biostatistician first screened papers, and then those that met study criteria were retrieved and analyzed using standardized forms for each author. The primary outcomes were adherence rates of CPAP. RESULTS A total of 82 controlled clinical trials for CPAP and 69 controlled and non-controlled surgery trials were identified for analysis. Variation in CPAP use within reported RCT trials were identified, and the majority of patients in the studies would eventually be considered non-adherent to CPAP. CONCLUSIONS When considering the numerous patient-related factors that come into play when CPAP is prescribed, the concept of CPAP as gold-standard therapy for OSA should be reconsidered. In many cases surgery can provide a better overall outcome. This study's results suggest that certain patients with OSA may be managed more effectively with surgery than CPAP, without confounding issues of treatment adherence.
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Affiliation(s)
- Brian W Rotenberg
- Department of Otolaryngology-Head and Neck Surgery, Western University, London, Ontario, Canada. .,St. Joseph's Hospital, Room B2-501, 268 Grosvenor Street, London, ON, N6A 4V2, Canada.
| | - Claudio Vicini
- Head & Neck Department, ASL of Romagna, ENT and Oral Surgery Unit, Morgagni-Pierantoni Hospital (Forlì), Ospedale degli Infermi (Faenza), Forlì, Italy
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112
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Geovanini GR, Pereira AC, Gowdak LHW, Dourado LOC, Poppi NT, Venturini G, Drager LF, Lorenzi-Filho G. Obstructive sleep apnoea is associated with myocardial injury in patients with refractory angina. Heart 2016; 102:1193-9. [DOI: 10.1136/heartjnl-2015-309009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 03/07/2016] [Indexed: 11/04/2022] Open
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113
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Maeder MT, Schoch OD, Rickli H. A clinical approach to obstructive sleep apnea as a risk factor for cardiovascular disease. Vasc Health Risk Manag 2016; 12:85-103. [PMID: 27051291 PMCID: PMC4807890 DOI: 10.2147/vhrm.s74703] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Obstructive sleep apnea (OSA) is associated with cardiovascular risk factors, cardiovascular diseases, and increased mortality. Epidemiological studies have established these associations, and there are now numerous experimental and clinical studies which have provided information on the possible underlying mechanisms. Mechanistic proof-of-concept studies with surrogate endpoints have been performed to demonstrate that treatment of OSA by continuous positive airway pressure (CPAP) has the potential to reverse or at least to attenuate not only OSA but also the adverse cardiovascular effects associated with OSA. However, no randomized studies have been performed to demonstrate that treatment of OSA by CPAP improves clinical outcomes in patients with cardiovascular risk factors and/or established cardiovascular disease and concomitant OSA. In the present review, we summarize the current knowledge on the role of OSA as a potential cardiovascular risk factor, the impact of OSA on cardiac function, the role of OSA as a modifier of the course of cardiovascular diseases such as coronary artery disease, atrial fibrillation, and heart failure, and the insights from studies evaluating the impact of CPAP therapy on the cardiovascular features associated with OSA.
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Affiliation(s)
- Micha T Maeder
- Department of Cardiology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Otto D Schoch
- Department of Respiratory Medicine, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Hans Rickli
- Department of Cardiology, Kantonsspital St Gallen, St Gallen, Switzerland
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114
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Paz Y Mar HL, Hazen SL, Tracy RP, Strohl KP, Auckley D, Bena J, Wang L, Walia HK, Patel SR, Mehra R. Effect of Continuous Positive Airway Pressure on Cardiovascular Biomarkers: The Sleep Apnea Stress Randomized Controlled Trial. Chest 2016; 150:80-90. [PMID: 26997243 DOI: 10.1016/j.chest.2016.03.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 02/26/2016] [Accepted: 03/01/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Although existing research highlights the relationship of OSA and cardiovascular disease, the effect of OSA treatment on cardiovascular biomarkers remains unclear. We evaluated the effect of OSA treatment on oxidative stress/inflammation measures. METHODS We conducted a parallel, randomized controlled trial in moderate to severe OSA (apnea-hypopnea index ≥ 15) patients to examine effects of 2-month CPAP vs sham-CPAP on the primary outcome of oxidative stress/inflammation (F2-isoprostanes: ng/mg) and myeloperoxidase: pmol/L) and secondary oxidative stress measures. Exploratory secondary analyses included vascular and systemic inflammation markers. Linear models adjusted for baseline values examined effect of CPAP on biomarker change (least squares means, 95% CI) including secondary stratified analyses examining CPAP adherence and degree of hypoxia. RESULTS Of 153 participants, 76 were randomized to CPAP and 77 to sham-CPAP. In an intent-to-treat analyses, no significant change was observed in the sham and CPAP groups respectively: F2-isoprostanes (-0.02 [-0.12 to 0.10] vs -0.08 [-0.18 to 0.03]) or myeloperoxidase (-3.33 [-17.02 to 10.37] vs -5.15 [-18.65 to 8.35]), nor other oxidative markers; findings that persisted in analyses stratified by adherence and hypoxia. Exploratory analyses revealed percentage reduction of soluble IL-6 receptor (ng/mL) levels (-0.04 [-0.08 to -0.01] vs 0.02 [-0.02 to 0.06], P = .019) and augmentation index (%) (-6.49 [-9.32 to -3.65] vs 0.44 [-2.22 to 3.10], P < .001) with CPAP compared with sham, respectively. CONCLUSIONS In moderate to severe OSA, 2-month CPAP vs sham did not reduce oxidative stress despite consideration of a broad range of measures, positive airway pressure adherence, and hypoxia burden. These findings suggest that nonoxidative stress pathways primarily modulate OSA-related cardiovascular consequences. TRIAL REGISTRATION ClinicalTrials.govNCT00607893.
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Affiliation(s)
- Hugo L Paz Y Mar
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Stanley L Hazen
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Russell P Tracy
- Departments of Biochemistry and Pathology, University of Vermont, Burlington, VT
| | - Kingman P Strohl
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH
| | - Dennis Auckley
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, MetroHealth Medical Center, Cleveland, OH
| | - James Bena
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Lu Wang
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Harneet K Walia
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Sanjay R Patel
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Reena Mehra
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, OH; Department of Molecular Cardiology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH.
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115
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Fatureto-Borges F, Lorenzi-Filho G, Drager LF. Effectiveness of continuous positive airway pressure in lowering blood pressure in patients with obstructive sleep apnea: a critical review of the literature. Integr Blood Press Control 2016; 9:43-7. [PMID: 27051313 PMCID: PMC4803254 DOI: 10.2147/ibpc.s70402] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Obstructive sleep apnea (OSA) is an extremely common comorbid condition in patients with hypertension, with a prevalence of ~50%. There is growing evidence suggesting that OSA is a secondary cause of hypertension, associated with both poor blood pressure (BP) control and target organ damage in patients with hypertension. The application of continuous positive airway pressure (CPAP) during sleep is the gold standard treatment of moderate- to-severe OSA and very effective in abolishing obstructive respiratory events. However, several meta-analyses showed that the overall impact of CPAP on BP is modest (~2 mmHg). There are several potential reasons for this disappointing finding, including the heterogeneity of patients studied (normotensive patients, controlled, and uncontrolled patients with hypertension), non-ideal CPAP compliance, clinical presentation (there is some evidence that the positive impact of CPAP on lowering BP is more evident in sleepy patients), and the multifactorial nature of hypertension. In this review, we performed a critical analysis of the literature evaluating the impact of CPAP on BP in several subgroups of patients. We finally discussed perspectives in this important research area, including the urgent need to identify predictors of BP response to CPAP and the importance of precision medicine in this scenario.
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Affiliation(s)
- Fernanda Fatureto-Borges
- Hypertension Unit, Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Geraldo Lorenzi-Filho
- Sleep Laboratory, Pulmonary Division, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Luciano F Drager
- Hypertension Unit, Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil; Hypertension Unit, Renal Division, University of Sao Paulo Medical School, Sao Paulo, Brazil
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116
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Parra O, Arboix A. Stroke and sleep-disordered breathing: A relationship under construction. World J Clin Cases 2016; 4:33-37. [PMID: 26881189 PMCID: PMC4733474 DOI: 10.12998/wjcc.v4.i2.33] [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: 06/17/2015] [Revised: 10/09/2015] [Accepted: 12/11/2015] [Indexed: 02/05/2023] Open
Abstract
The association between sleep-disordered breathing (SDB) and cardiovascular risk has been the focus of attention in recent years. Sleep disorders are emerging risk factors for cardiovascular disease and have been related to the whole spectrum of stroke, including transient ischemic attack, ischemic cerebral infarction and intracerebral haemorrhage. It has been shown that lacunar stroke or lacunar infarctions affecting the internal capsule or the protuberance are associated with a higher frequency of SDB. Acute stroke patients with associated SDB have a worse prognosis and a higher mortality as compared to patients with first-ever stroke without SDB. Preliminary studies provide evidence of the usefulness of treatment with continuous positive airway pressure when SDB is present in stroke patients.
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Pleister A, Khayat RN. Does Treating Sleep Apnea Reduce Heart Failure Risks? CURRENT CARDIOVASCULAR RISK REPORTS 2016. [DOI: 10.1007/s12170-016-0488-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Coloma Navarro R, Jiménez Caballero PE, Vega G, Ayo-Martín O, Segura Martín T. Cerebral hemodynamics is altered in patients with sleep apnea/hypopnea syndrome. SPRINGERPLUS 2016; 5:51. [PMID: 26835231 PMCID: PMC4720628 DOI: 10.1186/s40064-016-1691-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 01/08/2016] [Indexed: 11/10/2022]
Abstract
According to recent epidemiologic studies, patients with sleep apnea/hypopnea syndrome (SAHS) are at increased risk of cardiovascular diseases, including stroke. However, the mechanisms are not well defined. Nocturnal apneas can trigger acute cerebral ischemia in predisposed patients and impaired vasodilatation is present in SAHS, but few studies have explored vascular cerebral dysfunction and often gave inconclusive results. The aims of our study were to assess whether patients with SAHS have impairment of cerebral hemodynamics with respect to controls, and to investigate a possible relationship with clinical data. We studied two groups, one of 76 SAHS patients and another one of 76 non-SAHS subjects matched for age, sex and main cardiovascular risk factors. All participants underwent a daytime transcranial Doppler study of right middle cerebral artery to record cerebral blood flow velocity and cerebrovascular reactivity by means of breath-holding test (BHT). SAHS patients have a reduction in mean cerebral blood flow velocity (MFV) (52 ± 9 vs 60 ± 12 cms/s, p < 0.001) and BHT (31 ± 12 vs 36 ± 11 %, p = 0.005) when compared to non-SAHS controls. Moreover, MFV correlated negatively with the presence of coronary disease, and BHT with female sex and arterial pressure. On the other hand, in the SAHS group, MFV correlated negatively with oxygen desaturation severity. Patients with SAHS have impaired MFV and cerebrovascular reactivity when compared to controls. Interestingly, poorly controlled or unknown hypertension and severe nocturnal hypoxemia caused additional cerebral hemodynamic disturbances to these patients.
