Meta-Analysis of Cardiovascular Outcomes With Continuous Positive Airway Pressure Therapy in Patients With Obstructive Sleep Apnea

Cardiovascular effects of obstructive sleep apnoea and effects of continuous positive airway pressure therapy: evidence from different study models

Background

Cardiovascular consequences of obstructive sleep apnoea (OSA) and the effects of continuous positive airway pressure (CPAP) therapy on blood pressure, endothelial dysfunction and major adverse cardiovascular events (MACE) have been studied over decades using different study designs. However, clinical findings from different study models on cardiovascular outcomes are sometimes contradictory.

Methods

A literature search was conducted in PubMed for randomised controlled trials, meta-analyses, population-based epidemiological studies and OSA cohort studies up to September 2023 investigating the cardiovascular effects of OSA and CPAP in adults with OSA on the following cardiovascular end-points: blood pressure, arterial hypertension, endothelial function and MACE (myocardial infarction, stroke, transient ischaemic attack or cardiovascular death). The level of evidence for these outcomes was discussed on the basis of different study models.

Results and conclusions

There is high-level evidence of a causal relationship between OSA and arterial hypertension and endothelial dysfunction, as well as on higher MACE incidence among subgroups of patients with untreated OSA. The cardiovascular effects of OSA depend on the severity of OSA, symptoms, phenotype and comorbidities. The blood pressure-lowering effect of CPAP is mainly observed in uncontrolled and treatment-resistant hypertension. The MACE risk reduction in OSA depends on good long-term CPAP adherence. Younger, sleepy patients with more severe OSA, higher hypoxaemic burden and without overt cardiovascular end-organ disease may particularly benefit from CPAP treatment in terms of cardiovascular risk reduction. Randomised controlled trials of CPAP or other effective OSA treatments in primary cardiovascular prevention and in patients at highest risk are lacking.

CPAP Therapy for OSA and Its Impact on Various Cardiovascular Disorders

Obstructive sleep apnea (OSA), a highly prevalent and serious disorder with significant complications, causes considerable daytime and nighttime symptoms as well as long-term consequences and is yet an underdiagnosed and inadequately treated condition. Patients with OSA undergo frequent awakenings during the sleep cycle and find it impossible to get restorative sleep. Individuals are extremely fatigued, sleepy, and irritable throughout the day. Reduced exercise performance and physical activity contribute to a decrease in energy metabolism and weight gain. Those in this population may experience decreased motivation, which could result in depressive symptoms. The abrupt drops in oxygen levels during the sleep cycle result in profound spikes in blood pressure and strain the cardiovascular system. Given its close tie with major cardiovascular risk factors, OSA is linked with various cardiovascular diseases, including coronary artery disease, cardiac arrhythmia, poorly controlled blood pressure, heart failure, and stroke. Continuous positive airway pressure is an effective and tried-trusted approach for symptom relief and improving quality of life. Despite its benefits, patients struggle with compliance and often go untreated because of physical discomfort and perceived inconvenience of using these machines. One other explanation for this could be the lack of awareness, comprehensive data, and extensive research on its effects on long-term cardiovascular and metabolic complications caused by OSA. The current standard treatment for OSA, using adequate positive airway pressure, greatly reduces cardiovascular morbidity. Nevertheless, patients with cardiovascular disorders continue to be highly susceptible to OSA and its detrimental clinical consequences, even with effective therapy available. In summary, continuous positive airway pressure has an indirect potential to affect cardiovascular outcomes, but further studies should be done to address issues with patient compliance and adherence.

