Diagnostic and Therapeutic Approach to Sleep Disorders, High Blood Pressure and Cardiovascular Diseases: A Consensus Document by the Italian Society of Hypertension (SIIA)

STRUGGLE FOR. Italian-Polish-Spanish-Uzbek-Vietnamese Expert Forum Position Paper 2023 for better control of classical modifiable risk factors in clinical practice

The progress in pharmacotherapy that has been made in recent years, including the introduction of very effective and safe lipid-lowering and antihypertensive drugs, has not yet translated into the expected universal control of blood pressure, lipid disorders and diabetes. In the STRUGGLE FOR Italian- -Polish-Spanish-Uzbek-Vietnamese Expert Forum Position Paper 2023, experts from five countries recounted several points about the paradigms of cardiological and cardiometabolic care for better control of classical modifiable risk factors in the year 2023. It is believed herein, that the need to intensify treatment, actively search for patients with cardiovascular risk factors, especially with arterial hypertension, hypercholesterolemia and diabetes, should go hand in hand with the implementation of the latest therapy, based on single pill combinations including proven, effective antihypertensive, lipid-lowering and antidiabetic molecules, many of which are listed in the present document. There is a need to use both new technological concepts, completely new drugs, as well as novel treatment concepts such as metabolic treatment in coronary artery disease, try to intensify the fight against smoking in every way, including the available range of drugs and procedures reducing the harm. This approach will provide substantially better control of the underlying cardiovascular risk factors in countries as varied as Italy, Poland, Spain, Uzbekistan and Vietnam.

Effectiveness of Continuous Positive Airway Pressure in Treating Hypertension in Obstructive Sleep Apnea: A Traditional Review

Almost one billion individuals worldwide suffer from obstructive sleep apnea (OSA). The most widely used treatment for OSA has been continuous positive airway pressure (CPAP), but its effect on blood pressure (BP) has been challenged. Our review aims to evaluate the effects of treating OSA with CPAP on BP and BP-related morbidities in adult hypertensive patients. Medical subject headings (MeSH) terminology was used to search the PubMed Central, MEDLINE, and PubMed databases for articles on the use of CPAP in OSA patients with hypertension. We selected various forms of academic writing, encompassing complete texts that were published in the English language. The study included a total of 21 papers. OSA is a serious health concern associated with a higher risk of cardiovascular disease, kidney disease, pulmonary hypertension, and aortic stiffness, which is brought on by the periodic hypoxia caused by nocturnal respiratory episodes. For individuals with moderate-to-severe OSA, CPAP therapy has been shown to have a considerable long-term benefit with a median drop of 11 mm Hg, and high adherence results in a decrease in diastolic BP. CPAP therapy directly lowers BP in OSA patients with a body mass index (BMI) of more than 30 kg/m2 and has also demonstrated improvement in early signs of atherosclerosis with lower nocturnal systolic BP levels. OSA patients with resistant hypertension also experienced lower BP after using CPAP for a year. Therefore, our findings suggest that obesity, hypersomnolence, high nocturnal BP, prolonged CPAP usage, and resistant hypertension may all have a major impact on the BP response to CPAP therapy in individuals with severe OSA.

Sleep Disorders and Coronary Artery Disease

A sufficient amount and quality sleep is vital components for maintaining optimal physical wellbeing, cognition, and cardiovascular health. Normal sleep provides us with a low physiological stress that promotes overall cardiovascular health. Sleep disorders are common, and often goes undiagnosed. Patients with sleep disorders, commonly suffer from poor quality of life due to the poor quality of their sleep. They are associated with adverse effects on cardiovascular health, such as coronary artery disease. Sleep disorders discussed in this review article include sleep-disordered breathing (obstructive sleep apnea and central sleep apnea), insomnia and restless leg syndrome. Sleep disorders primarily have four acute adverse cardiovascular consequences. First, intermittent hypoxemia-reoxygenation in arterial blood along with PCO 2 fluctuation; second is excessive arousals; third, decreased parasympathetic and increased sympathetic tone; fourth being the large pressure swings in the intrathoracic cavity. This review focuses on classifications, and prevalence of the three major classes of sleep disorders, and the evidence to date on the association between these sleep disorders and coronary artery disease.

10-Year Risk for Cardiovascular Disease Associated with COMISA (Co-Morbid Insomnia and Sleep Apnea) in Hypertensive Subjects

Due to the few studies available, this study aimed to investigate the 10-year risk for cardiovascular disease (CVD) associated with COMISA (co-morbid insomnia and sleep apnea) in hypertensive subjects. Clinical data of 1009 hypertensive subjects extracted from the Sleep Laboratory database were analyzed. Framingham Risk Score ≥ 10% was used as a cut-off to identify hypertensive subjects with high 10-year risk for CVD. The association between 10-year risk for CVD and COMISA was investigated using logistic regression analyses. 65.3% of hypertensive subjects from our sample presented a high 10-year risk for CVD. After controlling for major confounding factors, multivariate logistic regression analyses demonstrated that unlike its components present separately, COMISA was significantly associated with high 10-year risk for CVD in hypertensive subjects (OR 1.88, 95% CI 1.01-3.51). In this study, we have demonstrated that the negative synergy between obstructive sleep apnea syndrome and insomnia disorder seems to play a central role in the 10-year risk for CVD in hypertensive subjects, which seems to indicate that the establishment of a systematic research and an adapted treatment of COMISA could open new perspectives to promote a better cardiovascular outcome in this specific subgroup of patients.