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Affiliation(s)
- R Coloma Navarro
- Servicio de Neumología, Complejo Hospitalario Universitario, C/Hermanos Falcó, s/n, 02006 Albacete, Spain
| | | | - G Vega
- Unidad de Cuidados Intensivos, Hospital de la Princesa, Madrid, Spain
| | - O Ayo-Martín
- Servicio de Neurología, Complejo Hospitalario Universitario, Albacete, Spain
| | - T Segura Martín
- Servicio de Neurología, Complejo Hospitalario Universitario, Albacete, Spain
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Emin M, Wang G, Castagna F, Rodriguez-Lopez J, Wahab R, Wang J, Adams T, Wei Y, Jelic S. Increased internalization of complement inhibitor CD59 may contribute to endothelial inflammation in obstructive sleep apnea. Sci Transl Med 2016; 8:320ra1. [PMID: 26738794 PMCID: PMC5485919 DOI: 10.1126/scitranslmed.aad0634] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Obstructive sleep apnea (OSA), characterized by intermittent hypoxia (IH) during transient cessation of breathing, triples the risk for cardiovascular diseases. We used a phage display peptide library as an unbiased approach to investigate whether IH, which is specific to OSA, activates endothelial cells (ECs) in a distinctive manner. The target of a differentially bound peptide on ECs collected from OSA patients was identified as CD59, a major complement inhibitor that protects ECs from the membrane attack complex (MAC). A decreased proportion of CD59 is located on the EC surface in OSA patients compared with controls, suggesting reduced protection against complement attack. In vitro, IH promoted endothelial inflammation predominantly via augmented internalization of CD59 and consequent MAC deposition. Increased internalization of endothelial CD59 in IH appeared to be cholesterol-dependent and was reversed by statins in a CD59-dependent manner. These studies suggest that reduced complement inhibition may mediate endothelial inflammation and increase vascular risk in OSA patients.
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Affiliation(s)
- Memet Emin
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
| | - Gang Wang
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
| | - Francesco Castagna
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
| | - Josanna Rodriguez-Lopez
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
| | - Romina Wahab
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
| | - Jing Wang
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
| | - Tessa Adams
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
| | - Ying Wei
- Division of Biostatistics, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
| | - Sanja Jelic
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA,Corresponding author.
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Gras E, Belaidi E, Briançon-Marjollet A, Pépin JL, Arnaud C, Godin-Ribuot D. Endothelin-1 mediates intermittent hypoxia-induced inflammatory vascular remodeling through HIF-1 activation. J Appl Physiol (1985) 2015; 120:437-43. [PMID: 26679613 DOI: 10.1152/japplphysiol.00641.2015] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 12/16/2015] [Indexed: 02/04/2023] Open
Abstract
Obstructive sleep apnea (OSA) is a major risk factor for cardiovascular mortality, and apnea-induced intermittent hypoxia (IH) is known to promote various cardiovascular alterations such as vascular remodeling. However, the mechanisms that underlie IH remain incompletely investigated. We previously demonstrated that the hypoxia-inducible factor-1 (HIF-1) and endothelin-1 (ET-1) are involved in arterial hypertension and myocardial susceptibility to infarction induced by IH. Thus the objective of the present study was to investigate whether both ET-1 and HIF-1 were also involved in the vascular inflammatory remodeling induced by IH. Mice partially deficient for the Hif1α gene (HIF-1α(+/-)) and their wild-type equivalents, as well as C57BL/6J mice, treated or not with bosentan, a dual endothelin receptor antagonist, were exposed to IH or normoxia for 2 wk, 8 h/day. Splenocyte proliferative and secretory capacities, aortic nuclear factor-κB (NF-κB) and HIF-1 activities, and expression of cytokines and intima-media thickness (IMT) were measured. IH induced a systemic and aortic inflammation characterized by an increase in splenocyte proliferative and secretory capacities, aortic NF-κB activity, and cytokine expression in the aortic wall. This was accompanied by an increase in IMT. These modifications were prevented in HIF-1α(+/-) and bosentan-treated mice. The results of this study suggest that ET-1 is a major contributor to the vascular inflammatory remodeling induced by OSA-related IH, probably through HIF-1-dependent activation of NF-κB.
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Affiliation(s)
- Emmanuelle Gras
- Université Grenoble Alpes, Laboratoire HP2, Grenoble, France; INSERM, U1042, Grenoble, France; and
| | - Elise Belaidi
- Université Grenoble Alpes, Laboratoire HP2, Grenoble, France; INSERM, U1042, Grenoble, France; and
| | - Anne Briançon-Marjollet
- Université Grenoble Alpes, Laboratoire HP2, Grenoble, France; INSERM, U1042, Grenoble, France; and
| | - Jean-Louis Pépin
- Université Grenoble Alpes, Laboratoire HP2, Grenoble, France; INSERM, U1042, Grenoble, France; and CHU de Grenoble, Grenoble, France
| | - Claire Arnaud
- Université Grenoble Alpes, Laboratoire HP2, Grenoble, France; INSERM, U1042, Grenoble, France; and
| | - Diane Godin-Ribuot
- Université Grenoble Alpes, Laboratoire HP2, Grenoble, France; INSERM, U1042, Grenoble, France; and
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Marsch E, Theelen TL, Janssen BJA, Briede JJ, Haenen GR, Senden JMG, van Loon LJC, Poeze M, Bierau J, Gijbels MJ, Daemen MJAP, Sluimer JC. The effect of prolonged dietary nitrate supplementation on atherosclerosis development. Atherosclerosis 2015; 245:212-21. [PMID: 26724532 DOI: 10.1016/j.atherosclerosis.2015.11.031] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 11/13/2015] [Accepted: 11/26/2015] [Indexed: 12/29/2022]
Abstract
BACKGROUND Short term dietary nitrate or nitrite supplementation has nitric oxide (NO)-mediated beneficial effects on blood pressure and inflammation and reduces mitochondrial oxygen consumption, possibly preventing hypoxia. As these processes are implicated in atherogenesis, dietary nitrate was hypothesized to prevent plaque initiation, hypoxia and inflammation. AIMS Study prolonged nitrate supplementation on atherogenesis, hypoxia and inflammation in low density lipoprotein receptor knockout mice (LDLr(-/-)). METHODS LDLr(-/-) mice were administered sodium-nitrate or equimolar sodium-chloride in drinking water alongside a western-type diet for 14 weeks to induce atherosclerosis. Plasma nitrate, nitrite and hemoglobin-bound nitric oxide were measured by chemiluminescence and electron parametric resonance, respectively. RESULTS Plasma nitrate levels were elevated after 14 weeks of nitrate supplementation (NaCl: 40.29 ± 2.985, NaNO3: 78.19 ± 6.837, p < 0.0001). However, prolonged dietary nitrate did not affect systemic inflammation, hematopoiesis, erythropoiesis and plasma cholesterol levels, suggesting no severe side effects. Surprisingly, neither blood pressure, nor atherogenesis were altered. Mechanistically, plasma nitrate and nitrite were elevated after two weeks (NaCl: 1.0 ± 0.2114, NaNO3: 3.977 ± 0.7371, p < 0.0001), but decreased over time (6, 10 and 14 weeks). Plasma nitrite levels even reached baseline levels at 14 weeks (NaCl: 0.7188 ± 0.1072, NaNO3: 0.9723 ± 0.1279 p = 0.12). Also hemoglobin-bound NO levels were unaltered after 14 weeks. This compensation was not due to altered eNOS activity or conversion into peroxynitrite and other RNI, suggesting reduced nitrite formation or enhanced nitrate/nitrite clearance. CONCLUSION Prolonged dietary nitrate supplementation resulted in compensation of nitrite and NO levels and did not affect atherogenesis or exert systemic side effects.
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Affiliation(s)
- Elke Marsch
- Department Pathology, CARIM, MUMC, Maastricht, The Netherlands
| | | | - Ben J A Janssen
- Department Pharmacology, CARIM, Maastricht University, Maastricht, The Netherlands
| | - Jacco J Briede
- Department Toxicogenomics, Maastricht University, Maastricht, The Netherlands
| | - Guido R Haenen
- Department Toxicology, Maastricht University, Maastricht, The Netherlands
| | - Joan M G Senden
- NUTRIM, School for Nutrition, Toxicology and Metabolism, MUMC, Maastricht, The Netherlands
| | - Lucas J C van Loon
- NUTRIM, School for Nutrition, Toxicology and Metabolism, MUMC, Maastricht, The Netherlands
| | - Martijn Poeze
- Department Surgery/Intensive Care Medicine, MUMC, Maastricht, The Netherlands
| | - Jörgen Bierau
- Department of Clinical Genetics, MUMC, Maastricht, The Netherlands
| | - Marion J Gijbels
- Department Pathology, CARIM, MUMC, Maastricht, The Netherlands; Department Molecular Genetics, CARIM, Maastricht University, Maastricht, The Netherlands; Department Medical Biochemistry, AMC, Amsterdam, The Netherlands
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Polotsky VY, Bevans-Fonti S, Grigoryev DN, Punjabi NM. Intermittent Hypoxia Alters Gene Expression in Peripheral Blood Mononuclear Cells of Healthy Volunteers. PLoS One 2015; 10:e0144725. [PMID: 26657991 PMCID: PMC4684377 DOI: 10.1371/journal.pone.0144725] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 11/22/2015] [Indexed: 12/11/2022] Open
Abstract
Obstructive sleep apnea is associated with high cardiovascular morbidity and mortality. Intermittent hypoxia of obstructive sleep apnea is implicated in the development and progression of insulin resistance and atherosclerosis, which have been attributed to systemic inflammation. Intermittent hypoxia leads to pro-inflammatory gene up-regulation in cell culture, but the effects of intermittent hypoxia on gene expression in humans have not been elucidated. A cross-over study was performed exposing eight healthy men to intermittent hypoxia or control conditions for five hours with peripheral blood mononuclear cell isolation before and after exposures. Total RNA was isolated followed by gene microarrays and confirmatory real time reverse transcriptase PCR. Intermittent hypoxia led to greater than two fold up-regulation of the pro-inflammatory gene toll receptor 2 (TLR2), which was not increased in the control exposure. We hypothesize that up-regulation of TLR2 by intermittent hypoxia may lead to systemic inflammation, insulin resistance and atherosclerosis in patients with obstructive sleep apnea.