An Alternative In-Home Protocol to Diagnose and Treat Obstructive Sleep Apnea

Objective  Obstructive sleep apnea (OSA) is a major public health problem of pandemic proportions. In-laboratory OSA diagnosis and continuous positive airway pressure (CPAP) titration are insufficient, considering the number of patients affected. Finding alternative ways to diagnose and treat OSA is mandatory, especially in this era of the coronavirus disease 2019 (COVID-19) pandemic. The present study aims to describe an alternative in-home protocol to diagnose and treat OSA. Materials and Methods  We enrolled consecutive patients aged ≥ 18 years with moderate/severe OSA, who underwent in-home type-III polysomnography and home-based titration with automatic CPAP, coupled with an oximetry sensor for 3 consecutive nights. Patients were remotely monitored for 90 days to evaluate CPAP compliance and the use of an engagement tool was encouraged. Results  We included 86 participants. The median time until the diagnosis was of one day. The mean time from the baseline visit until the acquisition and initiation of the CPAP therapy was of 33 (range: 17 to 52) days. Telemonitoring ensured good compliance in the first 30 (79.2%), 60 (76.3%) and 90 (74.3%) days, with an average daily use of 6.2 ± 1.4 h, 6.0 ± 1.4 h, and 6.0 ± 1.3 h respectively. About 1/3 of the patients used the engagement tool, and CPAP compliance was significantly higher among these patients compared with those who did not used the tool: 89.9% versus 73.5% ( p  < 0.002), 87.9% versus 70% ( p  < 0.003), and 86.6% versus 67.6% ( p  < 0.001) at 30, 60, and 90 days respectively. Conclusion  We demonstrated that an alternative in-home protocol to diagnose and treat OSA is effective, ensuring good CPAP compliance after 90 days. Telemonitoring and engagement tools could be strategies to improve CPAP compliance.

Factors Affecting CPAP Adherence in an OSA Population during the First Two Years of the COVID-19 Pandemic

Background: Obstructive sleep apnea (OSA) is a common disorder associated with major cardiovascular and neurocognitive sequelae. Continuous positive airway pressure (CPAP) is the standard treatment for OSA. The aim of this study was to investigate the prevalence and associations of long-term CPAP adherence in newly diagnosed OSA patients. Methods: We enrolled patients who were diagnosed with OSA during the COVID-19 pandemic. Adherence was defined as CPAP use ≥4 h per night on ≥70% of nights over 30 consecutive days. Patient demographics were retrieved from medical records, and CPAP adherence at 6 months and 1 year after initiation was monitored. Results: Overall, 107 patients were included in the analysis. A number of 73 (68%) and 63 (59%) patients were adherent to CPAP treatment at 6 months and 12 months accordingly. Among the factors examined and analyzed (age, gender, BMI, Apnea-Hypopnea Index (AHI)), no significant correlation was found. Further analysis revealed the potential role of comorbidities. CPAP compliance at 6 months was shown to be associated with better CPAP adherence at 12 months. Conclusions: CPAP adherence at 6 months is correlated to long-term adherence to treatment. Therefore, early close follow-up is important. Further prospective studies are needed to identify other potential predictors.

The Curious Role of PAI-1 in Severe Obstructive Sleep Apnea

Plasminogen activator inhibitor-1 (PAI-1) has a significant role in fibrinolysis, atherogenesis, cellular senescence, and chronic inflammation. OSA (obstructive sleep apnea) leads to increased PAI-1 levels and the development of cardiovascular disease (CVD). The aim of this study was to determine the effects of CPAP therapy on coagulation parameters and PAI-1 in patients with severe OSA. This prospective, controlled study enrolled 57 patients who were newly diagnosed with severe OSA, 37 of whom had had good CPAP adherence after 6 months of therapy (usage of the device for at least 4 h per night), and their data were analyzed. The analysis showed a statistically significant increase in D-dimer values before CPAP therapy (415 (316.5-537.5)) vs. after therapy (499 (327-652)), p = 0.0282, and a decrease in fibrinogen values (3.665 ± 0.752 before CPAP therapy vs. 3.365 ± 0.771 after therapy, p = 0.0075)). PAI-1 concentration values before and after CPAP therapy did not differ significantly (17.35 ± 7.01 ng/mL before CPAP therapy vs. 17.42 ± 6.99 ng/mL after therapy, p = 0.9367). This study shows a tendency for fibrinolytic capacity to improve in patients with OSA after CPAP therapy, although PAI-1 levels did not differ significantly.

