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Guimarães TM, Poyares D, Oliveira E Silva L, Luz G, Coelho G, Dal Fabbro C, Tufik S, Bittencourt L. The treatment of mild OSA with CPAP or mandibular advancement device and the effect on blood pressure and endothelial function after one year of treatment. J Clin Sleep Med 2021; 17:149-158. [PMID: 32964829 DOI: 10.5664/jcsm.8822] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
STUDY OBJECTIVES To evaluate and compare the effects of continuous positive airway pressure (CPAP), use of a mandibular advancement device (MAD), and no treatment on 24-hour ambulatory blood pressure monitoring and peripheral arterial tonometry at 6 and 12 months follow-up in individuals with mild obstructive sleep apnea (OSA), and in a subgroup who had an apnea-hypopnea index of < 5 events/h and adherence of ≥ 4 hours per night (effective-treatment subgroups). METHODS The inclusion criteria were individuals with mild obstructive sleep apnea, any sex, age between 18 and 65 years, and a body mass index of ≤ 35 kg/m². Patients were randomized into CPAP, MAD, and no-treatment groups. The evaluations included physical examination, full polysomnography, 24-hour ambulatory blood pressure monitoring, and peripheral arterial tonometry at baseline and after 6 and 12 months. A generalized linear mixed model was used for comparisons. RESULTS The CPAP and MAD groups had lower apnea-hypopnea indexes than the control group at 6 and 12 months, and the CPAP group had higher blood oxygen levels (SpO₂) than the MAD group. The MAD group had more hours of treatment per night and better adaptation to treatment than the CPAP group (MAD: 5.7 ± 2.7 h/night; CPAP: 3.8 ± 3.4 h/night; MAD: 16% did not adapt; CPAP: 42% did not adapt). No differences were found in the total sample and effective treatment in relation to peripheral arterial tonometry or 24-hour ambulatory blood pressure monitoring outcomes. CONCLUSIONS Treatment of mild obstructive sleep apnea with CPAP or MAD did not improve blood pressure or endothelial function after 1 year, even in patients with effective treatment. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Name: Continuous Positive Airway Pressure and Oral Appliances Treatments in Mild Obstructive Sleep Apnea; URL: https://clinicaltrials.gov/ct2/show/NCT01461486; Identifier: NCT01461486.
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Affiliation(s)
| | - Dalva Poyares
- Departamento de Psicobiologia, Universidade Federal de Sao Paulo, São Paulo, Brasil
| | | | - Gabriela Luz
- Departamento de Pneumologia, Universidade Federal de Sao Paulo, São Paulo, Brasil
| | - Glaury Coelho
- Departamento de Psicobiologia, Universidade Federal de Sao Paulo, São Paulo, Brasil
| | - Cibele Dal Fabbro
- Departamento de Psicobiologia, Universidade Federal de Sao Paulo, São Paulo, Brasil
| | - Sergio Tufik
- Departamento de Psicobiologia, Universidade Federal de Sao Paulo, São Paulo, Brasil
| | - Lia Bittencourt
- Departamento de Psicobiologia, Universidade Federal de Sao Paulo, São Paulo, Brasil
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Mochol J, Gawrys J, Gajecki D, Szahidewicz-Krupska E, Martynowicz H, Doroszko A. Cardiovascular Disorders Triggered by Obstructive Sleep Apnea-A Focus on Endothelium and Blood Components. Int J Mol Sci 2021; 22:5139. [PMID: 34066288 PMCID: PMC8152030 DOI: 10.3390/ijms22105139] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/09/2021] [Accepted: 05/10/2021] [Indexed: 12/19/2022] Open
Abstract
Obstructive sleep apnea (OSA) is known to be an independent cardiovascular risk factor. Among arousal from sleep, increased thoracic pressure and enhanced sympathetic activation, intermittent hypoxia is now considered as one of the most important pathophysiological mechanisms contributing to the development of endothelial dysfunction. Nevertheless, not much is known about blood components, which justifies the current review. This review focuses on molecular mechanisms triggered by sleep apnea. The recurrent periods of hypoxemia followed by reoxygenation promote reactive oxygen species (ROS) overproduction and increase inflammatory response. In this review paper we also intend to summarize the effect of treatment with continuous positive airway pressure (CPAP) on changes in the profile of the endothelial function and its subsequent potential clinical advantage in lowering cardiovascular risk in other comorbidities such as diabetes, atherosclerosis, hypertension, atrial fibrillation. Moreover, this paper is aimed at explaining how the presence of OSA may affect platelet function and exert effects on rheological activity of erythrocytes, which could also be the key to explaining an increased risk of stroke.