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Affiliation(s)
- Vsevolod Y. Polotsky
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Shannon Bevans-Fonti
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Dmitry N. Grigoryev
- Department of Medicine, Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Naresh M. Punjabi
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
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Obstructive Sleep Apnea, Hypertension, and Their Additive Effects on Atherosclerosis. Biochem Res Int 2015; 2015:984193. [PMID: 26697221 PMCID: PMC4678058 DOI: 10.1155/2015/984193] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Accepted: 09/29/2015] [Indexed: 01/30/2023] Open
Abstract
Background and Aims. It is widely accepted that obstructive sleep apnea (OSA) is independently associated with atherosclerosis. Similar to OSA, hypertension (HTN) is a condition associated with atherosclerosis. However, to date, the impact of the simultaneous presence of OSA and HTN on the risk of atherosclerosis has not been extensively studied. The aim of this study was to evaluate the consequences of the coexistence of OSA and HTN on carotid intima-media thickness (IMT) and on inflammatory markers of atherosclerosis (such as interleukin- [IL-] 6 and pentraxin- [PTX-] 3). Methods. The study design allowed us to define 4 groups: (1) controls (n = 30); (2) OSA patients without HTN (n = 30); (3) HTN patients without OSA (n = 30); (4) patients with OSA and HTN (n = 30). In the morning after portable monitoring (between 7 am and 8 am), blood samples were collected, and carotid IMT was measured. Results. Carotid IMT, IL-6, and PTX-3 in OSA normotensive patients and in non-OSA HTN subjects were significantly higher compared to control subjects; in addition, in OSA hypertensive patients they were significantly increased compared to OSA normotensive, non-OSA HTN, or control subjects. Conclusions. OSA and HTN have an additive role in the progression of carotid atherosclerosis and in blood levels of inflammatory markers for atherosclerosis, such as interleukin-6 and pentraxin-3.
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124
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Duggan E, Collop N. Building a Perioperative Sleep Apnea Algorithm: Applying the Literature to Your Practice. Bariatr Surg Pract Patient Care 2015. [DOI: 10.1089/bari.2015.0025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Elizabeth Duggan
- Department of Medicine, Emory University Hospital, Atlanta, Georgia
| | - Nancy Collop
- Department of Medicine, Emory University Hospital, Atlanta, Georgia
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125
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Chami HA, Vasan RS, Larson MG, Benjamin EJ, Mitchell GF, Gottlieb DJ. The association between sleep-disordered breathing and aortic stiffness in a community cohort. Sleep Med 2015; 19:69-74. [PMID: 27198950 DOI: 10.1016/j.sleep.2015.11.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 10/20/2015] [Accepted: 11/12/2015] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Sleep-disordered breathing is associated with hypertension and cardiovascular disease. Increased aortic stiffness is one possible linking mechanism. We evaluated the association between sleep-disordered breathing and aortic stiffness in a community-based sample. METHODS Our community-based cross-sectional observational study included 381 participants from the Framingham Heart Study (55% women, mean age 58.0 S.D. = 9.4 years, 51% ethnic minorities). Polysomnographically derived apnea-hypopnea index and CT90% (cumulative % sleep time with oxyhemoglobin saturation <90%) quantified sleep-disordered breathing severity. Carotid-femoral pulse wave velocity, the gold-standard measure of aortic stiffness, was calculated using arterial applanation tonometry-derived waveforms and body surface measured transit distance. We assessed associations between sleep-disordered breathing and carotid-femoral pulse wave velocity using multivariable regression. We adjusted for age, sex, race, body mass index, diabetes, alcohol consumption, hormone replacement therapy, cholesterol/high-density lipoprotein, lipid-lowering therapy, anti-hypertensive medication, smoking, hypertension, and prevalent cardiovascular disease. RESULTS After multivariable adjustment, carotid-femoral pulse wave velocity was associated with both apnea-hypopnea index (β = 0.03, 95% CI: 0.002-0.07, p= 0.04) and CT90% (β = 0.05, 95% CI: 0.005-0.1, p= 0.03). The adjusted mean carotid-femoral pulse wave velocity was 9.43 (95% CI: 9.12-9.74), 9.76 (95% CI: 9.25-10.26), and 10.15 (95% CI: 9.37-10.92) m/s, respectively, in subjects with apnea-hypopnea index <5, 5-14.9, and ≥15 events/h. CONCLUSIONS In a community-based sample of middle aged and older men and women, sleep-disordered breathing was associated with increased carotid-femoral pulse wave velocity, a strong predictor of cardiovascular risk.
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Affiliation(s)
- Hassan A Chami
- Department of Medicine, American University of Beirut, Beirut, Lebanon; The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA.
| | - Ramachandran S Vasan
- Sections of Cardiovascular and Preventive Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA; Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Martin G Larson
- Department of Mathematics and Statistics, Boston University, Boston, MA, USA; Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Emelia J Benjamin
- Sections of Cardiovascular and Preventive Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA; Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | | | - Daniel J Gottlieb
- VA Boston Healthcare System, Boston, MA, USA; Departments of Medicine and Neurology, Brigham & Women's Hospital, Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA
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Comparison of the effects of continuous positive airway pressure and mandibular advancement devices on sleepiness in patients with obstructive sleep apnoea: a network meta-analysis. THE LANCET RESPIRATORY MEDICINE 2015; 3:869-78. [PMID: 26497082 DOI: 10.1016/s2213-2600(15)00416-6] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 09/26/2015] [Accepted: 09/30/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Excessive daytime sleepiness is the most important symptom of obstructive sleep apnoea and can affect work productivity, quality of life, and the risk of road traffic accidents. We aimed to quantify the effects of the two main treatments for obstructive sleep apnoea (continuous positive airway pressure and mandibular advancement devices) on daytime sleepiness and to establish predictors of response to continuous positive airway pressure. METHODS We searched MEDLINE and the Cochrane Library from inception to May 31, 2015, to identify randomised controlled trials comparing the effects of continuous positive airway pressure, mandibular advancement devices or an inactive control (eg, placebo or no treatment) on the Epworth Sleepiness Scale (ESS, range 0-24 points) in patients with obstructive sleep apnoea. We did a network meta-analysis using multivariate random-effects meta-regression to assess the effect of each treatment on ESS. We used meta-regression to assess the association of the reported effects of continuous positive airway pressure versus inactive controls with the characteristics of trials and their risk of bias. FINDINGS We included 67 studies comprising 6873 patients in the meta-analysis. Compared with an inactive control, continuous positive airway pressure was associated with a reduction in ESS score of 2·5 points (95% CI 2·0-2·9) and mandibular advancement devices of 1·7 points (1·1-2·3). We estimated that, on average, continuous positive airway pressure reduced the ESS score by a further 0·8 points compared with mandibular advancement devices (95% CI 0·1-1·4; p=0·015). However, there was a possibility of publication bias in favour of continuous positive airway pressure that might have resulted in this difference. We noted no evidence that studies reporting higher continuous positive airway pressure adherence also reported larger treatment effects (p=0·70). INTERPRETATION Continuous positive airway pressure and mandibular advancement devices are effective treatments for reducing daytime sleepiness in patients with obstructive sleep apnoea. Continuous positive airway pressure seemed to be a more effective treatment than mandibular advancement devices, and had an increasingly larger effect in more severe or sleepier obstructive sleep apnoea patients when compared with inactive controls. However, mandibular advancement devices are an effective alternative treatment should continuous positive airway pressure not be tolerated. FUNDING Swiss National Science Foundation and the University of Zurich Clinical Research Priority Program Sleep and Health.
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127
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Furlan SF, Braz CV, Lorenzi-Filho G, Drager LF. Management of Hypertension in Obstructive Sleep Apnea. Curr Cardiol Rep 2015; 17:108. [DOI: 10.1007/s11886-015-0663-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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128
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Hoyos CM, Yee BJ, Wong KK, Grunstein RR, Phillips CL. Treatment of Sleep Apnea With CPAP Lowers Central and Peripheral Blood Pressure Independent of the Time-of-Day: A Randomized Controlled Study. Am J Hypertens 2015; 28:1222-8. [PMID: 25820243 DOI: 10.1093/ajh/hpv023] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 01/26/2015] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is a risk factor for hypertension and randomized controlled trials have shown that OSA treatment with continuous positive airway pressure (CPAP) reduces peripheral blood pressure and arterial stiffness. Arterial stiffness is known to augment central aortic blood pressure independent of peripheral brachial blood pressure. Currently, it is unclear whether the reduction in blood pressure with CPAP is similar between central and peripheral sites. It is also unknown whether there are any time-of-day influences on central blood pressure changes after CPAP. METHODS Thirty-eight patients received therapeutic and sham CPAP in random order for 8 weeks each with an intervening 1-month washout. Peripheral and central blood pressure and arterial stiffness (augmentation index and time to reflection) were measured by pulse wave analysis at end-of-treatment visits. Measurements were taken in the afternoon (~2 pm) and the next morning (~9 am). RESULTS Compared to sham, CPAP significantly reduced central systolic (mean difference: -4.1 mm Hg; P = 0.003), central diastolic (-3.9 mm Hg; P = 0.0009), peripheral systolic (-4.1mm Hg; P = 0.004), and peripheral diastolic (-3.8 mm Hg; P = 0.001) blood pressure. These effects were not influenced by time-of-day. Time to reflection was improved with CPAP compared to sham (3.7 ms; P = 0.01). There was no overall difference in augmentation index however when examined by time-of-day, a modest reduction with CPAP was observed in the morning (-2.5%; P = 0.03) but not in the evening (0.12%; P = 0.91). CONCLUSION CPAP reduces both central and peripheral blood pressure independent of the time-of-day. In contrast, modest improvements in conduit arterial stiffness after CPAP may only occur in the morning.