Impact of Obstructive Sleep Apnea Treatment on Cardiovascular Disease Associated Mortality and Morbidity: A Systematic Review

The association between untreated obstructive sleep apnea (OSA) and cardiovascular disease (CVD) is well known. In this literature review, we aim to review the existing literature on treatment effects of OSA and its impact on CVD morbidity and mortality, stratified by gender. We systematically reviewed PubMed, Medline, and Scopus per PRISMA guidelines and included 25 studies in the final review. Primary outcomes were CVD-associated morbidity and mortality. Out of 25 studies, 10 were meta-analysis, 8 observational, and 7 randomized controlled trials. The treatment modality was continuous positive airway pressure (CPAP) in 23 studies, noninvasive positive pressure ventilation, and oral appliance therapy in 2. Secondary prevention of CVD was the endpoint in 23 studies. A total of 165,775 participants between 45 and 75 years of age, 60%-90% males, and the average Epworth Sleepiness Scale (ESS) score was 5-9. CV outcomes included myocardial infarction, angina, heart failure (HF), acute coronary syndrome (ACS), coronary artery disease (CAD), ischemic heart disease, cardiomyopathy, atrial fibrillation (AF), and hypertension. In 4 studies, CPAP was associated with a reduction in CVD mortality, and 10 studies showed improvement in morbidity. Our review of literature did not show consistent benefits in CV outcomes in OSA patients. We identified many potential research areas, especially the lack of studies demonstrating dose-dependent effect of OSA treatment on CV outcomes, especially when stratified by severity of OSA and gender. Larger prospective studies with longer follow-up will be helpful to study these parameters.

Effects of continuous positive airway pressure on cardiac events and metabolic components in patients with moderate to severe obstructive sleep apnea and coronary artery disease: a meta-analysis

STUDY OBJECTIVES

This meta-analysis aimed to systematically assess the effects of continuous positive airway pressure (CPAP) in secondary prevention of major cardiovascular events (MACEs) in patients with moderate-to-severe obstructive sleep apnea and coronary artery disease.

METHODS

PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov were searched for observational studies and randomized controlled trials that compared CPAP with usual care in patients with moderate-to-severe obstructive sleep apnea with coronary artery disease. The primary outcomes were MACEs, all-cause death, acute coronary syndrome, rehospitalization for heart failure, repeat revascularization, and arrhythmia.

RESULTS

A total of 11 studies (5 randomized controlled trials and 6 observational studies) with 5,410 patients reported outcomes of MACEs. Treatment with CPAP was associated with a modest risk reduction in MACEs (risk ratio [RR] 0.87, 95% confidence interval [CI] 0.78 to 0.98; P = .02). Similarly, CPAP significantly reduced the risk of all-cause and cardiovascular death by 23% (RR 0.77, 95% CI 0.60 to 0.99; P = .04; I2 = 0%). Subgroup analysis revealed that CPAP adherence time ≥ 4 hours/night had a greater benefit on MACEs by 42% (RR 0.58, 95% CI 0.42 to 0.79; P < .001; I2 = 0%) and repeat revascularization by 44% (RR 0.56, 95% CI 0.34 to 0.92; P = .02; I2 = 0%). Also, CPAP had a positive effect on systolic and diastolic blood pressure.

CONCLUSIONS

CPAP therapy might prevent subsequent MACEs and all-cause death among patients with moderate to severe obstructive sleep apnea and concomitant coronary artery disease. CPAP use exceeding 4 hours/night may add more benefits on MACEs, repeat revascularization, and blood pressure.