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Affiliation(s)
| | | | | | | | | | - Adrian Doroszko
- Department of Internal Medicine, Hypertension and Clinical Oncology, Faculty of Medicine, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland; (J.M.); (J.G.); (D.G.); (E.S.-K.); (H.M.)
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Imes CC, Baniak LM, Choi J, Luyster FS, Morris JL, Ren D, Chasens ER. Correlates of Endothelial Function in Older Adults With Untreated Obstructive Sleep Apnea and Cardiovascular Disease. J Cardiovasc Nurs 2020; 34:E1-E7. [PMID: 30303893 PMCID: PMC6311347 DOI: 10.1097/jcn.0000000000000536] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is a highly prevalent and consequential sleep disorder in older adults. Untreated moderate to severe OSA substantially increases the risk for hypertension and cardiovascular disease (CVD), which can be attributed to the accelerated progression of atherosclerosis and endothelial dysfunction. OBJECTIVE The aim of this study was to identify factors that can function as correlates of endothelial function in older adults with untreated, moderate to severe OSA and CVD or CVD risk factors. METHODS A subsample (N = 126) of adults aged 65 years and older from the HeartBEAT study were included in the analyses. Univariate analyses and multiple linear regression models were conducted to establish which demographic and CVD risk factors were the best correlates of endothelial function. RESULTS In the univariate analyses, sex, employment status, body mass index, waist circumference, hip-to-waist ratio, neck circumference, diastolic blood pressure, total cholesterol, high-density lipoprotein cholesterol, total cholesterol to high-density lipoprotein cholesterol ratio, plasminogen activator inhibitor-1, calcium channel blocker use, and β-blocker use were associated with endothelial function at a level of P < .10. In the most parsimonious model, male sex (b = -0.305, P < .001), calcium channel blocker use (b = -0.148, P < .019), and body mass index (b = -.014, P < .037) were negatively associated with endothelial function after adjusting for the other covariates. CONCLUSIONS The authors identified correlates of endothelial function in older adults with untreated OSA and CVD or CVD risk factors, which are different than the correlates in middle-aged adults with the same conditions.
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Affiliation(s)
- Christopher C Imes
- Christopher C. Imes, PhD University of Pittsburgh School of Nursing, Pennsylvania. Lynn M. Baniak, PhD University of Pittsburgh School of Nursing, Pennsylvania. JiYeon Choi, PhD University of Pittsburgh School of Nursing, Pennsylvania; and Yonsei University College of Nursing, Seoul, Korea. Faith S. Luyster, PhD University of Pittsburgh School of Nursing, Pennsylvania. Jonna L. Morris, BSN University of Pittsburgh School of Nursing, Pennsylvania. Dianxu Ren, MD, PhD University of Pittsburgh School of Nursing, Pennsylvania. Eileen R. Chasens, PhD University of Pittsburgh School of Nursing, Pennsylvania
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Association between nondipping pattern and EndoPAT signal in patients with mild obstructive sleep apnea. Sleep Med 2018; 51:9-14. [PMID: 30077018 DOI: 10.1016/j.sleep.2018.05.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 04/30/2018] [Accepted: 05/03/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To compare vascular endothelial function between dipping (D) and nondipping (ND) patterns in patients with and without mild obstructive sleep apnea (OSA) using EndoPAT, a test of reactive hyperemia used to assess peripheral vascular endothelial function. METHODS The sample consisted of individuals of both genders between 18 and 65 years of age with a body mass index (BMI) of ≤35 kg/m2 and apnea/hypopnea index (AHI) of ≤15. The nondipping pattern was considered present when the dip of nocturnal blood pressure (NBP) was <10%. All of the sample underwent clinical and physical evaluation, full polysomnography, 24-hour ambulatory blood pressure monitoring, and EndoPAT evaluation. A generalized linear model was used for statistical analysis. RESULTS The sample comprised 120 individuals, 35 in the control group and 85 in the mild OSA group. Four groups were formed: Control-ND, Control-D, Mild OSA-ND, and Mild OSA-D according to nocturnal ABPM patterns. The frequency of nondipping was (34.1%) in the Mild OSA group and (17.1%) in the Control group (p = 0.07). The Mild OSA-ND group had a higher augmentation index (AIx) than the Mild OSA-D group. Regression analysis showed that male gender, higher age, and nondipping status were associated with these results, whereas oxygen desaturation index (ODI) and AHI did not. With respect to the reactive hyperemia index (RHI), the Mild OSA-D group had lower values compared to the Control-ND group, but an association with OSA was not confirmed in the regression model. CONCLUSION Nondipping status was associated with a worse augmentation index in both groups independently of AHI or oxygen desaturation index. Male gender, higher age, and nondipping status were associated with augmentation index. ClinicalTrials.gov Identifier: NCT01461486.
