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Sterling KL, Alpert N, Malik AS, Pépin JL, Benjafield AV, Malhotra A, Piccini JP, Cistulli PA. Association Between Sleep Apnea Treatment and Health Care Resource Use in Patients With Atrial Fibrillation. J Am Heart Assoc 2024; 13:e030679. [PMID: 38700039 PMCID: PMC11179930 DOI: 10.1161/jaha.123.030679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 03/01/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) contributes to the generation, recurrence, and perpetuation of atrial fibrillation, and it is associated with worse outcomes. Little is known about the economic impact of OSA therapy in atrial fibrillation. This retrospective cohort study assessed the impact of positive airway pressure (PAP) therapy adherence on health care resource use and costs in patients with OSA and atrial fibrillation. METHODS AND RESULTS Insurance claims data for ≥1 year before sleep testing and 2 years after device setup were linked with objective PAP therapy use data. PAP adherence was defined from an extension of the US Medicare 90-day definition. Inverse probability of treatment weighting was used to create covariate-balanced PAP adherence groups to mitigate confounding. Of 5867 patients (32% women; mean age, 62.7 years), 41% were adherent, 38% were intermediate, and 21% were nonadherent. Mean±SD number of all-cause emergency department visits (0.61±1.21 versus 0.77±1.55 [P=0.023] versus 0.95±1.90 [P<0.001]), all-cause hospitalizations (0.19±0.69 versus 0.24±0.72 [P=0.002] versus 0.34±1.16 [P<0.001]), and cardiac-related hospitalizations (0.06±0.26 versus 0.09±0.41 [P=0.023] versus 0.10±0.44 [P=0.004]) were significantly lower in adherent versus intermediate and nonadherent patients, as were all-cause inpatient costs ($2200±$8054 versus $3274±$12 065 [P=0.002] versus $4483±$16 499 [P<0.001]). All-cause emergency department costs were significantly lower in adherent and intermediate versus nonadherent patients ($499±$1229 and $563±$1292 versus $691±$1652 [P<0.001 and P=0.002], respectively). CONCLUSIONS These data suggest clinical and economic benefits of PAP therapy in patients with concomitant OSA and atrial fibrillation. This supports the value of diagnosing and managing OSA and highlights the need for strategies to enhance PAP adherence in this population.
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Affiliation(s)
| | | | | | - Jean-Louis Pépin
- Institut National de la Santé et de la Recherche Médicale (INSERM) U 1300, HP2 Laboratory (Hypoxia: Pathophysiology), Grenoble Alpes University Grenoble France
| | | | | | - Jonathan P Piccini
- Duke Heart Center, Department of Medicine Duke University Medical Center Durham NC
| | - Peter A Cistulli
- Charles Perkins Centre, Faculty of Medicine and Health University of Sydney Sydney Australia
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Bonsignore MR. Adaptive responses to chronic intermittent hypoxia: contributions from the European Sleep Apnoea Database (ESADA) Cohort. J Physiol 2023; 601:5467-5480. [PMID: 37218069 DOI: 10.1113/jp284108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 05/18/2023] [Indexed: 05/24/2023] Open
Abstract
Obstructive sleep apnoea (OSA) is a common disease in the general population, and is associated with increased cardiovascular risk and several comorbidities. Obesity favours upper airway collapsibility, but other pathophysiological traits have been identified, i.e. upper airway muscle activity, modulation of the respiratory drive, and the arousal threshold. OSA causes chronic intermittent hypoxia, inflammatory activation and autonomic imbalance with diurnal and nocturnal sympathetic hyperactivity. Disentangling so many components to investigate the pathogenesis of OSA's consequences is very hard clinically. However, albeit imperfect, clinical medicine constitutes a major source of inspiration for basic research, and a mutual exchange of information is essential between clinicians and physiologists to improve our understanding of disease states. OSA is no exception, and this narrative review will summarize the results of clinical studies performed over the years by the European Sleep Apnoea Database (ESADA) Study Group, to explore the variables linked to markers of intermittent hypoxia as opposed to the traditional assessment of OSA severity based on the frequency of respiratory events during sleep (the Apnoea Hypopnoea Index). The results of the clinical studies indicate that intermittent hypoxia variables are associated with several comorbidities, although evidence of a cause-effect relationship is still missing in many cases. It is also possible that adaptive rather than maladaptive responses could be evoked by intermittent hypoxia. The intensity, duration and frequency of intermittent hypoxia episodes causing adaptive rather than maladaptive responses, and their clinical implications, deserve further investigation.
