Association between sleep-disordered breathing and arterial stiffness in heart failure patients with reduced or preserved ejection fraction

Temporal Trends in the Practice Pattern for Sleep-Disordered Breathing in Patients With Cardiovascular Diseases in Japan - Insights From the Japanese Registry of All Cardiac and Vascular Diseases - Diagnosis Procedure Combination

BACKGROUND

After the publication of the Japanese Circulation Society guideline of sleep-disordered breathing (SDB) in 2010, with new evidence and changes to the health insurance system, trends in the practice pattern for SDB in patients with cardiovascular disease (CVD) might have changed.

METHODS AND RESULTS

This study evaluated the temporal changes in the practice pattern for SDB by using a nationwide claim database, the Japanese Registry of All Cardiac and Vascular Diseases - Diagnosis Procedure Combination (JROAD-DPC), from 2012 to 2019. The main findings were: (1) the number of CVD patients diagnosed with SDB increased (especially those with atrial fibrillation [AF] and heart failure [HF]); (2) the number of diagnostic tests for SDB performed during hospitalization increased for AF patients (from 1.3% in 2012 to 1.8% in 2019), whereas it decreased for other CVD patients; (3) the number of patients diagnosed with SDB increased in each type of CVD, except for patients with acute myocardial infarction (AMI); (4) continuous positive airway pressure (CPAP) treatment increased for AF patients (from 15.2% to 17.5%); (5) CPAP treatment decreased for patients with angina pectoris (AP) and AMI, and any treatment decreased for HF patients (from 46.1% to 39.7%); and (6) SDB was treated more often in HF patients than in AF, AP, and AMI patients (41.7% vs. 17.2%, 19.1% and 20.4%, respectively).

CONCLUSIONS

The practice pattern for SDB in CVD patients has changed from 2012 to 2019.

Association of Night-to-Night Adherence of Continuous Positive Airway Pressure With Day-to-Day Morning Home Blood Pressure and Its Seasonal Variation in Obstructive Sleep Apnea

Background

The aim of this study was to investigate the association between night‐to‐night adherence to continuous positive airway pressure (CPAP) therapy and both home blood pressure (BP) level on the following day and seasonal variation in home BP in patients with obstructive sleep apnea.

Methods and Results

We analyzed 105 participants who had been diagnosed with obstructive sleep apnea (average apnea‐hypopnea index, 49.7±18.4 per hour) and who were already receiving CPAP therapy. Home BP (twice every morning and evening) and CPAP adherence data were automatically transmitted to a server for 1 year. A mixed‐effects model for repeated measures analysis was used to examine associations of night‐to‐night good CPAP adherence with day‐to‐day home BP within the same patient after adjusting for covariates. The average number of days in which patients achieved both CPAP adherence and morning or evening home BP measurement was 206.6±122.7 days (21 487 readings) and 191.2±126.3 days (20 170 readings), respectively. Good CPAP adherence (>4 hours per night of use) was achieved on the evening or morning before home BP measurements (86.8% and 86.9%, respectively). After adjustment for confounders, good CPAP adherence was negatively associated with morning home systolic BP (β, −0.663; P=0.004) and diastolic BP (β, −0.829; P<0.001). Morning home systolic BP in winter in the individuals with good CPAP adherence was significantly lower than that in individuals without such adherence (P<0.05). These associations were not found in evening home BP.

Conclusions

Good adherence to CPAP therapy was negatively associated with morning home BP on the following day in patients with obstructive sleep apnea. The association was remarkable in the winter season.