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Silva LOE, Guimarães TM, Luz GP, Coelho G, Badke L, Almeida IR, Millani-Carneiro A, Tufik S, Bittencourt L, Togeiro SM. Metabolic Profile in Patients with Mild Obstructive Sleep Apnea. Metab Syndr Relat Disord 2017; 16:6-12. [PMID: 29148894 DOI: 10.1089/met.2017.0075] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Mild obstructive sleep apnea (OSA) is a highly prevalent disorder in adults. However, it is not clear whether mild OSA has significant metabolic complications. This study examined the prevalence of metabolic syndrome (MS) in patients with mild OSA compared to control group. METHODS Adults (18-65 years of age) of both genders with a body mass index (BMI) ≤35 kg/m2 were included. The mild OSA group comprised of patients with an apnea-hypopnea index (AHI) score of ≥5 but ≤15 events/hr of sleep, independent of other symptoms. The control group (CG) comprised individuals with an AHI of <5 events/hr of sleep and an Epworth Sleepiness Scale score of <10. The following were used for both groups: two questionnaires on sleepiness, the maintenance of wakefulness test, and full-night polysomnography. Anthropometric measurements and fasting blood samples were obtained, including fasting glucose and insulin, total cholesterol and its subfractions [low-density lipoprotein, very low-density lipoprotein, and low-density lipoprotein cholesterol (HDL-c)], triglycerides (TG), and the TG/HDL-c ratio. In addition, the quantitative insulin sensitivity check index and homeostasis model assessment indices were calculated. RESULTS Thirty-two percent of mild OSA patients had MS, 43.5% of mild OSA patients had hypertension, 14% showed dyslipidemia, and 56% had prediabetes. The OSA group showed increased TG (CG: 90.0 ± 51.9 vs. OSA: 140.3 ± 78.2 mg/dL, P = 0.004), and TG/HDL-c (CG: 1.9 ± 1.4 vs. OSA: 3.1 ± 2.0, P = 0.05), independent of adjustments. Independent of obesity (BMI <30 kg/m2), there was a negative correlation between total cholesterol and TG with mean oxygen saturation, independent of obesity (BMI <30 kg/m2). CONCLUSIONS Our findings showed dysregulation in lipid profiles after adjustments for confounders in the mild OSA group, and there was a correlation between these parameters and sleep hypoxemia. The TG/HDL-c ratio in particular was high, suggesting that it might be investigated as a marker of a detrimental metabolic profile in these patients.