CLINICAL TRIAL REGISTRATION

Registry: PROSPERO database; Name: Effects of Continuous Positive Airway Pressure on Cardiovascular Events and Metabolic Components in Patients with Obstructive Sleep Apnea and Coronary Artery Disease; URL: https://www.crd.york.ac.uk/prospero/display_record.php?ID= CRD42020213546; Identifier: CRD42020213546.

CITATION

Yang D, Li L, Dong J, Yang W, Liu Z. Effects of continuous positive airway pressure on cardiac events and metabolic components in patients with moderate to severe obstructive sleep apnea and coronary artery disease: a meta-analysis. J Clin Sleep Med. 2023;19(12):2015-2025.

From Snoring to Soaring: Unveiling the Positive Effects of Continuous Positive Airway Pressure Ventilation on Cardiovascular Health in Patients With Obstructive Sleep Apnoea Through a Systematic Review

Increased cardiovascular (CV) morbidity and death are linked to obstructive sleep apnoea (OSA). The primary method of treating OSA is continuous positive airway pressure (CPAP). CPAP has some debatable outcomes on CV events in people suffering from OSA. The current study investigates how CPAP affects CV outcomes. The goal is to evaluate CPAP's effectiveness in lowering CV outcomes in OSA patients. We used a computer to search the PubMed, PubMed Central Library, Science Direct, and Google Scholar databases for studies comparing the effects of CPAP and a control group on CV outcomes in OSA patients. These included randomised control trials (RCT), narrative reviews, systematic reviews, case-control studies, observational studies and meta-analyses. A total of 52,937 patients were included in the final analysis of six RCTs, four observational studies, 10 meta-analyses, one case-control study, two systematic reviews and one narrative review. The weighted mean follow-up lasted for a period of between three months and nine years. The risk of major cardiovascular adverse events (MACE) was the same for both the CPAP and control groups. According to subgroup analysis, patients with lower MACE adherence rates (four hours per night) were more likely to use CPAP. The risk of all-cause mortality, CV-related complications causing mortality, acute myocardial infarction acute stroke, or hospitalisations for angina was the same in the CPAP and control groups. The primary outcome was that in patients with therapy with CPAP in addition to usual care and usual care alone did not prevent CV events in patients with moderate-to-severe OSA and existing CV illness. Patients with OSA who utilise CPAP may not experience fewer CV events. Patients who use CPAP consistently (four hours per night) could benefit from improved CV results. Future research must assess how well-adherent patients with severe OSA and low CV event rates respond to CPAP therapy. In patients who use CPAP for more than four hours each night, CPAP therapy may minimise the risk of MACE and stroke. Additional randomised trials requiring adequate CPAP time adherence are needed to support this perception. Despite the fact that there is no evidence to support the claim that CPAP therapy improves CV outcomes, bias difficulties, CPAP adherence problems, and the patient groups included in each RCT may have made it more difficult to generalise the findings to all patients. Future research is therefore needed to look at these relevant results.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Single-night continuous positive airway pressure treatment improves blood fluid properties in individuals recently diagnosed with obstructive sleep apnoea

Obstructive sleep apnoea (OSA) is a prevalent disorder that causes repetitive, temporary collapses of the upper airways during sleep, resulting in intermittent hypoxaemia and sleep fragmentation. Given those with OSA also exhibit decreased blood fluidity, this clinical population is at heightened risk for cardiovascular disease (CVD) development. Continuous positive airway pressure (CPAP) remains a primary therapy in OSA, which improves sleep quality and limits sleep fragmentation. While CPAP effectively ameliorates nocturnal hypoxic events and associated arousals, it remains unclear whether CVD risk factors are positively impacted. The aim of the present study was thus to assess the effects of an acute CPAP therapy on sleep quality and the physical properties of blood that determine blood fluidity. Sixteen participants with suspected OSA were recruited into the current study. Participants attended the sleep laboratory for two visits: an initial diagnostic visit that included confirmation of OSA severity and comprehensive assessments of blood parameters, followed by a subsequent visit where participants were administered an individualised, acute CPAP therapy session and had their blood assessments repeated. Holistic appraisal of blood rheological properties included assessment of blood and plasma viscosity, red blood cell (RBC) aggregation, deformability, and osmotic gradient ektacytometry. Acute CPAP treatment significantly improved sleep quality parameters, which were associated with decreased nocturnal arousals and improved blood oxygen saturation. Whole blood viscosity was significantly decreased following acute CPAP treatment, which might be explained by the improved RBC aggregation during this visit. Although an acute increase in plasma viscosity was observed, it appears that the alterations in RBC properties that mediate cell-cell aggregation, and thus blood viscosity, overcame the increased plasma viscosity. While deformability of RBC was unaltered, CPAP therapy had mild effects on the osmotic tolerance of RBC. Collectively, novel observations demonstrate that a single CPAP treatment session acutely improved sleep quality, which was accompanied by improved rheological properties.

