Left ventricular diastolic dysfunction in obstructive sleep apnoea syndrome by an echocardiographic standardized approach: An observational study

Heart failure with preserved ejection fraction risk is associated with prevalence and severity of obstructive sleep apnea

STUDY OBJECTIVES

While heart failure with preserved ejection fraction (HFpEF) is associated with the presence of obstructive sleep apnea (OSA), few studies have examined the association between scoring systems used to predict HFpEF risk, such as the H2FPEF and HFA-PEFF scores, and OSA prevalence and severity.

METHODS

We performed chart review on all patients who underwent both an echocardiogram and sleep study at the University of Pennsylvania between July 1, 2020, and June 30, 2022. There were 277 patients in the final cohort after excluding patients with relevant comorbidities. Associations between echocardiographic parameters and OSA severity, as well as between H2FPEF score and OSA severity, were examined using linear tests of trend. The association between H2FPEF score and prevalent OSA was examined with logistic regression.

RESULTS

OSA severity was associated with echocardiographic markers, including left atrial volume index (P = .03) and left ventricular relative thickness (P = .008). Patients with high H2FPEF risk scores had over 17-fold higher odds of prevalent OSA compared with those with low-risk scores (17.7; 95% CI 4.3, 120.7; P < .001). Higher H2FPEF scores were strongly correlated with OSA severity (P < .001). After controlling for body mass index, H2FPEF scores were not associated with prevalence or severity of OSA.

CONCLUSIONS

In an ambulatory population referred for sleep study and echocardiogram, markers of diastolic dysfunction were associated with OSA severity. OSA prevalence and severity were associated with increased H2FPEF scores, although these associations were largely explained by obesity. Clinicians should have low thresholds for referring patients with OSA for cardiac workup and patients with HFpEF for sleep study.

CITATION

Connolly JE, Genuardi MV, Mora JI, Prenner SB. Heart failure with preserved ejection fraction risk is associated with prevalence and severity of obstructive sleep apnea. J Clin Sleep Med. 2024;20(3):381-387.

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

BACKGROUND AND OBJECTIVE

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

METHODS AND RESULTS

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

CONCLUSIONS

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

Assessment of right ventricular remodeling and dysfunction in obstructive sleep apnea syndrome: a prospective monocentric study

BACKGROUND

Obstructive sleep apnea (OSA) is a common sleep-related disorder that has been implicated in many serious cardiovascular diseases including cardiac remodeling and dysfunction. Since most investigations have focused on the left heart, little is known on right ventricular (RV) involvement in OSA. The role of the RV in the management of cardiovascular outcomes has become increasingly recognized. Early detection of subtle signs of RV dysfunction and remodeling in patients with OSA is crucial for optimal medical care.

PURPOSE

We aimed to investigate the effect of OSA and its severity on the RV structure and function using conventional echocardiography.

METHODS

We conducted a cross-sectional analytical study including patients with OSA who did not have heart failure or chronic pulmonary disease comparing them to controls without OSA. All patients underwent respiratory polygraphy at the Pneumology Department and standard echocardiography performed by the same blinded cardiologist at the Cardiology Department of Taher Sfar University Hospital.

RESULTS

A total of 139 patients with OSA and 45 controls were enrolled in the study. Amonth the patients, there were 32% (n = 44) with mild, 20% (n = 28) with moderate, and 48% (n = 67) with severe OSA. Sixty-three percent of the study population were women. The mean age was 54.1 ± 11.0 years. Early RV dilatation was present in the mild disease stage (RVID = 42.0 ± 7.7 mm vs. 32.4 ± 5.5 mm in controls; p < 0.0001) without obvious RVH. The systolic pulmonary artery pressure was significantly higher in patients with OSA (31.2 ± 8.2 vs. 20.9 ± 9.8; p < 0.0001). Tricuspid annular plane systolic excursion was borderline normal and significantly lower in patients with OSA (17.7 ± 4.7 vs. 26.0 ± 5.7, p < 0.0001). In multivariate analysis, an OSA was independently associated with RV remodeling (OR: 0.257, 95% CI [0.114-0.582], p = 0.001) but not with RV dysfunction.

CONCLUSION

OSA was independently associated with structural alterations of RV early in the disease course, suggesting that the reversibility of these deleterious effects requires earlier detection and initiation of treatment.

Obstructive sleep apnoea syndrome and left ventricular hypertrophy: a meta-analysis of echocardiographic studies

AIM

We investigated the association between obstructive sleep apnoea (OSA) and subclinical cardiac organ damage through a meta-analysis of echocardiographic studies that provided data on left ventricular hypertrophy (LVH), assessed as a categorical or continuous variable.

DESIGN

The PubMed, OVID-MEDLINE, and Cochrane library databases were systematically analyzed to search English-language articles published from 1 January 2000 to 15 August 2019. Studies were detected by using the following terms: 'obstructive sleep apnea', 'sleep quality', 'sleep disordered breathing', 'cardiac damage', 'left ventricular mass', 'left ventricular hypertrophy', and 'echocardiography'.