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Affiliation(s)
- Luciana Oliveira E Silva
- 1 Disciplina de Medicina e Biologia do Sono, Departamento de Psicobiologia, Universidade Federal de São Paulo , São Paulo, Brazil
| | - Thais M Guimarães
- 1 Disciplina de Medicina e Biologia do Sono, Departamento de Psicobiologia, Universidade Federal de São Paulo , São Paulo, Brazil
| | - Gabriela P Luz
- 2 Departamento de Pneumologia, Universidade Federal de São Paulo , São Paulo, Brazil
| | - Glaury Coelho
- 1 Disciplina de Medicina e Biologia do Sono, Departamento de Psicobiologia, Universidade Federal de São Paulo , São Paulo, Brazil
| | - Luciana Badke
- 2 Departamento de Pneumologia, Universidade Federal de São Paulo , São Paulo, Brazil
| | - Ildonete R Almeida
- 1 Disciplina de Medicina e Biologia do Sono, Departamento de Psicobiologia, Universidade Federal de São Paulo , São Paulo, Brazil
| | - Aline Millani-Carneiro
- 1 Disciplina de Medicina e Biologia do Sono, Departamento de Psicobiologia, Universidade Federal de São Paulo , São Paulo, Brazil
| | - Sergio Tufik
- 1 Disciplina de Medicina e Biologia do Sono, Departamento de Psicobiologia, Universidade Federal de São Paulo , São Paulo, Brazil
| | - Lia Bittencourt
- 1 Disciplina de Medicina e Biologia do Sono, Departamento de Psicobiologia, Universidade Federal de São Paulo , São Paulo, Brazil
| | - Sonia M Togeiro
- 1 Disciplina de Medicina e Biologia do Sono, Departamento de Psicobiologia, Universidade Federal de São Paulo , São Paulo, Brazil
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Ruzek L, Svobodova K, Olson LJ, Ludka O, Cundrle I. Increased microcirculatory heterogeneity in patients with obstructive sleep apnea. PLoS One 2017; 12:e0184291. [PMID: 28863183 PMCID: PMC5581006 DOI: 10.1371/journal.pone.0184291] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Accepted: 08/20/2017] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Obstructive sleep apnea (OSA) is the most common form of sleep disordered breathing and has been associated with major cardiovascular comorbidities. We hypothesized that the microcirculation is impaired in patients with OSA and that the magnitude of impairment correlates to OSA severity. METHODS Subjects were consecutive patients scheduled for routine diagnostic polysomnography (PSG). OSA was defined by paradoxical rib cage movements together with abdominal excursions and by the apnea-hypopnea index (AHI) (events/hour; no apnea AHI<5; mild apnea 5≤AHI<15; moderate apnea 15≤AHI<30; severe apnea AHI ≥30). Sidestream darkfield imaging was used to assess the sublingual microcirculation. Recordings of sublingual microcirculation (5 random sites) were performed before and after overnight PSG. Data are summarized as mean (±SD); p values <0.05 were considered statistically significant. RESULTS Thirty-three consecutive patients were included. OSA was diagnosed in 16 subjects (4 moderate, 12 severe). There was no significant difference in microcirculation between subjects with moderate OSA and without OSA. However, compared to subjects without OSA, subjects with severe OSA (AHI≥30) showed a significant decrease of microvascular flow index (-0.07±0.17 vs. 0.08±0.14; p = 0.02) and increase of microvascular flow index heterogeneity (0.06±0.15 vs. -0.06±0.11; p = 0.02) overnight. Multiple regression analysis (adjusted for age and gender) showed both decrease of flow and increase of flow heterogeneity associated with AHI (b = -0.41; F = 1.8; p = 0.04 and b = 0.43; F = 1.9; p = 0.03, respectively). CONCLUSION Acute overnight microcirculatory changes are observed in subjects with severe OSA characterized by decreased flow and increased flow heterogeneity.
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Affiliation(s)
- Lukas Ruzek
- Department of Anaesthesiology and Intensive Care, St. Anna's University Hospital Brno, Brno, Czech Republic
- International Clinical Research Center, St. Anna's University Hospital Brno, Brno, Czech Republic
| | | | - Lyle J. Olson
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Ondrej Ludka
- International Clinical Research Center, St. Anna's University Hospital Brno, Brno, Czech Republic
- Internal Cardiology Department, University Hospital Brno, Brno, Czech Republic
| | - Ivan Cundrle
- Department of Anaesthesiology and Intensive Care, St. Anna's University Hospital Brno, Brno, Czech Republic
- International Clinical Research Center, St. Anna's University Hospital Brno, Brno, Czech Republic
- * E-mail:
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Hoyos CM, Melehan KL, Liu PY, Grunstein RR, Phillips CL. Does obstructive sleep apnea cause endothelial dysfunction? A critical review of the literature. Sleep Med Rev 2015; 20:15-26. [PMID: 25088969 DOI: 10.1016/j.smrv.2014.06.003] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 06/09/2014] [Accepted: 06/12/2014] [Indexed: 01/29/2023]
Affiliation(s)
- Camilla M Hoyos
- NHMRC Centre for Integrated Research and Understanding of Sleep (CIRUS), Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia.