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Affiliation(s)
- Maria R Bonsignore
- PROMISE Department, University of Palermo, Palermo, Italy
- Sleep Disordered Breathing Clinic, Division of Pneumology, V. Cervello Hospital, Palermo, Italy
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Saleeb-Mousa J, Nathanael D, Coney AM, Kalla M, Brain KL, Holmes AP. Mechanisms of Atrial Fibrillation in Obstructive Sleep Apnoea. Cells 2023; 12:1661. [PMID: 37371131 DOI: 10.3390/cells12121661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/12/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Obstructive sleep apnoea (OSA) is a strong independent risk factor for atrial fibrillation (AF). Emerging clinical data cite adverse effects of OSA on AF induction, maintenance, disease severity, and responsiveness to treatment. Prevention using continuous positive airway pressure (CPAP) is effective in some groups but is limited by its poor compliance. Thus, an improved understanding of the underlying arrhythmogenic mechanisms will facilitate the development of novel therapies and/or better selection of those currently available to complement CPAP in alleviating the burden of AF in OSA. Arrhythmogenesis in OSA is a multifactorial process characterised by a combination of acute atrial stimulation on a background of chronic electrical, structural, and autonomic remodelling. Chronic intermittent hypoxia (CIH), a key feature of OSA, is associated with long-term adaptive changes in myocyte ion channel currents, sensitising the atria to episodic bursts of autonomic reflex activity. CIH is also a potent driver of inflammatory and hypoxic stress, leading to fibrosis, connexin downregulation, and conduction slowing. Atrial stretch is brought about by negative thoracic pressure (NTP) swings during apnoea, promoting further chronic structural remodelling, as well as acutely dysregulating calcium handling and electrical function. Here, we provide an up-to-date review of these topical mechanistic insights and their roles in arrhythmia.
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Affiliation(s)
- James Saleeb-Mousa
- School of Biomedical Sciences, Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
- School of Biomedical Sciences, Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Demitris Nathanael
- School of Biomedical Sciences, Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Andrew M Coney
- School of Biomedical Sciences, Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
- School of Biomedical Sciences, Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Manish Kalla
- School of Biomedical Sciences, Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
- Queen Elizabeth Hospital, Birmingham B15 2GW, UK
| | - Keith L Brain
- School of Biomedical Sciences, Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
- School of Biomedical Sciences, Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Andrew P Holmes
- School of Biomedical Sciences, Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
- School of Biomedical Sciences, Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
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Association of Obstructive Sleep Apnea and Atrial Fibrillation in Acute Ischemic Stroke: A Cross-Sectional Study. J Pers Med 2023; 13:jpm13030527. [PMID: 36983709 PMCID: PMC10051494 DOI: 10.3390/jpm13030527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 03/09/2023] [Accepted: 03/10/2023] [Indexed: 03/17/2023] Open
Abstract
Background: There is a growing body of evidence suggesting a link between obstructive sleep apnea (OSA) and atrial fibrillation (AF). The primary objective of this study is to evaluate the association between OSA and AF in acute ischemic stroke. The secondary objective is to describe the clinical features of patients with acute ischemic stroke and concomitant OSA. Methods: We enrolled consecutive patients with acute ischemic stroke. All patients underwent full-night cardiorespiratory polygraphy. To determine if there is an association between AF and OSA, we compared the observed frequency of this association with the expected frequency from a random co-occurrence of the two conditions. Subsequently, patients with and without OSA were compared. Results: A total of 174 patients were enrolled (mean age 67.3 ± 11.6 years; 95 males). OSA and AF were present in 89 and 55 patients, respectively. The association OSA + AF was observed in 33/174 cases, which was not statistically different compared to the expected co-occurrence of the two conditions. Patients with OSA showed a higher neck circumference and body mass index, a higher prevalence of hypertension and dysphagia, and a higher number of central apneas/hypoapneas. In the multivariate analysis, dysphagia and hypertension were independent predictors of OSA. A positive correlation was observed between OSA severity, BMI, and neck circumference. The number of central apneas/hypoapneas was positively correlated with stroke severity. Conclusions: Our data suggest that OSA and AF are highly prevalent but not associated in acute stroke. Our findings support the hypothesis that OSA acts as an independent risk factor for stroke.