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Affiliation(s)
- Camilla M Hoyos
- Sleep and Circadian Group, Centre for Integrated Research and Understanding of Sleep, Woolcock Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia; Discipline of Sleep Medicine, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia;
| | | | | | | | - Craig L Phillips
- Sleep and Circadian Group, Centre for Integrated Research and Understanding of Sleep, Woolcock Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia; Discipline of Sleep Medicine, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia; Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia
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129
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Floras JS. Obstructive sleep apnea syndrome, continuous positive airway pressure and treatment of hypertension. Eur J Pharmacol 2015; 763:28-37. [DOI: 10.1016/j.ejphar.2015.06.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 05/23/2015] [Accepted: 06/15/2015] [Indexed: 11/30/2022]
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Antic NA, Heeley E, Anderson CS, Luo Y, Wang J, Neal B, Grunstein R, Barbe F, Lorenzi-Filho G, Huang S, Redline S, Zhong N, McEvoy RD. The Sleep Apnea cardioVascular Endpoints (SAVE) Trial: Rationale, Ethics, Design, and Progress. Sleep 2015; 38:1247-57. [PMID: 25669180 DOI: 10.5665/sleep.4902] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Accepted: 11/22/2014] [Indexed: 01/13/2023] Open
Abstract
ABSTRACT The Sleep Apnea cardioVascular Endpoints (SAVE) study is an ongoing investigator-initiated and conducted, international, multicenter, open, blinded endpoint, randomized controlled trial that was designed to determine whether treatment of obstructive sleep apnea (OSA) with continuous positive airways pressure (CPAP) can reduce the risk of serious cardiovascular (CV) events in patients with established CV disease (clinical trial registration NCT00738179). The results of this study will have important implications for the provision of health care to patients with sleep apnea around the world. The SAVE study has brought together respiratory, sleep, CV and stroke clinicians-scientists in an interdisciplinary collaboration with industry and government sponsorship to conduct an ambitious clinical trial. Following its launch in Australia and China in late 2008, the recruitment network expanded across 89 sites that included New Zealand, India, Spain, USA, and Brazil for a total of 2,717 patients randomized by December 2013. These patients are being followed until December 2015 so that the average length of follow-up of the cohort will be over 4 y. This article describes the rationale for the SAVE study, considerations given to the design including how various cultural and ethical challenges were addressed, and progress in establishing and maintaining the recruitment network, patient follow-up, and adherence to CPAP and procedures. The assumptions underlying the original trial sample size calculation and why this was revised downward in 2012 are also discussed. CLINICAL TRIALS REGISTRATION NUMBER NCT00738179. AUSTRALIA NEW ZEALAND CLINICAL TRIALS REGISTRY NUMBER ACTRN12608000409370.
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Affiliation(s)
- Nick A Antic
- The Adelaide Institute for Sleep Health, Repatriation General Hospital, Daw Park, SA, Australia.,School of Medicine, Faculty of Medicine, Nursing and Health Sciences, Flinders University, Bedford Park, SA, Australia
| | - Emma Heeley
- School of Medicine, Faculty of Medicine, Nursing and Health Sciences, Flinders University, Bedford Park, SA, Australia.,The George Institute for Global Health, The University of Sydney, New South Wales, Australia
| | - Craig S Anderson
- School of Medicine, Faculty of Medicine, Nursing and Health Sciences, Flinders University, Bedford Park, SA, Australia.,The George Institute for Global Health, The University of Sydney, New South Wales, Australia.,Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Yuanming Luo
- State Key Laboratory of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jiguang Wang
- Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai, China
| | - Bruce Neal
- School of Medicine, Faculty of Medicine, Nursing and Health Sciences, Flinders University, Bedford Park, SA, Australia.,The George Institute for Global Health, The University of Sydney, New South Wales, Australia.,Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Imperial College, London, United Kingdom
| | - Ron Grunstein
- Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Centre for Integrated Research and Understanding of Sleep Woolcock Institute of Medical Research, University of Sydney, New South Wales, Australia
| | - Ferran Barbe
- School of Medicine at the University of Lleida Barcelona, Spain
| | | | | | - Susan Redline
- Department of Medicine and Division of Sleep, Brigham and Women's Hospital and Beth Israel Medical Center, Boston, MA
| | - Nanshan Zhong
- State Key Laboratory of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - R Doug McEvoy
- The Adelaide Institute for Sleep Health, Repatriation General Hospital, Daw Park, SA, Australia.,School of Medicine, Faculty of Medicine, Nursing and Health Sciences, Flinders University, Bedford Park, SA, Australia
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Drager LF, Polotsky VY, O'Donnell CP, Cravo SL, Lorenzi-Filho G, Machado BH. Translational approaches to understanding metabolic dysfunction and cardiovascular consequences of obstructive sleep apnea. Am J Physiol Heart Circ Physiol 2015; 309:H1101-11. [PMID: 26232233 DOI: 10.1152/ajpheart.00094.2015] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 07/22/2015] [Indexed: 12/17/2022]
Abstract
Obstructive sleep apnea (OSA) is known to be independently associated with several cardiovascular diseases including hypertension, myocardial infarction, and stroke. To determine how OSA can increase cardiovascular risk, animal models have been developed to explore the underlying mechanisms and the cellular and end-organ targets of the predominant pathophysiological disturbance in OSA-intermittent hypoxia. Despite several limitations in translating data from animal models to the clinical arena, significant progress has been made in our understanding of how OSA confers increased cardiovascular risk. It is clear now that the hypoxic stress associated with OSA can elicit a broad spectrum of pathological systemic events including sympathetic activation, systemic inflammation, impaired glucose and lipid metabolism, and endothelial dysfunction, among others. This review provides an update of the basic, clinical, and translational advances in our understanding of the metabolic dysfunction and cardiovascular consequences of OSA and highlights the most recent findings and perspectives in the field.
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Affiliation(s)
- Luciano F Drager
- Hypertension Unit, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil; Hypertension Unit, Renal Division, University of São Paulo Medical School, São Paulo, Brazil;
| | - Vsevolod Y Polotsky
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher P O'Donnell
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sergio L Cravo
- Department of Physiology, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, Brazil
| | - Geraldo Lorenzi-Filho
- Sleep Laboratory, Pulmonary Division, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil; and
| | - Benedito H Machado
- Department of Physiology, School of Medicine of Ribeirao Preto, University of São Paulo, São Paulo, Brazil
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132
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Toraldo DM, De Benedetto M, Scoditti E, De Nuccio F. Obstructive sleep apnea syndrome: coagulation anomalies and treatment with continuous positive airway pressure. Sleep Breath 2015; 20:457-65. [PMID: 26169715 DOI: 10.1007/s11325-015-1227-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 06/22/2015] [Accepted: 06/29/2015] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Obstructive sleep apnea syndrome (OSAS) is a highly prevalent sleep disorder associated with severe cardiovascular events, morbidity and mortality. Recent evidence has highlighted OSAS as an independent risk factor for an excessive platelet activation and arterial thrombosis, but the underlying mechanisms have not yet been determined. Studies in cell culture and animal models have significantly increased our understanding of the mechanisms of inflammation in OSAS. Hypoxia is a critical pathophysiological element that leads to an intense sympathetic activity, in association with systemic inflammation, oxidative stress and procoagulant activity. While platelet dysfunction and/or hypercoagulability play an important role in the pathogenesis of vascular disease, there are limited studies on the potential role of blood viscosity in the development of vascular disease in OSAS. CONCLUSION Further studies are required to determine the precise role of hypercoagulability in the cardiovascular pathogenesis of OSAS, particularly its interaction with oxidative stress, thrombotic tendency and endothelial dysfunction. Nasal continuous positive airway pressure (nCPAP), the gold standard treatment for OSAS, not only significantly reduced apnea-hypopnoea indices but also markers of hypercoagulability, thus representing a potential mechanisms by which CPAP reduces the rate of cardiovascular morbidity and mortality in OSAS patients.
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Affiliation(s)
| | | | - Egeria Scoditti
- National Research Council (CNR), Institute of Clinical Physiology, Lecce, Italy
| | - Francesco De Nuccio
- Laboratory of Human Anatomy and Neuroscience, Department of Biological and Environmental Sciences and Technologies, University of Salento, Via Prov. le Lecce-Monteroni (Centro Ecotekne), 73100, Lecce, Italy.
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Abstract
Hypertension is a highly prevalent problem worldwide, affecting at least one third of the adult general population. Although the exact prevalence is uncertain, it is estimated that at least 15% to 20% of individuals with hypertension have resistant hypertension. Resistant hypertension has been shown to predict more adverse cardiovascular and renal outcomes. In 2003, the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure recognized obstructive sleep apnea (OSA) as an important cause of secondary hypertension. A large body of epidemiologic evidence has linked OSA to resistant hypertension, nondipping nocturnal blood pressure, as well as target organ damage, including left ventricular hypertrophy, arterial stiffness, and microalbuminuria. The importance of OSA as a risk factor for the development of hypertension independent of other confounding factors also was observed in a prospective longitudinal study. More importantly, OSA predicts an increased risk of adverse cardiovascular outcomes, mortality, and sudden cardiac death. This article discusses the associations between OSA and resistant hypertension and reviews the latest understanding on the pathophysiologic mechanisms of hypertension in OSA. Nocturnal continuous positive airway pressure therapy is regarded as the standard treatment for OSA. Prospective randomized controlled trials and meta-analyses of prospective randomized controlled trials within the past 10 years that have examined the effects of continuous positive airway pressure therapy on blood pressure control in patients with OSA with or without hypertension are reviewed and summarized. The majority of the trials suggest a modest but significant benefit on blood pressure control with continuous positive airway pressure therapy. Whether continuous positive airway pressure therapy may improve hard outcomes of patients with OSA and resistant hypertension warrants further investigation.