Cluster analysis of clinical phenotypic heterogeneity in obstructive sleep apnea assessed using photoplethysmography

BACKGROUND

We evaluated heterogeneity in clinical phenotypes among patients with obstructive sleep apnea syndrome (OSAHS) using photoplethysmography (PPG) in cluster analysis.

METHODS

All enrolled patients underwent polysomnography (PSG) monitoring while wearing a PPG device. Pulse wave signals were recorded with a modified pulse oximetry probe in the PPG device. The pulse wave-derived cardiac risk composite parameter (CRI) and eight derived signal parameters were used to assess OSAHS phenotype. We defined a high cardiovascular risk OSAHS group (CRI ≥0.5) and low cardiovascular risk OSAHS group (CRI <0.5). K-means clustering was performed for analysis of clinical phenotype heterogeneity in OSAHS by combining the CRI and its derived signals.

RESULTS

The OSAHS group had high cardiovascular risk for sex, age, body mass index, systolic and diastolic blood pressure, apnea hypopnea index, and obstructive arousal index and higher risk of developing hypertension, diabetes, and cerebrovascular comorbidities. The low cardiovascular risk OSAHS group had higher blood oxygen levels. Three clinical phenotypes were identified in CRI clustering: 1) typical OSAHS with high risk of hypertension (characterized by middle age, obesity, hypertension with severe OSAHS); 2) older women and mild OSAHS; 3) older men and mild OSAHS. Three subtypes were obtained based on the eight cardiac risk-derived parameters: 1) hypoxia combined with decreased pulse wave amplitude variation; 2) decreased vascular pulse wave amplitude combined with decreased pulse frequency; 3) arrhythmia combined with hypoxia.

CONCLUSIONS

Establishing OSAHS clinical phenotypes with the CRI and derived parameters using PPG may help in establishing multi-dimensional assessment of cardiovascular risk in OSAHS.

Circadian Variations in Sympathetic Vasoconstriction in Older Adults with and Without Type 2 Diabetes

INTRODUCTION

An impact of the sympathetic nervous system in the higher rate of cardiovascular events in the early morning compared to the evening has been claimed. Augmented sympathetic vasoconstriction increases cardiovascular risk by augmenting pulse pressure and cardiac afterload. Type 2 diabetes (T2DM) further increases sympathetic neurovascular transduction and cardiovascular risk.

AIM

We assessed whether peripheral vasoconstriction triggered by a standardized sympathetic stressor is augmented at 6am vs 9pm in adults between 50-80 years with type 2 diabetes (T2DM50-80) vs healthy ones (H50-80).

METHODS

Mean values of sympathetic vasoconstrictor responsiveness (SVR), vascular conductance (VC), brachial artery blood flow, and mean arterial pressure were measured on the contralateral forearm over two 5-minute bouts of rest and handgrip-mediated sympathetic stimulation, respectively.

RESULTS

Although baseline VC values were lower (p < 0.01) in the morning vs evening in both groups, SVR values in response to sympathoexcitation were similar in H50-80 (- 0.43 ± 12.44 vs - 2.57 ± 11.63 %, p = 0.73) and T2DM50-80 (+6.64 ± 10.67 vs +5.21 ± 7.64 %, p = 0.90), but higher (p < 0.01) in T2DM50-80 vs H50-80 at both day hours. Individuals with T2DM reported positive SVR values and VC change-scores, while healthy individuals reported statistically different (p < 0.02) negative SVR values and VC change-scores.

CONCLUSION

Peripheral vasoconstriction triggered by a standardized sympathetic stressor is similar between morning and evening, regardless of T2DM and different baseline VC values. However, peripheral vasoconstriction responsiveness is blunted in individuals with T2DM as handgrip-mediated sympathoexcitation induces vasodilation in the contralateral forearm in adults with T2DM and vasoconstriction in healthy age-matched controls, highlighting a neurovascular response altered by T2DM.