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LncRNA XR_595552 inhibition alleviates intermittent hypoxia-induced cardiomyocyte damage via activating the PI3K/AKT pathway. Sleep Breath 2023; 27:129-136. [PMID: 35195829 DOI: 10.1007/s11325-022-02584-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 12/09/2021] [Accepted: 02/15/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Although the long noncoding RNAs (lncRNAs) expression profiles have been observed in previous study, the biological functions and underlying mechanisms of lncRNAs in OSA-related cardiac injury have not been elucidated. In the present study, we investigated a novel lncRNA, lncRNA XR_595552, and evaluated its role in intermittent hypoxia (IH)-induced damage in H9c2 cardiomyocytes. METHODS H9c2 cells were exposed to IH condition. Real-time quantitative polymerase chain reaction (RT-qPCR) was conducted to measure the expression changes of lncRNA XR_595552 in H9c2 cells stimulated by IH. H9c2 cells were subjected to IH after transfection. CCK-8 was used to evaluate cell viability, and apoptosis was analyzed by Western blotting. Additionally, the regulatory relationship between lncRNA XR_595552 and PI3K/AKT was tested by RT-qPCR and Western blot. RESULTS IH significantly induced injury in H9c2 cells (inhibited cell viability and promoted cell apoptosis). lncRNA XR_595552 was upregulated in a cell model of IH. Inhibition of lncRNA XR_595552 protected H9c2 cells against IH-induced damage, as the viability was increased, Bax, Caspase-9, and Caspase-3 were downregulated, and Bcl-2 was upregulated. More interestingly, lncRNA XR_595552 downregulation activated the PI3K/AKT pathway. Blocking the PI3K/AKT signal pathway by the use of LY294002 eliminated the myocardioprotective effects of lncRNA XR_595552 in H9c2 cells under IH condition. CONCLUSIONS The results show that lncRNA XR_595552, a novel lncRNA, may play a protective role in attenuating IH-induced injury in cardiomyocytes via a regulating PI3K/AKT pathway. The findings suggest that this lncRNA could serve as a therapeutic target to treat OSA-related cardiovascular disorders.
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Gong M, Shao J. Effect of Simultaneous Multiplane Surgery on Cardiopulmonary Function in Patients with Moderate to Severe Obstructive Sleep Apnea-Hypopnea Syndrome and Its Curative Effect. BIOMED RESEARCH INTERNATIONAL 2022; 2022:9241635. [PMID: 36158884 PMCID: PMC9499775 DOI: 10.1155/2022/9241635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/07/2022] [Accepted: 08/12/2022] [Indexed: 11/27/2022]
Abstract
Objective To investigate the changes in cardiopulmonary function in patients with obstructive sleep apnea-hypopnea syndrome (OSAHS) by one-stage multiplane surgery. Methods 70 patients with moderate and severe OSAHS underwent nasal in our hospital from July 2017 to February 2021, palatopharyngeal, and/or tongue operations simultaneously and were followed up for 6 months. The Epworth Sleeping Scale (ESS) scores of patients before and after surgery were compared to observe the surgical efficacy, and the changes in the cardiopulmonary function of patients before and after surgery were detected. The static and dynamic indexes of cardiopulmonary function, respiratory disturbance index (AHI), and blood oxygen saturation (SaO2) were compared before and after the operation. Results After surgery, all patients' indexes of static lung function were improved compared with that before surgery. After surgery, the percentage of maximal oxygen uptake peak to the predicted value, percentage of oxygen pulse to the predicted value, the ratio of oxygen uptake power, anaerobic threshold, and maximum ventilatory capacity per minute/maximum exercise volume were increased compared with that before surgery, and AHI and SaO2 were improved compared with that before surgery. Conclusion This study suggests that it is feasible for patients with OSAHS who are unable to tolerate or unwilling to undergo noninvasive assisted ventilation to undergo simultaneous surgery for multiplane stenosis. It can reduce clinical symptoms and improve cardiopulmonary function.
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Affiliation(s)
- Mingjie Gong
- Department of Otorhinolaryngology-Head and Neck Surgery, Affiliated Hospital of Jiangnan University, China
| | - Jingwen Shao
- Department of Otorhinolaryngology-Head and Neck Surgery, Affiliated Hospital of Jiangnan University, China
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Xu W, Yang YM, Zhu J, Wu S, Wang J, Zhang H, Shao XH, Mo R, Tan JS, Wang JY. Clinical characteristics and thrombotic risk of atrial fibrillation with obstructive sleep apnea: results from a multi-center atrial fibrillation registry study. BMC Cardiovasc Disord 2022; 22:331. [PMID: 35879670 PMCID: PMC9310481 DOI: 10.1186/s12872-022-02773-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 07/13/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sleep apnea is a risk factor for atrial fibrillation (AF) but it is underdiagnosed. Whether obstructive sleep apnea (OSA) is correlated with thrombotic risk in AF remains unclear. The aim of the present study was to analyze the clinical characteristics and assess the thrombotic risk of AF with OSA. METHODS In the present registry study,1990 consecutive patients with AF from 20 centers were enrolled. The patients were divided into 2 groups depending on whether they presented with both AF and OSA. All the patients were followed up for 1 year to evaluate the incidences of stroke and non-central nervous system (CNS) embolism. RESULTS Of the 1990 AF patients, 70 (3.5%) and 1920 (96.5%) patients were in the OSA group and non-OSA group, respectively. The results of the multivariate logistic model analysis showed that male sex, body mass index (BMI), smoking, and major bleeding history were independent risk factors for patients with AF and OSA. The comparison of the Kaplan-Meier curves using the log-rank test revealed that AF with OSA was correlated with an increased risk of non-CNS embolism (p < 0.01). After multivariate adjustments were performed, OSA remained an independent risk factor for non-CNS embolism (HR 5.42, 95% CI 1.34-22.01, p = 0.02), but was not correlated with the risk of stroke in patients with AF. CONCLUSIONS The present study revealed that male sex, high BMI values, smoking, and major bleeding history were independent risk factors for patients with AF and OSA. Moreover, OSA was an independent risk factor for non-CNS embolism in AF. Our results indicate that non-CNS embolism requires focus in patients with AF and OSA.