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134
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Hypertension and Sleep Apnea. Can J Cardiol 2015; 31:889-97. [DOI: 10.1016/j.cjca.2015.05.003] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 05/07/2015] [Accepted: 05/07/2015] [Indexed: 12/28/2022] Open
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Gaisl T, Bratton DJ, Kohler M. The impact of obstructive sleep apnoea on the aorta. Eur Respir J 2015; 46:532-44. [DOI: 10.1183/09031936.00029315] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 04/29/2015] [Indexed: 11/05/2022]
Abstract
Obstructive sleep apnoea (OSA) has been shown to be a causal factor in the pathogenesis of vascular dysfunction and hypertension, conditions which can promote dilation and subsequent aortic dissection and rupture. The objective of this review is to summarise the current literature on the possible association between OSA and aortic disease and delineate the underlying mechanisms.Relevant studies were found by searching for terms including “obstructive sleep apnoea” in combination with “aortic aneurysm, dissection, and dilation” in the MEDLINE and EMBASE databases.Observational studies consistently reported that OSA is highly prevalent among patients with aortic aneurysms and aortic dissections. Patients with co-occurring OSA and Marfan's syndrome as well as patients at the more severe end of the spectrum of OSA seem to be especially vulnerable to aortic disease.Several mechanisms are discussed concerning the link between OSA and aortic disease: nocturnal negative intrathoracic pressure surges leading to mechanical stretching of the aorta and ultimately aortic distension; arousal-induced reflex sympathetic activation with subsequent hypertension; and intermittent hypoxia associated with autonomic nervous system activation and consequently increased oxidative stress. Further well controlled studies are needed in order to define the exact role of OSA as a risk factor for aortic disease.
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Sharples L, Glover M, Clutterbuck-James A, Bennett M, Jordan J, Chadwick R, Pittman M, East C, Cameron M, Davies M, Oscroft N, Smith I, Morrell M, Fox-Rushby J, Quinnell T. Clinical effectiveness and cost-effectiveness results from the randomised controlled Trial of Oral Mandibular Advancement Devices for Obstructive sleep apnoea-hypopnoea (TOMADO) and long-term economic analysis of oral devices and continuous positive airway pressure. Health Technol Assess 2015; 18:1-296. [PMID: 25359435 DOI: 10.3310/hta18670] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Obstructive sleep apnoea-hypopnoea (OSAH) causes excessive daytime sleepiness (EDS), impairs quality of life (QoL) and increases cardiovascular disease and road traffic accident risks. Continuous positive airway pressure (CPAP) treatment is clinically effective but undermined by intolerance, and its cost-effectiveness is borderline in milder cases. Mandibular advancement devices (MADs) are another option, but evidence is lacking regarding their clinical effectiveness and cost-effectiveness in milder disease. OBJECTIVES (1) Conduct a randomised controlled trial (RCT) examining the clinical effectiveness and cost-effectiveness of MADs against no treatment in mild to moderate OSAH. (2) Update systematic reviews and an existing health economic decision model with data from the Trial of Oral Mandibular Advancement Devices for Obstructive sleep apnoea-hypopnoea (TOMADO) and newly published results to better inform long-term clinical effectiveness and cost-effectiveness of MADs and CPAP in mild to moderate OSAH. TOMADO A crossover RCT comparing clinical effectiveness and cost-effectiveness of three MADs: self-moulded [SleepPro 1™ (SP1); Meditas Ltd, Winchester, UK]; semibespoke [SleepPro 2™ (SP2); Meditas Ltd, Winchester, UK]; and fully bespoke [bespoke MAD (bMAD); NHS Oral-Maxillofacial Laboratory, Addenbrooke's Hospital, Cambridge, UK] against no treatment, in 90 adults with mild to moderate OSAH. All devices improved primary outcome [apnoea-hypopnoea index (AHI)] compared with no treatment: relative risk 0.74 [95% confidence interval (CI) 0.62 to 0.89] for SP1; relative risk 0.67 (95% CI 0.59 to 0.76) for SP2; and relative risk 0.64 (95% CI 0.55 to 0.76) for bMAD (p < 0.001). Differences between MADs were not significant. Sleepiness [as measured by the Epworth Sleepiness Scale (ESS)] was scored 1.51 [95% CI 0.73 to 2.29 (SP1)] to 2.37 [95% CI 1.53 to 3.22 (bMAD)] lower than no treatment (p < 0.001), with SP2 and bMAD significantly better than SP1. All MADs improved disease-specific QoL. Compliance was lower for SP1, which was unpopular at trial exit. At 4 weeks, all devices were cost-effective at £20,000/quality-adjusted life-year (QALY), with SP2 the best value below £39,800/QALY. META-ANALYSIS A MEDLINE, EMBASE and Science Citation Index search updating two existing systematic reviews (one from November 2006 and the other from June 2008) to August 2013 identified 77 RCTs in adult OSAH patients comparing MAD with conservative management (CM), MADs with CPAP or CPAP with CM. MADs and CPAP significantly improved AHI [MAD -9.3/hour (p < 0.001); CPAP -25.4/hour (p < 0.001)]. Effect difference between CPAP and MADs was 7.0/hour (p < 0.001), favouring CPAP. No trials compared CPAP with MADs in mild OSAH. MAD and CPAP reduced the ESS score similarly [MAD 1.6 (p < 0.001); CPAP 1.6 (p < 0.001)]. LONG-TERM COST-EFFECTIVENESS An existing model assessed lifetime cost-utility of MAD and CPAP in mild to moderate OSAH, using the revised meta-analysis to update input values. The TOMADO provided utility estimates, mapping ESS score to European Quality of Life-5 Dimensions three-level version for device cost-utility. Using SP2 as the standard device, MADs produced higher mean costs and mean QALYs than CM [incremental cost-effectiveness ratio (ICER) £6687/QALY]. From a willingness to pay (WTP) of £15,367/QALY, CPAP is cost-effective, although the likelihood of MADs (p = 0.48) and CPAP (p = 0.49) being cost-effective is very similar. Both were better than CM, but there was much uncertainty in the choice between CPAP and MAD (at a WTP £20,000/QALY, the probability of being the most cost-effective was 47% for MAD and 52% for CPAP). When SP2 lifespan increased to 18 months, the ICER for CPAP compared with MAD became £44,066. The ICER for SP1 compared with CM was £1552, and for bMAD compared with CM the ICER was £13,836. The ICER for CPAP compared with SP1 was £89,182, but CPAP produced lower mean costs and higher mean QALYs than bMAD. Differential compliance rates for CPAP reduces cost-effectiveness so MADs become less costly and more clinically effective with CPAP compliance 90% of SP2. CONCLUSIONS Mandibular advancement devices are clinically effective and cost-effective in mild to moderate OSAH. A semi-bespoke MAD is the appropriate first choice in most patients in the short term. Future work should explore whether or not adjustable MADs give additional clinical and cost benefits. Further data on longer-term cardiovascular risk and its risk factors would reduce uncertainty in the health economic model and improve precision of effectiveness estimates. TRIAL REGISTRATION This trial is registered as ISRCTN02309506. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 67. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Linda Sharples
- University of Leeds Clinical Trials Research Unit, Leeds, UK
| | - Matthew Glover
- Health Economics Research Unit, Brunel University, Uxbridge, UK
| | | | - Maxine Bennett
- Medical Research Council Biostatistics Unit, Cambridge, UK
| | - Jake Jordan
- Health Economics Research Unit, Brunel University, Uxbridge, UK
| | - Rebecca Chadwick
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK
| | - Marcus Pittman
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK
| | - Clare East
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK
| | - Malcolm Cameron
- Maxillofacial Unit, Addenbrooke's NHS Foundation Trust, Cambridge, UK
| | - Mike Davies
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK
| | - Nick Oscroft
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK
| | - Ian Smith
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK
| | - Mary Morrell
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Timothy Quinnell
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK
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137
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Wons AM, Kohler M. Established vascular effects of continuous positive airway pressure therapy in patients with obstructive sleep apnoea-an update. J Thorac Dis 2015; 7:912-9. [PMID: 26101649 DOI: 10.3978/j.issn.2072-1439.2015.03.06] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 02/04/2015] [Indexed: 01/09/2023]
Abstract
The aim of this review was to summarize the current data from randomised controlled trials (RCTs) on vascular effects of continuous positive airway pressure (CPAP) therapy in patients with obstructive sleep apnoea (OSA). There is good evidence from RCTs that CPAP lowers blood pressure (BP) to a clinically significant amount. The effect seems to be dependent on the hours of nightly CPAP usage. Data from RCTs have also proven a beneficial effect of CPAP on measures of vascular function such as endothelial function and arterial stiffness. However, there is still a lack of evidence from RCTs proving that CPAP reduces vascular events and mortality.
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Affiliation(s)
- Annette Marie Wons
- 1 Sleep Disorders Centre and Pulmonary Division, University Hospital Zurich, Zurich, Switzerland ; 2 Centre for Integrative Human Physiology, 3 Centre for Interdisciplinary Sleep Research, University of Zurich, Zurich, Switzerland
| | - Malcolm Kohler
- 1 Sleep Disorders Centre and Pulmonary Division, University Hospital Zurich, Zurich, Switzerland ; 2 Centre for Integrative Human Physiology, 3 Centre for Interdisciplinary Sleep Research, University of Zurich, Zurich, Switzerland
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138
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Feres MC, Fonseca FAH, Cintra FD, Mello-Fujita L, de Souza AL, De Martino MC, Tufik S, Poyares D. An assessment of oxidized LDL in the lipid profiles of patients with obstructive sleep apnea and its association with both hypertension and dyslipidemia, and the impact of treatment with CPAP. Atherosclerosis 2015; 241:342-9. [PMID: 26071656 DOI: 10.1016/j.atherosclerosis.2015.05.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 04/25/2015] [Accepted: 05/06/2015] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Obstructive sleep apnea (OSA) has been linked to increased oxidative stress, lipid peroxidation and worsening atherosclerosis. This study investigated oxidized low-density lipoprotein (oxLDL) as a marker of lipid peroxidation, and total LDL cholesterol (direct LDL-C), as a marker of the lipid profile among individuals with OSA, and its association with hypertension (HYP) and dyslipidemia (DYS). The impact of one year of continuous positive airway pressure (CPAP) was also assessed. METHODS Blood was collected after 12 h of fasting from 99 consecutive patients who were diagnosed with OSA via polysomnography, and were also diagnosed with both HYP and DYS via clinical and laboratory studies. The patients were classified into the following three groups: GI [OSA with comorbidities (HYP or DYS)], GII [OSA without comorbidities], and GIII [control]. Thirty-five patients with an apnea/hypopnea index >20 per hour of sleep were randomized to groups that received either Sham-CPAP or CPAP treatments over 12 months. RESULTS In a binary regression controlled for sex, age, body mass index, and glycemia, model 1 which analyzed direct LDL-C, demonstrated significant levels of risk in the setting of DYS but not in the settings of HYP and OSA. In model 2, which analyzed oxLDL, DYS (p = 0.01), HYP (p = 0.032), and OSA (p = 0.039) were statistically significant. Significant alterations were observed in only the sleep parameters following one year of CPAP. CONCLUSIONS Based on the statistical regression model, only the presence of DYS (p = 0.001) was associated with the levels of direct LDL-C. The remaining comorbidities (OSA and HYP) were not significantly related to the levels of direct LDL-C. Regarding oxLDL, OSA, HYP and DYS each added significant score values to the levels of oxLDL. These findings are suggestive of the importance of assessing oxLDL among patients presenting with OSA, both with and without comorbidities.