Hypertension treatment in patients with sleep apnea from the European Sleep Apnea Database (ESADA) cohort - towards precision medicine

We recruited 5,970 hypertensive patients with obstructive sleep apnea (OSA) on current antihypertensive treatment from the European Sleep Apnea Database (ESADA) cohort. The group was subdivided into those receiving monotherapy (n = 3,594) and those receiving dual combined therapy (n = 2,376). We studied how major OSA confounders like age, gender, and body mass index as well as the degree of sleep apnea modified office systolic and diastolic blood pressure. Beta-blockers alone or in combination with a diuretic were compared with other antihypertensive drug classes. Monotherapy with beta-blocker was associated with lower systolic blood pressure, particularly in non-obese middle-aged males with hypertension. Conversely, the combination of a beta-blocker and a diuretic was associated with lower systolic and diastolic blood pressure in hypertensive patients with moderate-severe OSA. Systolic blood pressure was better controlled in female patients using this combined treatment. Our cross-sectional data suggest that specific clinical characteristics and type of antihypertensive medication influence the degree of blood pressure control in hypertensive OSA patients. Controlled trials are warranted.

Association between sleep quality and occupational factors in Brazilian correctional officers

OBJECTIVE

To analyze the occupational factors associated with poor sleep quality in correctional officers (COs).

METHOD

This is a cross-sectional study involving COs who work at four prison facilities in the state of São Paulo, Brazil. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). Logistic and linear regression models were used to calculate the odds ratio (OR) and beta coefficient (β) of poor sleep quality and the corresponding 95% confidence interval (CI), respectively. The analyses were adjusted for the main confounders.

RESULTS

Considering the 256 male COs who participated in the study, 148 (57.8%) had poor sleep quality. In the adjusted analyses, poor sleep quality was associated with higher mental demands (OR = 3.10; 95% CI: 1.40-6.85), having suffered psychological violence at work (OR = 2.13; 95% CI: 1.04-4.35), agreeing with the following statement: "I think about work-related issues in my free time" (OR = 5.13; 95% CI: 1.26-20.78), feeling partially dissatisfied (OR = 2.26; 95% CI: 1.09-4.68) or dissatisfied with work (OR = 4.52; CI: 1.32-15.46) and willingness to find another job (OR = 3.20; 95% CI: 1.53-6.71). The occupational factors dissatisfaction with work (β = 1.02; 95% CI: 0.05-1.98) and having health problems related to the work environment (β = 0.32; 95% CI: 0.24-2.41) were also associated with higher scores on the PSQI.

CONCLUSION

Poor quality of sleep is a highly frequent health problem among correctional officers, and this condition is associated with the perception of poor working conditions, professional dissatisfaction and the fact that such professionals think about work during their free time.

Circadian rhythms and renal pathophysiology

The reality of life in modern times is that our internal circadian rhythms are often out of alignment with the light/dark cycle of the external environment. This is known as circadian disruption, and a wealth of epidemiological evidence shows that it is associated with an increased risk for cardiovascular disease. Cardiovascular disease remains the top cause of death in the United States, and kidney disease in particular is a tremendous public health burden that contributes to cardiovascular deaths. There is an urgent need for new treatments for kidney disease; circadian rhythm-based therapies may be of potential benefit. The goal of this Review is to summarize the existing data that demonstrate a connection between circadian rhythm disruption and renal impairment in humans. Specifically, we will focus on chronic kidney disease, lupus nephritis, hypertension, and aging. Importantly, the relationship between circadian dysfunction and pathophysiology is thought to be bidirectional. Here we discuss the gaps in our knowledge of the mechanisms underlying circadian dysfunction in diseases of the kidney. Finally, we provide a brief overview of potential circadian rhythm-based interventions that could provide benefit in renal disease.

Efficacy of Prolonged-Release Melatonin 2 mg (PRM 2 mg) Prescribed for Insomnia in Hospitalized Patients for COVID-19: A Retrospective Observational Study

BACKGROUND

we have observed the effect of insomnia treatment in clinical and prognostic differences of patients admitted for COVID-19 pneumonia in respiratory sub-intensive units that were administered a prolonged-release melatonin 2 mg (PRM 2 mg) therapy versus a group of patients out of therapy.

MATERIALS AND METHODS

We evaluated 40 patients on prolonged-release melatonin 2 mg (PRM 2 mg) therapy versus a control group of 40 patients out of therapy.

RESULTS

patients in the PRM 2 mg group had a shorter duration of therapy with non-invasive ventilation (5.2 ± 3.0 vs. 12.5 ± 4.2; p < 0.001), with a shorter stay in sub-intensive care (12.3 ± 3.2 vs. 20.1 ± 6.1; p < 0.001), and, therefore, a shorter overall duration of hospitalization (31.3 ± 6.8 vs. 34.3 ± 6.9 p = 0.03). In addition, a lower incidence of delirium was found (2.2 ± 1.1 vs. 3.3 ± 1.3; p < 0.001).

CONCLUSIONS

A significant increase in sleep hours and a reduction in delirium episodes occurs in hospitalized insomniac patients treated with PRM 2 mg, compared to untreated patients. Based on these preliminary results, we can assume that there are benefits of prolonged-release melatonin 2 mg in COVID-19 therapy.