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Affiliation(s)
- Wei Xu
- Emergency Center, National Center for Cardiovascular Disease, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, 100037, Beijing, People's Republic of China
| | - Yan-Min Yang
- Emergency Center, National Center for Cardiovascular Disease, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, 100037, Beijing, People's Republic of China.
| | - Jun Zhu
- Emergency Center, National Center for Cardiovascular Disease, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, 100037, Beijing, People's Republic of China
| | - Shuang Wu
- Emergency Center, National Center for Cardiovascular Disease, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, 100037, Beijing, People's Republic of China
| | - Juan Wang
- Emergency Center, National Center for Cardiovascular Disease, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, 100037, Beijing, People's Republic of China
| | - Han Zhang
- Emergency Center, National Center for Cardiovascular Disease, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, 100037, Beijing, People's Republic of China
| | - Xing-Hui Shao
- Emergency Center, National Center for Cardiovascular Disease, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, 100037, Beijing, People's Republic of China
| | - Ran Mo
- Emergency Center, National Center for Cardiovascular Disease, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, 100037, Beijing, People's Republic of China
| | - Jiang-Shan Tan
- Emergency Center, National Center for Cardiovascular Disease, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, 100037, Beijing, People's Republic of China
| | - Jing-Yang Wang
- Emergency Center, National Center for Cardiovascular Disease, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, 100037, Beijing, People's Republic of China
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Effect of continuous positive airway pressure therapy on recurrence of atrial fibrillation after pulmonary vein isolation in patients with obstructive sleep apnea: A randomized controlled trial. Heart Rhythm 2022; 19:1433-1441. [PMID: 35716856 DOI: 10.1016/j.hrthm.2022.06.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 06/07/2022] [Accepted: 06/10/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is associated with atrial fibrillation (AF). It is unknown whether treatment with continuous positive airway pressure (CPAP) reduces AF recurrence after catheter ablation with pulmonary vein isolation (PVI). OBJECTIVE We aimed to assess the effect of CPAP treatment on the recurrence and burden of AF after PVI in patients with OSA. METHODS We randomized patients with paroxysmal AF and an apnea-hypopnea index (AHI) ≥15 events/h to treatment with CPAP or standard care. Heart rhythm was monitored by an implantable loop recorder. AF recurrence after PVI was defined as any episode of AF lasting more than 2 minutes after a 3-month blanking period. RESULTS PVI was performed in 83 patients. 37 patients were randomized to CPAP treatment and 46 patients to standard care. The AHI was reduced from 26.7 ± 14 to 1.7 ± 1.3 events/h at follow-up in the CPAP group (P = .001). 57 % of patients in both the CPAP group and the standard care group had at least one episode of AF 3-12 months after PVI (P for difference = 1.00). AF burden after ablation was reduced in both groups, with no between-group difference (P = .69). CONCLUSION In patients with paroxysmal AF and OSA, treatment with CPAP did not further reduce the risk of AF recurrence after ablation. PVI considerably reduced the burden of AF in OSA-patients, without any difference between the groups.
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Can Weight Loss Improve the Cardiovascular Outcomes of Patients with Obesity and Obstructive Sleep Apnea? HEARTS 2022. [DOI: 10.3390/hearts3020008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Cardiovascular events are the primary cause of mortality in patients with obstructive sleep apnea and obesity. The rising prevalence of obstructive sleep apnea in recent decades has been linked to increasing rates of obesity. Obstructive sleep apnea has also been linked with many different cardiovascular diseases including coronary artery disease, stroke, heart failure, hypertension, and atrial fibrillation. Obesity is an increasing health concern globally, in part because obesity complications such as hypertension, diabetes, and obstructive sleep apnea increase the risk of cardiovascular diseases. More than 10% weight loss may be required to prevent or reverse obesity complications. Treatment approaches to obesity include nutritional therapy, exercise therapy, pharmacotherapy, and surgical therapies. This review intends to identify the effects of weight loss on cardiovascular outcomes in patients with obesity and obstructive sleep apnea. Despite the strong association between cardiovascular diseases and obstructive sleep apnea, randomized trials have failed to demonstrate that treatment of obstructive sleep apnea reduces cardiovascular events, even in patients with established cardiovascular diseases. Weight loss in patients with obstructive sleep apnea improves HbA1c, systolic blood pressure, HDL cholesterol, and triglycerides, but thus far no changes in cardiovascular events have been shown. The combination of weight loss with continuous positive airway pressure (CPAP) appears more beneficial than either treatment in isolation. Large well-controlled trials in patients with obstructive sleep apnea to assess the effects of different weight reduction programs on cardiovascular disease are still needed.