Sustained improvements in the cardiometabolic profile of patients with obstructive sleep apnea after a weight-loss Mediterranean diet/lifestyle intervention: 12-month follow-up (6 months post-intervention) of the "MIMOSA" randomized clinical trial

BACKGROUND AND AIMS

Obstructive sleep apnea (OSA) and the metabolic syndrome (MS) frequently coexist and lead to increased cardiometabolic morbidity. We aimed to explore the long-term cardiometabolic benefits of a weight-loss Mediterranean diet/lifestyle intervention in OSA.

METHODS AND RESULTS

As many as 180 adults with overweight/obesity and polysomnography-diagnosed moderate-to-severe OSA were randomized to a standard care (SCG, n = 62), a Mediterranean diet (MDG, n = 59) or a Mediterranean lifestyle group (MLG, n = 59). All groups were prescribed with continuous positive airway pressure (CPAP), while intervention arms (MDG/MLG) additionally participated in a 6-month weight-loss intervention based on the Mediterranean diet/lifestyle. Cardiometabolic parameters were evaluated at baseline and 12 months (6 months post-intervention). Data were analyzed using the intention-to-treat method, and 12-month between-group differences were explored while adjusting for age, sex, baseline status and CPAP use. Compared to the SCG, intervention arms exhibited lower insulin, triglycerides and high-sensitivity C-reactive protein, and higher high-density lipoprotein cholesterol; the MDG also exhibited lower diastolic blood pressure, while the MLG exhibited lower glucose and systolic blood pressure (all P < 0.050). The relative risk (95% confidence interval) of MS was 0.60 (0.36, 0.99) in the MDG versus the SCG, 0.33 (0.20, 0.55) in the MLG versus the SCG and 0.55 (0.32, 0.93) in the MLG versus the MDG. The risk of MS remained lower in the MLG versus the other study groups (both P < 0.050) after additional adjustment for body weight change.

CONCLUSION

Cardiometabolic benefits of a 6-month healthy dietary/lifestyle intervention are sustainable 6 months post-intervention in OSA.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02515357, August 4, 2015.

Clinical application of headache impact test (HIT)-6 and epworth sleepiness scale (ESS) for sleep apnea headache

Background

Sleep apnea headache is a major symptom accompanying obstructive sleep apnea (OSA), but relatively little evidence has been reported on the magnitude of its negative effects on patients or the evaluation of therapeutic effects. We quantitatively assessed sleep apnea headache using the Epworth sleepiness scale (ESS) and headache impact test (HIT)-6.

Methods

The first part of this study enrolled 86 patients (72 male; mean [± standard deviation] age 53.2 ± 13.8 years) who had been diagnosed with OSA by polysomnography in our sleep center and investigated the prevalence and characteristics of sleep apnea headache. The second part enrolled 21 patients (12 male; mean age, 47.5 ± 13.0 years) diagnosed with sleep apnea headache by polysomnography and/or peripheral arterial tonometry and evaluated the effects of OSA therapy on headache. Medical records including ESS, HIT-6, and polysomnographic data were retrospectively analyzed.