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Affiliation(s)
- Marcia C Feres
- Psychobiology Department, Universidade Federal de Sao Paulo - UNIFESP, Sao Paulo, Brazil.
| | | | - Fatima D Cintra
- Psychobiology Department, Universidade Federal de Sao Paulo - UNIFESP, Sao Paulo, Brazil; Medicine Department, Universidade Federal de Sao Paulo - UNIFESP, Sao Paulo, Brazil
| | - Luciane Mello-Fujita
- Psychobiology Department, Universidade Federal de Sao Paulo - UNIFESP, Sao Paulo, Brazil; Instituto do Sono de Sao Paulo, São Paulo, Brazil
| | - Altay Lino de Souza
- Psychobiology Department, Universidade Federal de Sao Paulo - UNIFESP, Sao Paulo, Brazil
| | | | - Sergio Tufik
- Psychobiology Department, Universidade Federal de Sao Paulo - UNIFESP, Sao Paulo, Brazil; Instituto do Sono de Sao Paulo, São Paulo, Brazil; Associaçao Fundo de Incentivo à Pesquisa - AFIP, Sao Paulo, Brazil
| | - Dalva Poyares
- Psychobiology Department, Universidade Federal de Sao Paulo - UNIFESP, Sao Paulo, Brazil; Instituto do Sono de Sao Paulo, São Paulo, Brazil
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139
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Wu X, Lv S, Yu X, Yao L, Mokhlesi B, Wei Y. Treatment of OSA reduces the risk of repeat revascularization after percutaneous coronary intervention. Chest 2015; 147:708-718. [PMID: 25412159 DOI: 10.1378/chest.14-1634] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The impact of OSA treatment with CPAP on percutaneous coronary intervention (PCI) outcomes remains largely unknown. METHODS Between 2002 and 2012, we identified 390 patients with OSA who had undergone PCI. OSA was diagnosed through in-laboratory sleep studies and defined by an apnea-hypopnea index ≥ 5 events/h. The cohort was divided into three groups: (1) moderate-severe OSA successfully treated with CPAP (n = 128), (2) untreated moderate-severe OSA (n = 167), and (3) untreated mild OSA (n = 95). Main outcomes included repeat revascularization, major adverse cardiac events (MACEs) (ie, death, nonfatal myocardial infarction, repeat revascularization), and major adverse cardiac or cerebrovascular events (MACCEs). The median follow-up period was 4.8 years (interquartile range, 3.0-7.1). RESULTS The untreated moderate-severe OSA group had a higher incidence of repeat revascularization than the treated moderate-severe OSA group (25.1% vs 14.1%, P = .019). There were no differences in mortality (P = .64), MACE (P = .33), and MACCE (P = .76) among the groups. In multivariate analysis adjusted for potential confounders, untreated moderate-severe OSA was associated with increased risk of repeat revascularization (hazard ratio, 2.13; 95% CI, 1.19-3.81; P = .011). CONCLUSIONS Untreated moderate-severe OSA was independently associated with a significant increased risk of repeat revascularization after PCI. CPAP treatment reduced this risk.
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Affiliation(s)
- Xiaofan Wu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Shuzheng Lv
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaohong Yu
- Department of Medicine, Section of Pulmonary and Critical Care, Sleep Disorders Center, University of Chicago, Chicago, IL
| | - Linyin Yao
- Department of Otolaryngology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Babak Mokhlesi
- Department of Medicine, Section of Pulmonary and Critical Care, Sleep Disorders Center, University of Chicago, Chicago, IL
| | - Yongxiang Wei
- Department of Otolaryngology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
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Liu A, Cardell J, Ariel D, Lamendola C, Abbasi F, Kim SH, Holmes TH, Tomasso V, Mojaddidi H, Grove K, Kushida CA, Reaven GM. Abnormalities of lipoprotein concentrations in obstructive sleep apnea are related to insulin resistance. Sleep 2015; 38:793-9. [PMID: 25348129 DOI: 10.5665/sleep.4678] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 10/05/2014] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVE Prevalence of cardiovascular disease (CVD) is increased in patients with obstructive sleep apnea (OSA), possibly related to dyslipidemia in these individuals. Insulin resistance is also common in OSA, but its contribution to dyslipidemia of OSA is unclear. The study's aim was to define the relationships among abnormalities of lipoprotein metabolism, clinical measures of OSA, and insulin resistance. DESIGN Cross-sectional study. OSA severity was defined by the apnea-hypopnea index (AHI) during polysomnography. Hypoxia measures were expressed as minimum and mean oxygen saturation, and the oxygen desaturation index. Insulin resistance was quantified by determining steady-state plasma glucose (SSPG) concentrations during the insulin suppression test. Fasting plasma lipid/lipoprotein evaluation was performed by vertical auto profile methodology. SETTING Academic medical center. PARTICIPANTS 107 nondiabetic, overweight/obese adults. MEASUREMENTS AND RESULTS Lipoprotein particles did not correlate with AHI or any hypoxia measures, nor were there differences noted by categories of OSA severity. By contrast, even after adjustment for age, sex, and BMI, SSPG was positively correlated with triglycerides (r = 0.30, P < 0.01), very low density lipoprotein (VLDL) and its subclasses (VLDL1+2) (r = 0.21-0.23, P < 0.05), and low density lipoprotein subclass 4 (LDL4) (r = 0.30, P < 0.01). SSPG was negatively correlated with high density lipoprotein (HDL) (r = -0.38, P < 0.001) and its subclasses (HDL2 and HDL3) (r = -0.32, -0.43, P < 0.01), and apolipoprotein A1 (r = -0.33, P < 0.01). Linear trends of these lipoprotein concentrations across SSPG tertiles were also significant. CONCLUSIONS Pro-atherogenic lipoprotein abnormalities in obstructive sleep apnea (OSA) are related to insulin resistance, but not to OSA severity or degree of hypoxia. Insulin resistance may represent the link between OSA-related dyslipidemia and increased cardiovascular disease risk.
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Affiliation(s)
- Alice Liu
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - James Cardell
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Danit Ariel
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Cindy Lamendola
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Fahim Abbasi
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Sun H Kim
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Tyson H Holmes
- Stanford Sleep Medicine Center, Stanford University School of Medicine, Stanford, CA
| | - Vanessa Tomasso
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Hafasa Mojaddidi
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Kaylene Grove
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Clete A Kushida
- Stanford Sleep Medicine Center, Stanford University School of Medicine, Stanford, CA
| | - Gerald M Reaven
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
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Daulatzai MA. “Boomerang Neuropathology” of Late-Onset Alzheimer’s Disease is Shrouded in Harmful “BDDS”: Breathing, Diet, Drinking, and Sleep During Aging. Neurotox Res 2015; 28:55-93. [DOI: 10.1007/s12640-015-9528-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2014] [Revised: 04/03/2015] [Accepted: 04/03/2015] [Indexed: 12/12/2022]
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Use of continuous positive airway pressure for sleep apnea in the treatment of hypertension. Curr Opin Nephrol Hypertens 2015; 23:462-7. [PMID: 24992567 DOI: 10.1097/mnh.0000000000000047] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
PURPOSE OF REVIEW Obstructive sleep apnea (OSA) and hypertension are highly prevalent and treatable conditions that often coexist and both contribute to an increased cardiovascular risk. The ability of continuous positive airway pressure (CPAP) to improve blood pressure in hypertensive patients with OSA is debated. This review highlights findings from recent studies that have investigated the impact of CPAP on blood pressure in patients with OSA. RECENT FINDINGS Comparing the results of various studies is complicated by important methodological differences among them. In hypertensive patients with OSA, treatment with CPAP improves blood pressure to a smaller degree than that derived from antihypertensive medication. Patients with more severe OSA and with greater adherence to CPAP are likely to gain the most benefit from the therapy. SUMMARY CPAP should be used in combination with antihypertensive medications in hypertensive patients with OSA. CPAP has the additional benefits of restoring nocturnal dipping and improving arterial stiffness, thus potentially influencing cardiovascular morbidity in these high-risk patients.
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The impact of obstructive sleep apnea on high-sensitivity C-reactive protein in subjects with or without metabolic syndrome. Sleep Breath 2015; 19:1449-57. [PMID: 25847321 DOI: 10.1007/s11325-015-1166-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 02/27/2015] [Accepted: 03/24/2015] [Indexed: 12/29/2022]
Abstract
BACKGROUND It is unclear whether obstructive sleep apnea (OSA) is independently associated with increased levels of the acute-phase reactant C-reactive protein (CRP). The purpose of this study was to evaluate the relationship between OSA and high-sensitivity CRP (hs-CRP) levels according to the presence or absence of metabolic syndrome (MetS). METHODS This study recruited 245 male bus drivers from one transportation company in Taiwan. Each participant was evaluated by a polysomnography (PSG) test, blood lipids examination, and hs-CRP. Severity of OSA was categorized according to the apnea-hypopnea index (AHI). RESULTS Subjects were categorized into severe OSA group (n = 44; 17.9 %), moderate and mild OSA group (n = 117; 47.8 %), and non-OSA group (n = 84; 34.3 %). AHI had a significant association with hs-CRP (β = 0.125, p = 0.009) adjusting for age, smoking, drinking, and MetS status. Hs-CRP was elevated with severe OSA (β = 0.533, p = 0.005) even adjusting for BMI and MetS. Moreover, there was an independent effect for adjusted odds ratios (AORs) between the stratification of the severity for OSA and MetS. CONCLUSION Elevated hs-CRP level is associated with severe OSA, independent of known confounders. The effect of OSA in CRP is independent of MetS was identified.