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[A long-term ischemic stroke risk score model in patients aged 60 years and older with obstructive sleep apnea: a multicenter prospective cohort study]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2022; 42:338-346. [PMID: 35426796 PMCID: PMC9010997 DOI: 10.12122/j.issn.1673-4254.2022.03.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To analyze the independent risk factors of long-term ischemic stroke and establish a nomogram for predicting the long-term risks in elderly patients with obstructive sleep apnea (OSA). METHODS This multicenter prospective cohort study was conducted from January, 2015 to October, 2017 among consecutive elderly patients (≥60 years) with newly diagnosed OSA without a history of cardio-cerebrovascular diseases and loss of important clinical indicators. The follow-up outcome was the occurrence of ischemic stroke. The baseline demographic and clinical data, sleep parameters, laboratory and ultrasound results were collected from all the patients, who were randomized into the modeling group (n=856) and validation group (n=258) at a 3∶1 ratio. LASSO regression was used for variable reduction and dimension screening, and the risk score prediction model of ischemic stroke was established based on Cox proportional hazard regression. RESULTS In the total of 1141 patients enrolled in this study, 58 (5.08%) patients experienced ischemic stroke during the median follow-up of 42 months (range 41-54 months). The cumulative incidence of ischemic stroke was 5.14% in the model group and 4.91% in the verification group (P < 0.05). Age (HR=3.44, 95% CI: 2.38- 7.77), fasting blood glucose (FPG) (HR=2.13, 95% CI: 1.22-3.72), internal diameter of the ascending aorta (HR=2.60, 95% CI: 1.0- 4.47), left atrial anteroposterior diameter (HR=1.98, 95% CI: 1.75-2.25) and minimum oxygen saturation (LSpO2) (HR=1.57, 95% CI: 1.20-1.93) were identified as independent risk factors for ischemic stroke (P < 0.05 or 0.01). A long-term ischemic stroke risk score model was constructed based the regression coefficient ratios of these 5 risk variables. Before and after the application of the Bootstrap method, the AUC of the cohort risk score model was 0.84 (95% CI: 0.78- 0.90) and 0.85 (95% CI: 0.78- 0.89) in the model group and was 0.83 (95% CI: 0.73-0.93) and 0.82 (95%CI: 0.72-0.90) in the verification group, respectively, suggesting a good prediction efficiency and high robustness of the model. At the best clinical cutoff point, the cumulative incidence of ischemic stroke was significantly higher in the high-risk group than in the low-risk group (P=0.021). CONCLUSION This model can help to identify high-risk OSA patients for early interventions of the risks of ischemic stroke associated with OSA.
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Jensen MH, Dalgaard F, Laub RR, Gottlieb V, Hansen ML, Vendelboe O, Hansen J, Lamberts M. Protocol for detecting unrecognized sleep apnea in patients with atrial fibrillation by a home-monitoring device: the DAN-APNO study. BMC Cardiovasc Disord 2022; 22:6. [PMID: 34998370 PMCID: PMC8742371 DOI: 10.1186/s12872-021-02453-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 12/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Determining the presence of modifiable risk factors for atrial fibrillation (AF), such as sleep apnea is of clinical importance due to the potential impact targeting these risk factors can have on the progression and burden of AF. Using new digital-based technology is a promising solution to the underreporting of sleep apnea highlighted by academical societies in recent years. The aim of this study is to report the prevalence and severity of sleep apnea in patients with AF and, secondarily, assess the accuracy and feasibility of a new home-screening device for sleep apnea (NightOwl™ by Ectosense). METHODS DAN-APNO is a cross-sectional study at the Department of Cardiology, Herlev-Gentofte Hospital recruiting patients with AF referred to anticoagulation initiation aged 18 to 90 years without known sleep apnea. At least 150 patients will be recruited and undergo medical history, clinical evaluation, several sleep-apnea questionnaires, and a sleep-recording evaluation for four nights with sleep apnea home-monitoring device NightOwl™. Additionally, the first 20 participants and participants with moderate-severe sleep apnea by screening are referred to cardio-respiratory monitoring (CRM). This clinical evaluation allows the comparison of standard evaluation method and the NightOwl™. Clinical measures include Apnea-Hypopnea Index (AHI), Oxygen Desaturation Index (ODI), pulse rate, as well as questionaries about sleep apnea assessment and the clinical feasibility of the NightOwl™ device. Main outcomes comprise analysis of the prevalence and severity of sleep apnea, and clinical and demographic predictors of moderate and severe sleep apnea. In addition, correlation analyses for accuracy measures between CRM and NightOwl™ will be conducted along with patient ease-of-use and satisfaction questionnaires. DISCUSSION This study is limited by selection bias; only patients with atrial fibrillation from anticoagulation clinic is asked to participate, which could limit the generalizability of our results. However, this study aims to test whether a miniaturized simple home-monitoring device for detecting sleep apnea in patients with AF potentially can evaluate sleep apnea more conveniently and easier. Trial Registration The study is registered the 18-02-2021 at clinicaltrials.gov with registration number: NCT04760002.