Positionspapier „Schlafmedizin in der Kardiologie“, Update 2021

Es hat sich viel getan in der Welt der Schlafmedizin in der Kardiologie, weshalb eine vollwertige Überarbeitung des Positionspapiers „Schlafmedizin in der Kardiologie“ erforderlich wurde. In der aktuellen neuartigen Version finden sich nicht nur alle verfügbaren Studien, Literaturstellen und Updates zu Pathophysiologie, Diagnostik- und Therapieempfehlungen, sondern auch Ausblicke auf neue Entwicklungen und zukünftige Forschungserkenntnisse. Dieses überarbeitete Positionspapier gibt Empfehlungen für Diagnostik und Therapie von Patienten mit kardiovaskulären Erkrankungen mit schlafassoziierten Atmungsstörungen und erteilt darüber hinaus einen fundierten Überblick über verfügbare Therapien und Evidenzen, gibt aber ebenso Ratschläge wie mit Komorbiditäten umzugehen ist. Insbesondere enthält dieses überarbeitete Positionspapier aktualisierte Stellungnahmen zu schlafassoziierten Atmungsstörungen bei Patienten mit koronarer Herzerkrankung, Herzinsuffizienz, arterieller Hypertonie, aber auch für Patienten mit Vorhofflimmern. Darüber hinaus finden sich erstmals Empfehlungen zur Telemedizin als eigenes, neues Kapitel. Dieses Positionspapier bietet Kardiologen sowie Ärzten in der Behandlung von kardiovaskulären Patienten die Möglichkeit einer evidenzbasierten Behandlung der wachsend bedeutsamen und mit zunehmender Aufmerksamkeit behafteten Komorbidität schlafassoziierter Atmungsstörungen. Und nicht zuletzt besteht mit diesem neuen Positionspapier eine enge Verknüpfung mit dem neuen Curriculum Schlafmedizin der Deutschen Gesellschaft für Kardiologie, weshalb dieses Positionspapier eine Orientierung für die erworbenen Fähigkeiten des Curriculums im Umgang von kardiovaskulären Patienten mit schlafassoziierten Atmungsstörungen darstellt.

Association of free fatty acid binding protein with central aortic stiffness, myocardial dysfunction and preserved ejection fraction heart failure

There is an established link between cardiometabolic abnormality, central arterial stiffness, and preserved ejection fraction heart failure (HFpEF). Adipocyte free fatty acid binding protein (a-FABP) has been shown to signal endothelial dysfunction through fatty acid toxicity, though its role in mediating ventricular-arterial dysfunction remains unclear. We prospectively examined the associations of a-FABP with central arterial pressure using non-invasive applanation tonometry (SphygmoCor) and cardiac structure/function (i.e., tissue Doppler imaging [TDI] and global longitudinal myocardial strain [GLS]) in patients with cardiometabolic (CM) risk (n = 150) and HFpEF (n = 50), with healthy volunteers (n = 49) serving as a control. We observed a graded increase of a-FABP across the healthy controls, CM individuals, and HFpEF groups (all paired p < 0.05). Higher a-FABP was independently associated with higher central systolic and diastolic blood pressures (CSP/CPP), increased arterial augmentation index (Aix), lower early myocardial relaxation velocity (TDI-e'), higher left ventricle (LV) filling (E/TDI-e') and worsened GLS (all p < 0.05). During a median of 3.85 years (interquartile range: 3.68-4.62 years) follow-up, higher a-FABP (cutoff: 24 ng/mL, adjusted hazard ratio: 1.01, 95% confidence interval: 1.001-1.02, p = 0.04) but not brain natriuretic peptide, and higher central hemodynamic indices were related to the incidence of heart failure (HF) in fully adjusted Cox models. Furthermore, a-FABP improved the HF risk classification over central hemodynamic information. We found a mechanistic pathophysiological link between a-FABP, central arterial stiffness, and myocardial dysfunction. In a population with a high metabolic risk, higher a-FABP accompanied by worsened ventricular-arterial coupling may confer more unfavorable outcomes in HFpEF.

B-type natriuretic peptide is associated with post-discharge stroke in hospitalized patients with heart failure

Aims

Recently, B‐type natriuretic peptide (BNP) has been attracting attention as a predictor of stroke in patients with atrial fibrillation or those with prior stroke experience. However, the association between BNP and stroke has not been examined in patients with chronic heart failure (CHF). In the current study, we assessed whether BNP is associated with future occurrence of stroke in patients with CHF.