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S K, C B, A S, K R. Effect of Short Term CPAP Therapy in Obstructive Sleep Apnea Patients with Metabolic Syndrome. J Clin Diagn Res 2015; 9:CC07-10. [PMID: 26023552 DOI: 10.7860/jcdr/2015/13301.5859] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 03/20/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Patients of obstructive sleep apnea (OSA) with metabolic syndrome (MetS) are at increased risk of cardiovascular morbidity and mortality. The role of oxidative stress in pathogenesis of OSA and MetS has been widely reported. Continuous positive airway pressure (CPAP) therapy remains the first-line of treatment in OSA. The beneficial effect of long term CPAP therapy in OSA is well-known. However, the effect of short term CPAP on the components of MetS and oxidative stress-antioxidant levels is still unclear. AIM The present study explored the effects of one night of CPAP therapy on the oxidant-antioxidant status and components of MetS in patients of OSA with MetS. MATERIALS AND METHODS Twenty adult males and postmenopausal females with MetS and symptoms suggestive of OSA were enrolled in the study. None of the subjects were smoker or alcoholic. They did not consume any drugs that would alter their antioxidant levels. Overnight polysomnography was done to confirm diagnosis and assess CPAP pressure. Following which they spent one night in the sleep lab for CPAP therapy. Blood pressure data and blood samples were collected at baseline and after CPAP. Collected samples were transferred immediately to the laboratory for analysis of serum thiol, lipid peroxidation, insulin resistance (HOMA-IR) and lipid profile. RESULTS Paired t-test with two-tail significance was used to compare the changes in study parameters in the same patient before and after treatment. The antioxidant level increased and oxidative stress decreased as evidenced by serum thiol concentration (204.2±65.7 vs 254.9±72 μmol/L, p<0.001) and lipid peroxidation levels (13.1±6.2 vs 8.4±3.1 μmol/L, p<0.01).There was a significant decrease in both systolic (132.1±16.1 vs 127.2±14.3 mmHg, p<0.01) and diastolic blood pressure (86.4±9.4 vs 81.2±9.8 mmHg, p<0.01) after one night of CPAP. However, there was no change in lipid parameters and the reduction seen in insulin resistance was not statistically significant. CONCLUSION One night of CPAP therapy seems to be helpful in reducing oxidative stress, improving antioxidant levels and decreasing the severity of various components of MetS.
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Affiliation(s)
- Kanimozhi S
- Assistant Professor, Department of Physiology, SRM MCH & RC , Chennai, India
| | - Balaji C
- Associate Professor, Department of Paediatrics, SRM MCH & RC , Chennai, India
| | - Saravanan A
- Professor and HOD, Department of Physiology, SRM MCH & RC , Chennai, India
| | - Ravi K
- Professor and HOD, Department of Physiology, V.P. Chest Institute , Delhi, India
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Shah N, Allison M, Teng Y, Wassertheil-Smoller S, Sotres-Alvarez D, Ramos AR, Zee PC, Criqui MH, Yaggi HK, Gallo LC, Redline S, Kaplan RC. Sleep apnea is independently associated with peripheral arterial disease in the Hispanic Community Health Study/Study of Latinos. Arterioscler Thromb Vasc Biol 2015; 35:710-5. [PMID: 25657310 PMCID: PMC4545273 DOI: 10.1161/atvbaha.114.304625] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Sleep apnea (SA) has been linked with various forms of cardiovascular disease, but little is known about its association with peripheral artery disease (PAD) measured using the ankle-brachial index. This relationship was evaluated in the Hispanic Community Health Study/Study of Latinos. APPROACH AND RESULTS We studied 8367 Hispanic Community Health Study/Study of Latinos participants who were 45 to 74 years of age. Sleep symptoms were examined with the self-reported Sleep Health Questionnaire. SA was assessed using an in-home sleep study. Systolic blood pressure was measured in all extremities to compute the ankle-brachial index. PAD was defined as ankle-brachial index <0.90 in either leg. Multivariable logistic regression was used to investigate the association between moderate-to-severe SA, defined as apnea-hypopnea index ≥15, and the presence of PAD. Analyses were adjusted for covariates. The prevalence of PAD was 4.7% (n=390). The mean apnea-hypopnea index was significantly higher among adults with PAD compared with those without (11.1 versus 8.6 events/h; P=0.046). After adjusting for covariates, moderate-to-severe SA was associated with a 70% increase in the odds of PAD (odds ratio, 1.7; 95% confidence interval, 1.1-2.5; P=0.0152). This association was not modified by sex (P=0.8739). However, there was evidence that the association between moderate-to-severe SA and PAD varied by Hispanic/Latino background (P<0.01). Specifically, the odds were stronger in Mexican (adjusted odds ratio, 2.9; 95% confidence interval, 1.3-6.2) and in Puerto Rican Americans (adjusted odds ratio, 2.0; 95% confidence interval, 0.97-4.2) than in other backgrounds. CONCLUSIONS Moderate-to-severe SA is associated with higher odds of PAD in Hispanic/Latino adults.
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Affiliation(s)
- Neomi Shah
- From the Department of Medicine, Montefiore Medical Center (N.S.) and Department of Epidemiology and Population Health (N.S., S.W.-S., R.C.K.), Albert Einstein College of Medicine, Bronx, NY; Department of Medicine, University of Southern California San Diego, La Jolla (M.A., M.H.C., L.C.G.); Department of Biostatistics, Collaborative Studies Coordinating Center, Gillings School of Global Public Health, University of North Carolina, Chapel Hill (Y.T., D.S.-A.); Department of Medicine, University of Miami, FL (A.R.R.); Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL (P.C.Z.); Department of Medicine, Yale School of Medicine, New Haven, CT (H.K.Y.); and Department of Medicine, Brigham and Women's Hospital, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (S.R.).
| | - Matthew Allison
- From the Department of Medicine, Montefiore Medical Center (N.S.) and Department of Epidemiology and Population Health (N.S., S.W.-S., R.C.K.), Albert Einstein College of Medicine, Bronx, NY; Department of Medicine, University of Southern California San Diego, La Jolla (M.A., M.H.C., L.C.G.); Department of Biostatistics, Collaborative Studies Coordinating Center, Gillings School of Global Public Health, University of North Carolina, Chapel Hill (Y.T., D.S.-A.); Department of Medicine, University of Miami, FL (A.R.R.); Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL (P.C.Z.); Department of Medicine, Yale School of Medicine, New Haven, CT (H.K.Y.); and Department of Medicine, Brigham and Women's Hospital, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (S.R.)
| | - Yanping Teng
- From the Department of Medicine, Montefiore Medical Center (N.S.) and Department of Epidemiology and Population Health (N.S., S.W.-S., R.C.K.), Albert Einstein College of Medicine, Bronx, NY; Department of Medicine, University of Southern California San Diego, La Jolla (M.A., M.H.C., L.C.G.); Department of Biostatistics, Collaborative Studies Coordinating Center, Gillings School of Global Public Health, University of North Carolina, Chapel Hill (Y.T., D.S.-A.); Department of Medicine, University of Miami, FL (A.R.R.); Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL (P.C.Z.); Department of Medicine, Yale School of Medicine, New Haven, CT (H.K.Y.); and Department of Medicine, Brigham and Women's Hospital, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (S.R.)
| | - Sylvia Wassertheil-Smoller
- From the Department of Medicine, Montefiore Medical Center (N.S.) and Department of Epidemiology and Population Health (N.S., S.W.-S., R.C.K.), Albert Einstein College of Medicine, Bronx, NY; Department of Medicine, University of Southern California San Diego, La Jolla (M.A., M.H.C., L.C.G.); Department of Biostatistics, Collaborative Studies Coordinating Center, Gillings School of Global Public Health, University of North Carolina, Chapel Hill (Y.T., D.S.-A.); Department of Medicine, University of Miami, FL (A.R.R.); Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL (P.C.Z.); Department of Medicine, Yale School of Medicine, New Haven, CT (H.K.Y.); and Department of Medicine, Brigham and Women's Hospital, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (S.R.)
| | - Daniela Sotres-Alvarez
- From the Department of Medicine, Montefiore Medical Center (N.S.) and Department of Epidemiology and Population Health (N.S., S.W.-S., R.C.K.), Albert Einstein College of Medicine, Bronx, NY; Department of Medicine, University of Southern California San Diego, La Jolla (M.A., M.H.C., L.C.G.); Department of Biostatistics, Collaborative Studies Coordinating Center, Gillings School of Global Public Health, University of North Carolina, Chapel Hill (Y.T., D.S.-A.); Department of Medicine, University of Miami, FL (A.R.R.); Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL (P.C.Z.); Department of Medicine, Yale School of Medicine, New Haven, CT (H.K.Y.); and Department of Medicine, Brigham and Women's Hospital, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (S.R.)
| | - Alberto R Ramos
- From the Department of Medicine, Montefiore Medical Center (N.S.) and Department of Epidemiology and Population Health (N.S., S.W.-S., R.C.K.), Albert Einstein College of Medicine, Bronx, NY; Department of Medicine, University of Southern California San Diego, La Jolla (M.A., M.H.C., L.C.G.); Department of Biostatistics, Collaborative Studies Coordinating Center, Gillings School of Global Public Health, University of North Carolina, Chapel Hill (Y.T., D.S.-A.); Department of Medicine, University of Miami, FL (A.R.R.); Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL (P.C.Z.); Department of Medicine, Yale School of Medicine, New Haven, CT (H.K.Y.); and Department of Medicine, Brigham and Women's Hospital, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (S.R.)
| | - Phyllis C Zee
- From the Department of Medicine, Montefiore Medical Center (N.S.) and Department of Epidemiology and Population Health (N.S., S.W.-S., R.C.K.), Albert Einstein College of Medicine, Bronx, NY; Department of Medicine, University of Southern California San Diego, La Jolla (M.A., M.H.C., L.C.G.); Department of Biostatistics, Collaborative Studies Coordinating Center, Gillings School of Global Public Health, University of North Carolina, Chapel Hill (Y.T., D.S.-A.); Department of Medicine, University of Miami, FL (A.R.R.); Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL (P.C.Z.); Department of Medicine, Yale School of Medicine, New Haven, CT (H.K.Y.); and Department of Medicine, Brigham and Women's Hospital, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (S.R.)
| | - Michael H Criqui
- From the Department of Medicine, Montefiore Medical Center (N.S.) and Department of Epidemiology and Population Health (N.S., S.W.-S., R.C.K.), Albert Einstein College of Medicine, Bronx, NY; Department of Medicine, University of Southern California San Diego, La Jolla (M.A., M.H.C., L.C.G.); Department of Biostatistics, Collaborative Studies Coordinating Center, Gillings School of Global Public Health, University of North Carolina, Chapel Hill (Y.T., D.S.-A.); Department of Medicine, University of Miami, FL (A.R.R.); Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL (P.C.Z.); Department of Medicine, Yale School of Medicine, New Haven, CT (H.K.Y.); and Department of Medicine, Brigham and Women's Hospital, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (S.R.)