Results

The prevalence of sleep apnea headache among OSA patients was 22.1%, and was higher in female (50.0%) than in male (16.7%). The proportion of N3 and HIT-6 score showed a significant negative correlation (Pearson’s R = -0.51, p < 0.05). In female, median apnea–hypopnea index (AHI) was significantly lower in patients with headache (26.1 /h [interquartile range 21.4–29.6 /h]) than in patients without (54.2 /h [41.3–73.9 /h], p < 0.05, Wilcoxon rank-sum test). HIT-6 and ESS scores improved from 56.4 ± 9.7 to 45.9 ± 8.4 and from 9.0 ± 4.4 to 5.3 ± 4.2 in patients with oral appliance (OA), and from 54.3 ± 10.7 to 44.6 ± 6.1 and from 10.0 ± 4.0 to 4.9 ± 2.9 with continuous positive airway pressure (CPAP). In patients with good CPAP adherence, these scores improved from 58.1 ± 10.8 to 44.0 ± 6.0 and from 9.6 ± 3.8 to 3.6 ± 1.7.

Conclusion

Among patients with OSA, prevalence of sleep apnea headache was higher in female than in male. In female, headache was associated with relatively mild OSA. OA showed substantial effects on headache in mild to moderate OSA patients. CPAP adherence was important for improving the headache. HIT-6 score appears useful for the diagnosis and management of sleep apnea headache.

MoCA-T como herramienta de evaluación remota para precisar deterioro cognitivo en pacientes con SAHOS moderado a severo

La pandemia de COVID-19 ha dado lugar al surgimiento de herramientas tecnológicas que permiten la valoración de pacientes de forma remota. La prueba de evaluación cognitiva de Montreal, versión telefónica (MoCA-T), es una de ellas. Se considera como un recurso de la telemedicina que permite la tamización cognitiva a distancia en épocas de pandemia y en la población con dificultades en el acceso a los centros de salud. El deterioro cognitivo leve (DCL) es un hallazgo usual en pacientes con síndrome de apnea-hipopnea obstructiva del sueño (SAHOS); sin embargo, no se ha estudiado la aplicación de pruebas telefónicas para su tamización cognitiva. El objetivo principal de este trabajo es determinar la frecuencia de deterioro cognoscitivo mediante la aplicación de MoCA-T como prueba de tamización remota en pacientes con SAHOS moderado y severo. Para ello, se aplicó la prueba de MoCA-T en 104 pacientes entre 18 y 65 años con diagnóstico polisomnográfico de SAHOS moderado y severo, excluyéndose a pacientes con comorbilidades que afectasen las capacidades cognoscitivas. Se obtuvieron resultados anormales de MoCA-T en el 43% de los pacientes, siendo los dominios cognitivos de la memoria y la atención los más comúnmente afectados. Finalmente, los resultados anormales de MoCA-T se correlacionaron con la autopercepción de las dificultades en la memoria, estando más frecuentemente alterada en quienes manifestaron quejas cognitivas. La prueba MoCA-T podría ser una herramienta tecnológica breve, validada y factible para realizar el tamizaje cognitivo de pacientes con SAHOS en épocas de pandemia y en pacientes con barreras asistenciales.

Developing OurSleepKit: A Couple-focused mHealth Tool to Support Adherence to Positive Airway Pressure Treatment

BACKGROUND AND AIM

Existing interventions promoting positive airway pressure (PAP) adherence focus only on the diagnosed individual, despite the fact that partners are often the most impacted by obstructive sleep apnea (OSA), and are delivered mostly by health professionals, with limited success. The goal of this work is to develop a prototype of OurSleepKit, a couple-focused mobile health (mHealth) tool to coach mutual engagement and promote adherence to PAP treatment.