RESULTS

Meta-analysis included 5550 patients with OSA and 2329 non-OSA controls from 39 studies. The prevalence of LVH in the pooled OSA population was 45% (CI 35--55%). Meta-analysis of studies comparing the prevalence of LVH in participants with OSA and controls showed that OSA was associated with an increased risk of LVH (OR = 1.70, CI 1.44-2.00, P < 0.001). LV mass was significantly increased in patients with severe OSA as compared with controls (SMD 0.46 ± 0.08, CI 0.29-0.62, P < 0.001) or with mild OSA. This was not the case for studies comparing patients with unselected or predominantly mild OSA and controls (0.33 ± 0.17, CI -0.01 to 0.67, P = 0.057).

CONCLUSION

The present meta-analysis expands previous information on the relationship between OSA and echocardiographic LVH, so far based on individual studies. The overall evidence strongly suggests that the likelihood of LVH increases with the severity of OSA, thus exhibiting a continuous relationship.

[Cardiac functional alterations and its risk factors in elderly patients with obstructive sleep apnea syndrome free of cardiovascular disease]

OBJECTIVE

To evaluate the changes of cardiac structure and function and their risk factors in elderly patients with obstructive sleep apnea syndrome (OSA) without cardiovascular complications.

METHODS

Eighty-two elderly OSA patients without cardiovascular disease admitted between January, 2015 and October, 2016 were enrolled in this study. According to their apnea-hypopnea index (AHI, calculated as the average number of episodes of apnoea and hypopnoea per hour of sleep), the patients were divided into mild OSA group (AHI < 15) and moderate to severe OSA group (AHI ≥ 15). The demographic data and the general clinical data were recorded and fasting blood samples were collected from the patients on the next morning following polysomnographic monitoring for blood cell analysis and biochemical examination. Echocardiography was performed within one week after overnight polysomnography, and the cardiac structure, cardiac function and biochemical indexes were compared between the two groups.

RESULTS

Compared with those with mild OSA group, the patients with moderate to severe OSA had significantly higher hematocrit (0.22±0.08 vs 0.17±0.04, P=0.032) and serum creatinine level (70.94± 27.88 vs 54.49±34.22 μmol/L, P=0.022). The left ventricular ejection fraction, interventricular septal thickness, left ventricular posterior wall thickness, left atrial diameter and left ventricular end-diastolic diameter were all similar between the two groups. With a similar early diastolic mitral flow velocity (E) between the two groups, the patients with moderate to severe OSA had a significantly higher late diastolic mitral flow velocity (A) (70.35±6.87 vs 64.09±8.31, P=0.0001) and a significantly lower E/A ratio (0.98±0.06 vs 1.08±0.05, P=0.0001) than the patients with mild OSA. Multiple linear regression showed that the E/A ratio was negatively correlated with AHI (β =- 0.645, P=0.0001).

CONCLUSIONS

Cardiac diastolic function impairment may occur in elderly patients with moderate or severe OSA who do not have hypertension or other cardiovascular diseases, and the severity of the impairment is positively correlated with AHI.

Association Between Sleep Disordered Breathing and Left Ventricular Function: A Cross-Sectional Analysis of the ECHO-SOL Ancillary Study

BACKGROUND

Prior studies have found that sleep-disordered breathing (SDB) is common among those with left ventricular (LV) dysfunction and heart failure. Few epidemiological studies have examined this association, especially in US Hispanic/Latinos, who may be at elevated risk of SDB and heart failure.

METHODS

We examined associations between SDB and LV diastolic and systolic function using data from 1506 adults aged 18 to 64 years in the Hispanic Community Health Study/Study of Latinos ECHO-SOL Ancillary Study (2011-2014). Home sleep testing was used to measure the apnea-hypopnea index, a measure of SDB severity. Echocardiography was performed a median of 2.1 years later to quantify LV diastolic function, systolic function, and structure. Multivariable linear regression was used to model the association between apnea-hypopnea index and echocardiographic measures while accounting for the complex survey design, demographics, body mass, and time between sleep and echocardiographic measurements.

RESULTS

Each 10-unit increase in apnea-hypopnea index was associated with 0.2 (95% CI, 0.1-0.3) lower E', 0.3 (0.1-0.5) greater E/E' ratio, and 1.07-fold (1.03-1.11) higher prevalence of diastolic dysfunction as well as 1.3 (0.3-2.4) g/m2 greater LV mass index. These associations persisted after adjustment for hypertension and diabetes mellitus. In contrast, no association was identified between SDB severity and subclinical markers of LV systolic function.

CONCLUSIONS

Greater SDB severity was associated with LV hypertrophy and subclinical markers of LV diastolic dysfunction. These findings suggest SDB in Hispanic/Latino men and women may contribute to the burden of heart failure in this population.

Targeting Concentric Left Ventricular Hypertrophy in Obstructive Sleep Apnea Syndrome. A Meta-analysis of Echocardiographic Studies

AIM

We assessed the association between obstructive sleep apnea (OSA) and left ventricular hypertrophy (LVH) subtypes (i.e., concentric and eccentric LVH) trough a meta-analysis of echocardiographic studies.