| | - Henry K Yaggi
- From the Department of Medicine, Montefiore Medical Center (N.S.) and Department of Epidemiology and Population Health (N.S., S.W.-S., R.C.K.), Albert Einstein College of Medicine, Bronx, NY; Department of Medicine, University of Southern California San Diego, La Jolla (M.A., M.H.C., L.C.G.); Department of Biostatistics, Collaborative Studies Coordinating Center, Gillings School of Global Public Health, University of North Carolina, Chapel Hill (Y.T., D.S.-A.); Department of Medicine, University of Miami, FL (A.R.R.); Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL (P.C.Z.); Department of Medicine, Yale School of Medicine, New Haven, CT (H.K.Y.); and Department of Medicine, Brigham and Women's Hospital, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (S.R.)
| | - Linda C Gallo
- From the Department of Medicine, Montefiore Medical Center (N.S.) and Department of Epidemiology and Population Health (N.S., S.W.-S., R.C.K.), Albert Einstein College of Medicine, Bronx, NY; Department of Medicine, University of Southern California San Diego, La Jolla (M.A., M.H.C., L.C.G.); Department of Biostatistics, Collaborative Studies Coordinating Center, Gillings School of Global Public Health, University of North Carolina, Chapel Hill (Y.T., D.S.-A.); Department of Medicine, University of Miami, FL (A.R.R.); Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL (P.C.Z.); Department of Medicine, Yale School of Medicine, New Haven, CT (H.K.Y.); and Department of Medicine, Brigham and Women's Hospital, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (S.R.)
| | - Susan Redline
- From the Department of Medicine, Montefiore Medical Center (N.S.) and Department of Epidemiology and Population Health (N.S., S.W.-S., R.C.K.), Albert Einstein College of Medicine, Bronx, NY; Department of Medicine, University of Southern California San Diego, La Jolla (M.A., M.H.C., L.C.G.); Department of Biostatistics, Collaborative Studies Coordinating Center, Gillings School of Global Public Health, University of North Carolina, Chapel Hill (Y.T., D.S.-A.); Department of Medicine, University of Miami, FL (A.R.R.); Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL (P.C.Z.); Department of Medicine, Yale School of Medicine, New Haven, CT (H.K.Y.); and Department of Medicine, Brigham and Women's Hospital, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (S.R.)
| | - Robert C Kaplan
- From the Department of Medicine, Montefiore Medical Center (N.S.) and Department of Epidemiology and Population Health (N.S., S.W.-S., R.C.K.), Albert Einstein College of Medicine, Bronx, NY; Department of Medicine, University of Southern California San Diego, La Jolla (M.A., M.H.C., L.C.G.); Department of Biostatistics, Collaborative Studies Coordinating Center, Gillings School of Global Public Health, University of North Carolina, Chapel Hill (Y.T., D.S.-A.); Department of Medicine, University of Miami, FL (A.R.R.); Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL (P.C.Z.); Department of Medicine, Yale School of Medicine, New Haven, CT (H.K.Y.); and Department of Medicine, Brigham and Women's Hospital, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (S.R.)
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Síndrome de apnea/hipopnea obstructiva del sueño y su asociación con las enfermedades cardiovasculares. REVISTA COLOMBIANA DE CARDIOLOGÍA 2015. [DOI: 10.1016/j.rccar.2014.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Aggarwal S, Jan MF, Agarwal A, Tajik AJ. Hypertrophic cardiomyopathy associated with sleep apnea: serious implications and cogent management strategy. Expert Rev Cardiovasc Ther 2015; 13:277-84. [PMID: 25634133 DOI: 10.1586/14779072.2015.1004314] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Obstructive sleep apnea (OSA) affects an estimated 20 million adult Americans and is present in a large proportion of patients with hypertension and in those with other cardiovascular disorders, including hypertrophic cardiomyopathy (HCM). This review seeks to highlight concepts and evidence important to understanding the interactions between OSA and HCM, with particular attention to more recent advances in patient-oriented research. Studies of patients with HCM have found the prevalence of sleep-disordered breathing to range from 40 to 80%. Increased sympathetic activity, impaired vagal activity, increased afterload, insulin resistance and endothelial dysfunction have been proposed as potential mechanisms for the association. Specific questions include whether OSA is important in unmasking symptoms in hitherto undiagnosed patients with HCM, whether OSA in patients with established HCM accelerates disease progression and whether treatment of OSA results in clinical improvement, fewer cardiovascular events and reduced mortality. Because obesity, cardiovascular disease, metabolic syndrome, and diabetes are often present in patients with OSA, it can be difficult to attribute abnormalities evident in the sleep apnea patient with HCM to the effects of OSA, the effects of HCM or synergies between these conditions. Although further research is needed to answer these specific questions, recent investigations have clearly shown the coexistence of OSA and HCM, as well as elucidated the contribution of heightened sympathetic nerve activity in OSA to drug-refractory symptoms and worsening left ventricular outflow tract obstruction. This review aims to highlight the current literature available on the association of OSA and HCM, provide directions for future research and summarize the key features related to this association based on the authors' best understanding and experience.
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148
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Dobrosielski DA, Patil S, Schwartz AR, Bandeen-Roche K, Stewart KJ. Effects of exercise and weight loss in older adults with obstructive sleep apnea. Med Sci Sports Exerc 2015; 47:20-6. [PMID: 24870569 PMCID: PMC4246024 DOI: 10.1249/mss.0000000000000387] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE Obstructive sleep apnea (OSA) is prevalent among older individuals and is linked to increased cardiovascular disease morbidity. This study examined the change in OSA severity after exercise training and dietary-induced weight loss in older adults and the association of the changes in OSA severity, body composition, and aerobic capacity with arterial distensibility. METHODS Obese adults (n = 25) with OSA, age 60 yr or older, were instructed to participate in supervised exercise (3 d·wk) and follow a calorie-restricted diet. Baseline assessments of OSA parameters, body weight and composition, aerobic capacity, and arterial distensibility were repeated at 12 wk. RESULTS Nineteen participants completed the intervention. At 12 wk, there were reductions in body weight (-9%) and percentage of total body fat (-5%) and trunk fat (-8%) whereas aerobic capacity improved by 20% (all P < 0.01). The apnea-hypopnea index decreased by 10 events per hour (P < 0.01) and nocturnal SaO2 (mean SaO2) improved from 94.9% at baseline to 95.2% after intervention (P = 0.01). Arterial distensibility for the group was not different from that at baseline (P = 0.99), yet individual changes in distensibility were associated with the change in nocturnal desaturations (r = -0.49, P = 0.03) but not with the change in body weight, apnea-hypopnea index, or aerobic capacity. CONCLUSIONS The severity of OSA was reduced after an exercise and weight loss program among older adults, suggesting that this lifestyle approach may be an effective first-line nonsurgical and nonpharmacological treatment for older patients with OSA.
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Affiliation(s)
- Devon A. Dobrosielski
- Department of Kinesiology, Towson University, Towson, MD
- Division of Cardiology, Johns Hopkins School of Medicine, Baltimore MD
| | - Susheel Patil
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore MD
| | - Alan R. Schwartz
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore MD
| | - Karen Bandeen-Roche
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Kerry J. Stewart
- Division of Cardiology, Johns Hopkins School of Medicine, Baltimore MD
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149
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Lipid profile after long-term APAP in OSA patients. Sleep Breath 2014; 19:931-7. [PMID: 25510508 DOI: 10.1007/s11325-014-1095-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 10/22/2014] [Accepted: 12/01/2014] [Indexed: 01/14/2023]
Abstract
PURPOSE This study aimed to explore the impact of an 8-year therapy with autoadjusting positive airway pressure (APAP) on fasting lipid level in a sample of Portuguese moderate/severe obstructive sleep apnea (OSA) patients. Besides contributing to the comprehension of the complex relationship between dyslipidemia and OSA, it provided new data regarding the effectiveness of a long term APAP treatment. METHODS Thirty-nine male patients with moderate to severe OSA were included in the study. APAP was prescribed to all patients. Fifteen patients were under lipid-lowering medication throughout the study, and another 15 patients never used lipid-lowering medication at any time during the study. Fasting morning venous blood samples were collected at three time points (baseline 6 months and 8 years) and lipids were estimated. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) 21.0 software. RESULTS After 8 years of APAP treatment, patients presented a similar body mass index but a significantly less severe daytime sleepiness. Patients on lipid-lowering medication exhibited a higher reduction in total cholesterol than those naïf from that medication, but the reduction was not statistically significant after adjusting for medication and APAP adherence. CONCLUSIONS Long-term APAP treatment improves OSA but does not seem to contribute to changes in fasting lipids.
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Luyster FS, Kip KE, Aiyer AN, Reis SE, Strollo PJ. Relation of obstructive sleep apnea to coronary artery calcium in non-obese versus obese men and women aged 45-75 years. Am J Cardiol 2014; 114:1690-4. [PMID: 25307200 DOI: 10.1016/j.amjcard.2014.08.040] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 08/26/2014] [Accepted: 08/26/2014] [Indexed: 02/02/2023]
Abstract
Sleep apnea and obesity are strongly associated, and both increase the risk for coronary artery disease. Several cross-sectional studies have reported discrepant results regarding the role obesity plays in the relation between sleep apnea and coronary artery calcium (CAC), a marker of subclinical coronary disease. The aim of the present study was to investigate the association between sleep apnea and the presence of CAC in a community cohort of middle-aged men and women without preexisting cardiovascular disease, stratified by body mass index (<30 vs ≥30 kg/m(2)). Participants underwent electron-beam computed tomography to measure CAC and underwent home sleep testing for sleep apnea. The presence of CAC was defined as an Agatston score >0. Sleep apnea was analyzed categorically using the apnea-hypopnea index. The sample was composed of primarily men (61%) and Caucasians (56%), with a mean age of 61 years. The prevalence of CAC was 76%. In participants with body mass indexes <30 kg/m(2) (n = 139), apnea-hypopnea index ≥15 (vs <5) was associated with 2.7-fold odds of having CAC, but the effect only approached significance. Conversely, in participants with body mass indexes ≥30 kg/m(2), sleep apnea was not independently associated with CAC. In conclusion, sleep apnea is independently associated with early atherosclerotic plaque burden in nonobese patients.
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