| | - Kerri L Melehan
- NHMRC Centre for Integrated Research and Understanding of Sleep (CIRUS), Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia; Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, Australia
| | - Peter Y Liu
- Division of Endocrinology, Department of Medicine, Harbor-UCLA Medical Center and Los Angeles Biomedical Research Institute, Torrance, CA, USA
| | - Ronald R Grunstein
- NHMRC Centre for Integrated Research and Understanding of Sleep (CIRUS), Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia; Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, Australia
| | - Craig L Phillips
- NHMRC Centre for Integrated Research and Understanding of Sleep (CIRUS), Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia; Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, Sydney, Australia
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Blomster H, Tuomilehto H. Author response to: Endothelial function is not always well preserved in obese patients with mild OSA. Sleep Breath 2015; 19:17-8. [DOI: 10.1007/s11325-014-1017-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 06/02/2014] [Indexed: 11/30/2022]
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Endothelial function is not always well preserved in obese patients with mild OSA. Sleep Breath 2015; 19:15. [DOI: 10.1007/s11325-014-1010-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Accepted: 05/16/2014] [Indexed: 11/26/2022]
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Blomster H, Laitinen TP, Hartikainen JE, Laitinen TM, Vanninen E, Gylling H, Sahlman J, Kokkarinen J, Randell J, Seppä J, Tuomilehto H. Mild obstructive sleep apnea does not modulate baroreflex sensitivity in adult patients. Nat Sci Sleep 2015. [PMID: 26203292 PMCID: PMC4487157 DOI: 10.2147/nss.s82443] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is a chronic and progressive disease. OSA is associated with increased cardiovascular morbidity and mortality, the risk being more frequently encountered with severe degrees of OSA. Increased sympathetic activation and impaired cardiac autonomic control as reflected by depressed baroreceptor reflex sensitivity (BRS) are possible mechanisms involved in the cardiovascular complications of OSA. However, it is not known at what stage of OSA that changes in BRS appear. The aim of this study was to evaluate BRS in patients with mild OSA. METHODS The study population consisted of 81 overweight patients with mild OSA and 46 body weight-matched non-OSA subjects. BRS, apnea-hypopnea index, body mass index, and metabolic parameters were assessed. The phenylephrine test was used to measure BRS. RESULTS Patients in the OSA group were slightly but significantly older than the non-OSA population (50.3±9.3 years vs 45.7±11.1 years, P=0.02). Body mass index, percentage body fat, blood pressure, fasting glucose, insulin, and lipid levels did not differ between the OSA patients and non-OSA subjects. Absolute BRS values in patients with mild OSA and non-OSA subjects (9.97±6.70 ms/mmHg vs 10.51±7.16 ms/mmHg, P=0.67) and BRS values proportional to age-related and sex-related reference values (91.4%±22.7% vs 92.2%±21.8%, P=0.84) did not differ from each other. BRS <50% of the sex-specific reference value was found in 6% of patients with mild OSA and in 2% of non-OSA subjects (P=0.29). CONCLUSION Patients with mild OSA did not show evidence of disturbed BRS in comparison with weight-matched non-OSA controls.
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Affiliation(s)
- Henry Blomster
- Department of Otorhinolaryngology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Tomi P Laitinen
- Department of Clinical Physiology and Nuclear Medicine, University of Eastern Finland, Kuopio, Finland
| | - Juha Ek Hartikainen
- Department of Internal Medicine, University of Eastern Finland, Kuopio, Finland ; Heart Center, Kuopio University Hospital, Kuopio, Finland
| | - Tiina M Laitinen
- Department of Clinical Physiology and Nuclear Medicine, University of Eastern Finland, Kuopio, Finland
| | - Esko Vanninen
- Department of Clinical Physiology and Nuclear Medicine, University of Eastern Finland, Kuopio, Finland
| | - Helena Gylling
- Department of Clinical Nutrition, School of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland ; Department of Medicine, Division of Internal Medicine, University of Helsinki, Helsinki, Finland
| | - Johanna Sahlman
- Department of Otorhinolaryngology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Jouko Kokkarinen
- Department of Respiratory Medicine, Kuopio University Hospital, Kuopio, Finland
| | - Jukka Randell
- Department of Respiratory Medicine, Kuopio University Hospital, Kuopio, Finland
| | - Juha Seppä
- Department of Otorhinolaryngology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Henri Tuomilehto
- Department of Clinical Nutrition, School of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland ; Oivauni Sleep Clinic, Kuopio, Finland
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Strong interplay between metabolic syndrome, obstructive sleep apnoea, oxidative stress and arterial dysfunction. Sleep Breath 2013; 18:223-4. [PMID: 23904242 DOI: 10.1007/s11325-013-0882-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 07/19/2013] [Indexed: 01/09/2023]
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