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Affiliation(s)
- Mads Hashiba Jensen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Kildegaardsvej 28, 2900, Hellerup, Denmark.
| | - Frederik Dalgaard
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Kildegaardsvej 28, 2900, Hellerup, Denmark
| | - Rasmus Rude Laub
- Department of Pulmonology, Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - Vibeke Gottlieb
- Department of Pulmonology, Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - Morten Lock Hansen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Kildegaardsvej 28, 2900, Hellerup, Denmark
| | - Olav Vendelboe
- Department of Cardiology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Jim Hansen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Kildegaardsvej 28, 2900, Hellerup, Denmark
| | - Morten Lamberts
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Kildegaardsvej 28, 2900, Hellerup, Denmark
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Čarná Z, Osmančík P. The Effect of Obesity, Hypertension, Diabetes Mellitus, Alcohol, and Sleep Apnea on the Risk of Atrial Fibrillation. Physiol Res 2021. [DOI: 10.33549//physiolres.934744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia associated with a two-fold increase in mortality caused by a higher risk of stroke and heart failure. Currently, AF is present in ~ 2 % of the general population, and its incidence and prevalence are increasing. Obesity, hypertension, diabetes mellitus, obstructive sleep apnea, and alcohol consumption increase the risk of AF. Each unit of increase in BMI increases the risk of AF by 3 %, and intensive weight loss is also associated with reduced AF recurrence. Hypertension increases the risk of AF by 50 % in men and by 40 % in women, and explains ≈ 20 % of new AF cases. Patients with obstructive sleep apnea are at four times higher risk of developing AF than subjects without sleep apnea. Higher concentrations of pro-inflammatory cytokines, higher amounts of epicardial adipose tissue, and a higher degree of ventricular diffuse myocardial fibrosis are present in AF patients and patients with the aforementioned metabolic disorders. Several prospective cohort studies and randomized trials have been initiated to show whether weight loss and treatment of other risk factors will be associated with a reduction in AF recurrences.
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Affiliation(s)
| | - P Osmančík
- Cardiocenter, Charles University Prague, Dept. Of Cardiology, Prague, Czech Republic.
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Predicting Incident Atrial Fibrillation Using Single Channel Nocturnal Oximetry: Can Necessity Become the Mother of Intervention? Ann Am Thorac Soc 2021; 18:952-954. [PMID: 34076560 PMCID: PMC8456733 DOI: 10.1513/annalsats.202103-281ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
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Boriani G, Vitolo M, Diemberger I, Proietti M, Valenti AC, Malavasi VL, Lip GYH. Optimizing indices of AF susceptibility and burden to evaluate AF severity, risk and outcomes. Cardiovasc Res 2021; 117:1-21. [PMID: 33913486 PMCID: PMC8707734 DOI: 10.1093/cvr/cvab147] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/15/2021] [Accepted: 04/29/2021] [Indexed: 02/06/2023] Open
Abstract
Atrial fibrillation (AF) has heterogeneous patterns of presentation concerning symptoms,
duration of episodes, AF burden, and the tendency to progress towards the terminal step of
permanent AF. AF is associated with a risk of stroke/thromboembolism traditionally
considered dependent on patient-level risk factors rather than AF type, AF burden, or
other characterizations. However, the time spent in AF appears related to an incremental
risk of stroke, as suggested by the higher risk of stroke in patients with clinical AF vs.