Methods and results

We prospectively studied 1803 consecutive patients who were admitted for decompensated HF and assessed the predictive value of circulating BNP levels for occurrence of post‐discharge stroke.

A total of 69 (3.8%) patients experienced a stroke (the stroke group) during the post‐discharge follow‐up period of a median of 1150 days. The stroke group showed a higher CHADS₂ score. With respect to past medical history, the stroke group had a higher prevalence of arterial hypertension, atrial fibrillation, prior stroke, and chronic kidney disease. Echocardiographic parameters showed no significant differences between the two groups. In contrast, BNP levels were significantly higher in the stroke group than in the non‐stroke group (452.1 vs. 222.7 pg/mL, P < 0.001). Multivariate Cox proportional hazard analysis indicated that BNP levels were independently associated with post‐discharge stroke (hazard ratio 2.636, 95% confidence interval 1.595–4.357, P < 0.001). The survival classification and regression tree analysis revealed that the accurate cut‐off point of BNP in predicting post‐discharge stroke was 187.7 pg/mL. We added high BNP level (BNP ≥ 180 pg/mL) as one point to CHADS₂ score. The BNP‐added CHADS₂ score was compared with CHADS₂ score alone by using c‐statistics. The areas under the curve of CHADS₂ score, BNP, and BNP‐added CHADS₂ score were 0.698, 0.616, and 0.723, respectively. The predictive value of BNP‐added CHADS₂ score was higher compared with those of CHADS₂ score (P = 0.026).

Conclusions

The assessment of BNP may predict the occurrence of stroke in CHF patients used alone or in combination with established CHADS₂ score.

Expression of MuRF1 or MuRF2 is essential for the induction of skeletal muscle atrophy and dysfunction in a murine pulmonary hypertension model

BACKGROUND

Pulmonary hypertension leads to right ventricular heart failure and ultimately to cardiac cachexia. Cardiac cachexia induces skeletal muscles atrophy and contractile dysfunction. MAFbx and MuRF1 are two key proteins that have been implicated in chronic muscle atrophy of several wasting states.

METHODS

Monocrotaline (MCT) was injected over eight weeks into mice to establish pulmonary hypertension as a murine model for cardiac cachexia. The effects on skeletal muscle atrophy, myofiber force, and selected muscle proteins were evaluated in wild-type (WT), MuRF1, and MuRF2-KO mice by determining muscle weights, in vitro muscle force and enzyme activities in soleus and tibialis anterior (TA) muscle.

RESULTS

In WT, MCT treatment induced wasting of soleus and TA mass, loss of myofiber force, and depletion of citrate synthase (CS), creatine kinase (CK), and malate dehydrogenase (MDH) (all key metabolic enzymes). This suggests that the murine MCT model is useful to mimic peripheral myopathies as found in human cardiac cachexia. In MuRF1 and MuRF2-KO mice, soleus and TA muscles were protected from atrophy, contractile dysfunction, while metabolic enzymes were not lowered in MuRF1 or MuRF2-KO mice. Furthermore, MuRF2 expression was lower in MuRF1KO mice when compared to C57BL/6 mice.

CONCLUSIONS

In addition to MuRF1, inactivation of MuRF2 also provides a potent protection from peripheral myopathy in cardiac cachexia. The protection of metabolic enzymes in both MuRF1KO and MuRF2KO mice as well as the dependence of MuRF2 expression on MuRF1 suggests intimate relationships between MuRF1 and MuRF2 during muscle atrophy signaling.