DESIGN

The PubMed, OVID-MEDLINE, and Cochrane library databases were systematically analyzed to search full papers published from 1st January 2000 to 31st August 2019. Studies were detected by using the following terms: "obstructive sleep apnea", "sleep disordered breathing", "left ventricular mass", "left ventricular geometry", "left ventricular hypertrophy", "echocardiography".

RESULTS

Meta-analysis included 1,760 patients with OSA and 1,284 non-OSA controls from 9 studies. The prevalence rates of concentric and eccentric LVH in the pooled OSA population were 24.0% (confidence interval [CI] 16.0-33.0%) and 16.0% (CI 12.0-23.0%), respectively. Meta-analysis of six studies comparing the prevalence of LVH subtypes in participants with OSA and controls showed that OSA was associated with an increased risk of both concentric (odds ratio [OR] = 1.62, CI: 1.27-2.07, P < 0.0001) and eccentric (OR = 1.34, CI: 1.07-1.67, P < 0.009) LVH, respectively.

CONCLUSIONS

Our findings suggest that in the OSA setting concentric LVH is more frequent than eccentric LVH. From a practical perspective, in consideration of the particularly adverse prognostic significance of concentric LVH, a comprehensive echocardiographic evaluation targeting LVH subtypes could improve cardiovascular risk stratification in patients with OSA.

Subclinical impairment of dynamic left ventricular systolic and diastolic function in patients with obstructive sleep apnea and preserved left ventricular ejection fraction

Background

Hypoxia affects myocardial oxygen supply resulting in subclinical cardiac dysfunction in obstructive sleep apnea (OSA) patients, with cardiovascular complications being associated with increased oxidative burst (OB). The aims of our study were to assess left ventricular (LV) dynamic myocardial deformation and diastolic reserve at rest and upon exercise, along with OB determination in this patients subset.

Methods

Conventional echocardiography, Doppler myocardial imaging and LV 2D speckle tracking echocardiography were performed in 55 OSA patients with preserved LV ejection fraction (EF) and 35 age and sex-comparable healthy controls. Peripheral OB levels were evaluated by flow cytometry.

Results

Despite comparable LVEF, LV global longitudinal strain (GLS) was significantly reduced in OSA at rest (− 13.4 ± 3.8 vs − 18.4 ± 3.3 in controls, P <  0.001) and at peak exercise (− 15.8 ± 2.6 vs − 23.4 ± 4.3, P <  0.001). Systolic pulmonary artery pressure (sPAP) and E/E′ ratios increase during effort were higher in OSA than in controls (ΔsPAP 44.3% ± 6.4 vs 32.3% ± 5.5, P <  0.0001, and ΔE/E’ 87.5% ± 3.5 vs 25.4% ± 3.3, P <  0.0001, respectively). The best correlate of E/E′ at peak stress was peak exertion capacity (r = − 0.50, P <  0.001). OB was also increased in OSA patients (P = 0.001) but, unlike OSA severity, was not associated with LV diastolic dysfunction.

Conclusions

Evaluation of diastolic function and myocardial deformation during exercise is feasible through stress echocardiography. OSA patients with preserved LVEF show subclinical LV systolic dysfunction, impaired LV systolic and diastolic reserve, reduced exercise tolerance, and increased peripheral levels of OB. Therapy aimed at increasing LV diastolic function reserve might improve the quality of life and exercise tolerability in OSA patients.

Nocturnal Hypoxemia Impacts Right Ventricle Diastolic Function in Obstructive Sleep Apnea: A Retrospective Observational Study

Obstructive sleep apnea (OSA), although a growing healthcare problem and documented risk factor for cardiovascular diseases, is still under-diagnosed in cardiac patients. To investigate the correlation between OSA and echocardiographic parameters of right ventricle diastolic (RVD) dysfunction, in particular trans-tricuspid E-wave deceleration time (EDT), we retrospectively analyzed data of 103 pure (comorbidity-free) OSA patients with comprehensive echocardiographic examination (ETT). Apnea/hypopnea index (AHI), oxygen desaturation index (ODI), mean nighttime oxyhemoglobin saturation (SpO₂), time elapsed with SpO₂ < 90% (T90) and mean peak desaturation of nocturnal events (Mdes, graded as mild, medium or severe) were compared with echocardiographic parameters. We found RVD dysfunction present in 58.3% of patients. Altered EDT correlated significantly with mean SpO₂, T90, and Mdes (p < 0.01, all). Nocturnal desaturators had a significantly worse EDT than non-desaturators (p = 0.027) and a higher risk of prolonged EDT (odds ratio, OR = 2.86). EDT differed significantly according to Mdes severity (p = 0.005) with a higher risk of prolonged EDT in medium/severe vs. mild Mdes (OR = 3.44). EDT detected the presence of RVD dysfunction in 58.3% of our pure OSA patients. It correlated poorly with AHI severity but strongly with nocturnal desaturation severity, independently of age. This ETT marker may be useful for deciding appropriate diagnostic and therapeutic strategies.