subclinical episodes and in patients with non-paroxysmal AF vs. paroxysmal AF. In patients
with device-detected atrial tachyarrhythmias, AF burden is a dynamic process with
potential transitions from a lower to a higher maximum daily arrhythmia burden, thus
justifying monitoring its temporal evolution. In clinical terms, the appearance of the
first episode of AF, the characterization of the arrhythmia in a specific AF type, the
progression of AF, and the response to rhythm control therapies, as well as the clinical
outcomes, are all conditioned by underlying heart disease, risk factors, and
comorbidities. Improved understanding is needed on how to monitor and modulate the effect
of factors that condition AF susceptibility and modulate AF-associated outcomes. The
increasing use of wearables and apps in practice and clinical research may be useful to
predict and quantify AF burden and assess AF susceptibility at the individual patient
level. This may help us reveal why AF stops and starts again, or why AF episodes, or
burden, cluster. Additionally, whether the distribution of burden is associated with
variations in the propensity to thrombosis or other clinical adverse events. Combining the
improved methods for data analysis, clinical and translational science could be the basis
for the early identification of the subset of patients at risk of progressing to a longer
duration/higher burden of AF and the associated adverse outcomes.
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Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Igor Diemberger
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Cardiology, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Marco Proietti
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Geriatric Unit, IRCCS Istituti Clinico Scientifici Maugeri, Milan, Italy
| | - Anna Chiara Valenti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Vincenzo Livio Malavasi
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Cai H, Wang XP, Yang GY. Sleep Disorders in Stroke: An Update on Management. Aging Dis 2021; 12:570-585. [PMID: 33815883 PMCID: PMC7990374 DOI: 10.14336/ad.2020.0707] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 07/07/2020] [Indexed: 12/18/2022] Open
Abstract
Stroke is a leading cause of disability and mortality all over the world. Due to an aging population, the incidence of stroke is rising significantly, which has led to devastating consequences for patients. In addition to traditional risk factors such as age, hypertension, hyperlipidemia, diabetes and atrial fibrillation, sleep disorders, as independent modifiable risk factors for stroke, have been highlighted increasingly. In this review, we provide an overview of common types of current sleep disturbances in cerebrovascular diseases, including insomnia, hypersomnia, breathing-related sleep disorders, and parasomnias. Moreover, evidence-based clinical therapeutic strategies and pitfalls of specific sleep disorders after stroke are discussed. We also review the neurobiological mechanisms of these treatments as well as their effects on stroke. Since depression after stroke is so prevalent and closely related to sleep disorders, treatments of post-stroke depression are also briefly mentioned in this review article.
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Affiliation(s)
- Hongxia Cai
- Department of Neurology, Tong-Ren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Xiao-Ping Wang
- Department of Neurology, Tong-Ren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Guo-Yuan Yang
- Med-X Research Institute and School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China.
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Should we incorporate obstructive sleep apnea in CHA2DS2-VASc score? Sleep Breath 2021; 25:2099-2101. [PMID: 33527257 DOI: 10.1007/s11325-021-02305-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 01/10/2021] [Accepted: 01/18/2021] [Indexed: 10/22/2022]
Abstract
Atrial fibrillation (AF) is considered a significant challenge in cardiovascular medicine related to significant morbidity and mortality. Obstructive sleep apnea (OSA) is associated with stroke and constitutes an important risk factor for AF. However, it is still ambiguous whether OSA is independently related to stroke or systemic embolism in AF patients, and whether or not OSA should be included in CHA2DS2-VASc score. In a recent study, the presence of OSA in patients with AF was associated with higher rates of adverse events, namely stroke and systemic embolism. Patients with OSA have higher CHA2DS2-VASc scores and mean CHA2DS2-VASc scores that increase with OSA severity. The addition of OSA to CHA2DS2-VASc resulted in improved discrimination, but this improvement was modest and clinically non-significant. However, cardiovascular risk factors that accompany OSA and not OSA per se might be responsible for the increased thromboembolic risk in these patients. It is noteworthy that patients with OSA with CHA2DS2-VASc <2 had a higher incidence of stroke compared to those without. Unfortunately, the event rates for stroke in these patients were too low to reach statistically validated conclusions. Therefore, it seems reasonable to suggest that in borderline stroke risk patients (CHA2DS2-VASc <2), the presence of OSA should be taken into account in the treatment decision. More studies are needed to elucidate whether or not OSA should be incorporated in CHA2DS2-VASc score.