Differences in blood pressure riser pattern in patients with acute heart failure with reduced mid-range and preserved ejection fraction

Aims

Heart failure (HF) is classified into three types according to left ventricular ejection fraction (EF). The effect of blood pressure (BP) on the pathogenesis of each type is assumed to be different. However, the association between the prognosis of each type of HF and abnormal BP variations assessed by ambulatory BP monitoring (ABPM), such as nocturnal hypertension and the riser pattern, remains unclear.

Methods and results

We studied 325 consecutive patients with decompensated HF who were acutely admitted to our hospital and underwent ABPM at discharge. During a mean follow‐up of 30.0 months, 52 cardiovascular and 112 all‐cause deaths occurred. The Cox proportional hazards model showed that the mean values of 24 h, awake, and sleep‐time systolic BP (SBP), and abnormal 24 h ABPM patterns, such as nocturnal hypertension and non‐dipper pattern, were not associated with either all‐cause or cardiovascular mortality in patients with HF with reduced EF (HFrEF), HF with mid‐range EF (HFmrEF), or HF with preserved EF (HFpEF), except for sleep‐time SBP in HFrEF. However, the riser pattern was a significant and independent predictor of all‐cause and cardiovascular deaths in patients with HFpEF (hazard ratio, 2.01; 95% confidence interval, 1.12–3.62; 0.0200; and hazard ratio, 2.48; 95% confidence interval, 1.08–5.90; 0.0332, respectively). Sleep‐time pulse rate was similarly decreased in both the riser and non‐riser groups.

Conclusions

The riser pattern of SBP was associated with an increased risk of adverse outcomes among patients with HFpEF but not HFrEF or HFmrEF.

Sleep Disordered Breathing and Cardiovascular Diseases

Sleep disordered breathing (SDB), which causes sleep deprivation, intermittent hypoxia, and negative intrathoracic pressure swings, can be accompanied by other harmful pathophysiologies relating to cardiovascular diseases (CVD), including sudden death, atrial fibrillation, stroke, and coronary artery disease leading to heart failure. Continuous positive airway pressure (CPAP) therapy for SDB has been reported to provide favorable effects such as lowered systemic blood pressure and improved endothelial function. However, in recent randomized controlled trials, CPAP has failed to demonstrate its beneficial prognostic impact on the primary or secondary setting of CVD. In this review article, we describe the characteristics of SDB complicated with CVD, the prognostic impacts of SDB in CVD, and the beneficial effects of CPAP on CVD.

Association between sleep-disordered breathing and arterial stiffness in heart failure patients with reduced or preserved ejection fraction

AIMS

Sleep-disordered breathing (SDB) is associated with arterial stiffness, which may be one of the factors that lead to heart failure (HF). We examined the relationship between pulse wave velocity (PWV) and SDB in patients who have HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF).

METHODS AND RESULTS

We measured the apnoea-hypopnoea index (AHI) by polysomnography, echocardiographic parameters, and PWV in 221 HF patients. Age, blood pressure, and PWV were higher in HFpEF (ejection fraction > 50%, n = 70) patients than in HFrEF (ejection fraction < 50%, n = 151) patients. All HF patients were divided into three groups according to AHI: none-to-mild SDB group (AHI < 15 times/h, n = 77), moderate SDB group (15 < AHI < 30 times/h, n = 59), and severe SDB group (AHI > 30 times/h, n = 85). Although blood pressure and echocardiographic parameters did not differ among the three groups, PWV was significantly higher in the severe SDB group than in the none-to-mild and moderate SDB groups (P = 0.002). When the HFrEF and HFpEF patients were analysed separately, PWV was significantly higher in the severe SDB group than in the none-to-mild and moderate SDB groups in patients with HFpEF (P = 0.002), but not in those with HFrEF (P = 0.068). In the multiple regression analysis to determine PWV, the presence of severe SDB was found to be an independent predictor of high PWV in HFpEF (β = 0.234, P = 0.005), but not in HFrEF patients.

CONCLUSIONS

Severe SDB is associated with elevated arterial stiffness and may be related to the pathophysiology of HF, especially in HFpEF patients.