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Pengo MF, Faini A, Grote L, Ludka O, Joppa P, Pataka A, Dogas Z, Mihaicuta S, Hein H, Anttalainen U, Ryan S, Lombardi C, Parati G. Impact of Sleep Apnea on Cardioembolic Risk in Patients With Atrial Fibrillation: Data From the ESADA Cohort. Stroke 2020; 52:712-715. [PMID: 33272126 DOI: 10.1161/strokeaha.120.030285] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE An accurate determination of the cardioembolic risk in patients with atrial fibrillation (AF) is crucial to prevent consequences like stroke. Obstructive sleep apnea (OSA) is a known risk factor for both AF and stroke. We aim to explore a possible association between OSA and an increased cardioembolic risk in patients with AF. METHODS We assessed data from the ESADA (European Sleep Apnea Database) cohort where patients with known AF and OSA were included. Parameters of OSA severity and related hypoxia like lowest Spo2 and 4% oxygen desaturation index were analyzed. Patients were stratified according to their cardioembolic risk estimated with the CHA2DS2-VASc score. RESULTS From the initial cohort of 14 646 patients, a final set of 363 patients were included in the analysis. Indices of hypoxia during sleep were associated with increased CHA2DS2-VASc score (4% oxygen desaturation index 17.9 versus 29.6 versus 30.5 events/hour and the lowest Spo2 81.2 versus 77.8 versus 77.5% for low, moderate, and high cardioembolic risk, respectively, P<0.05). CONCLUSIONS These results support the potential role of OSA-related hypoxia in the risk for cardioembolic complications such as stroke in patients with AF.
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Affiliation(s)
- Martino F Pengo
- IRCCS Istituto Auxologico Italiano, Milan, Italy (M.F.P., A.F., C.L., G.P.)
| | - Andrea Faini
- IRCCS Istituto Auxologico Italiano, Milan, Italy (M.F.P., A.F., C.L., G.P.)
| | - Ludger Grote
- Sleep Disorders Center, Respiratory Medicine, Sahgrenska University Hospital, Gothenburg, Sweden (L.G.)
| | - Ondrej Ludka
- Department of Internal Medicine and Cardiology, University Hospital Brno (O.L.)
| | - Pavol Joppa
- University Hospital L. Pasteur Košice - Univerzitná nemocnica L. Pasteura Košice, Slovakia (P.J.)
| | - Athanasia Pataka
- Department of Respiratory Medicine, Respiratory Failure Unit, G.Papanikolaou Hospital, Aristotle University of Thessaloniki, Greece (A.P.)
| | - Zoran Dogas
- Sleep Medicine Center, Department of Neurosciences, University of Split School of Medicine, Split, Croatia (Z.D.)
| | - Stefan Mihaicuta
- Department of Pulmonology, CardioPrevent Foundation, University of Medicine and Pharmacy Victor Babes Timisoara, Romania (S.M.)
| | - Holger Hein
- Sleep Disorders Center, Reinbeck, Germany (H.H.)
| | - Ulla Anttalainen
- Division of Medicine, Department of Pulmonary Diseases, Turku University Hospital, University of Turku, Finland (U.A.)
| | - Silke Ryan
- Pulmonary and Sleep Disorders Unit, St Vincent's University Hospital and School of Medicine, University College Dublin, Ireland (S.R.)
| | - Carolina Lombardi
- IRCCS Istituto Auxologico Italiano, Milan, Italy (M.F.P., A.F., C.L., G.P.).,Department of Medicine and Surgery, University of Milan-Bicocca, Italy (C.L., G.P.)
| | - Gianfranco Parati
- IRCCS Istituto Auxologico Italiano, Milan, Italy (M.F.P., A.F., C.L., G.P.).,Department of Medicine and Surgery, University of Milan-Bicocca, Italy (C.L., G.P.)
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Riaz S, Bhatti H, Sampat PJ, Dhamoon A. The Converging Pathologies of Obstructive Sleep Apnea and Atrial Arrhythmias. Cureus 2020; 12:e9388. [PMID: 32754415 PMCID: PMC7386049 DOI: 10.7759/cureus.9388] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/25/2020] [Indexed: 11/05/2022] Open
Abstract
Obstructive sleep apnea (OSA) is highly prevalent in the United States (US). Along with epidemic rates of obesity, the rate of OSA cases is also on the rise. OSA is associated with multiple chronic health conditions, including hypertension, diabetes, stroke, myocardial ischemia, and heart rhythm disturbances. OSA is commonly treated with continuous positive airway pressure (CPAP) therapy. Several reports indicate that effective treatment of OSA can reduce the risk of cardiovascular diseases, including cardiac arrhythmias, especially atrial fibrillation (AF). CPAP therapy helps to maintain sinus rhythm after interventions such as electrical cardioversion and catheter ablation in patients with AF. However, more data is required to establish a relationship between OSA and other atrial arrhythmias as well to evaluate the effect of CPAP. This review will compile the latest evidence on the pathophysiology, management, and treatment of atrial arrhythmias associated with OSA.
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Affiliation(s)
- Sana Riaz
- Internal Medicine, State University of New York Upstate Medical University, Syracuse, USA
| | - Harneet Bhatti
- Internal Medicine, State University of New York Upstate Medical University, Syracuse, USA
| | - Parth J Sampat
- Internal Medicine, State University of New York Upstate Medical University, Syracuse, USA
| | - Amit Dhamoon
- Internal Medicine, State University of New York Upstate Medical University, Syracuse, USA
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