METHODS

We used an iterative participatory approach working with future end users of OurSleepKit to support the development of this prototype. We conducted a total of 14 semi-structured in-depth open-ended dyadic interviews with OSA patients and their partners. Phase 1 of the development was to inform key functions of an engaging tool. Phase 2 focused on developing functions to engage positive conversation in the dyad and obtained feedback for this initial prototype.

RESULTS

The OurSleepKit prototype was developed and demonstrated high acceptability and engagement. Three key functions included periodic assessments based on developmental stages of PAP treatment, a Coaching Board which provides customized and dynamically updated support content - primarily brief story-telling videos featuring real-life couples' experiences - and timely tailored prompts (for action, learning, and conversation) through push notifications in the evening to facilitate positive conversation in the dyad and offer in-the-moment support for PAP use.

CONCLUSIONS

Going beyond the traditional and prevailing view of PAP use as an individual phenomenon, OurSleepKit is a novel mHealth intervention engaging both the patient and partner holding great promise to promote PAP adherence.

Impact of CPAP Therapy on New Inflammation Biomarkers

Obstructive sleep apnea (OSA) is a common sleep disorder leading to increased risk of developing cardiovascular diseases (CVDs) by supporting a low-grade chronic inflammation as one of the pathological mechanisms. The continuous positive airway pressure (CPAP) device is used as an effective treatment for moderate and severe OSA. Neutrophil–lymphocyte ratio (NLR), platelet–lymphocyte ratio (PLR), white blood cell–mean platelet volume ratio (WMR), C-reactive protein–albumin ratio (CAR) and fibrinogen–albumin ratio (FAR) are new potential inflammatory biomarkers that are widely available and were shown to be possibly favorable screening or follow-up tools for moderate- or severe-grade OSA, as well as indirect indicators for cardiovascular risk. Our study evaluated the impact of CPAP therapy in patients with severe OSA and acceptable therapy adherence on NLR, PLR, WMR, FAR and CAR. Of 57 patients who were initially enrolled and had no exclusion criteria, 37 had a satisfactory CPAP adherence (usage of ≥4 h per night) after a minimum of 6 months of therapy. There was a statistically significant difference in NLR (2.122 ± 0.745 before therapy vs. 1.888 ± 0.735 after therapy) and FAR (86.445 ± 18.763 before therapy vs. 77.321 ± 19.133 after therapy) suggesting a positive effect of the CPAP therapy on chronic inflammatory states, thereby possibly reducing cardiovascular risk.

Circadian rhythm and clinical characteristics in patients with acute myocardial infarction combined with obstructive sleep apnea

OBJECTIVE

The present study aimed to investigate the circadian rhythm and clinical characteristics of patients with acute myocardial infarction (AMI) combined with obstructive sleep apnea (OSA).

METHODS

Patients with AMI combined with OSA were enrolled in the study, and those that met the inclusion criteria were divided into three time-period groups based on their sleep-wake rhythm (22:00-5:59, 6:00-13:59, and 14:00-21:59). The differences between the three groups of patients in sleep-monitoring data, blood routine, biochemical indicators, and coronary angiographic parameters were analyzed and compared. Count data were expressed as the number of cases, and the chi-square test was used for statistical analysis. Continuous data were expressed as mean ± standard deviation, and analysis of variance was used for the statistical analysis of these data. The characteristics of circadian rhythm and clinical features in patients with AMI combined with OSA were analyzed.

RESULTS

Of the 148 patients, 90/148 (61%) had chest pain and 58/148 (39%) had non-chest pain symptoms. In the 22:00-05:59 group, there were 70/148 (47%) patients with AMI (of these, 46/70 [66%] had chest pain). In the 06:00-13:59 period group, there were 44/148 (30%) patients with AMI (of these, 26/44 [60%] had chest pain). In the 14:00-21:59 period group, there were 34/148 (23%) patients with AMI (of these, 17/34 [50%] had chest pain). There was no statistically significant difference in the apnea-hypopnea index (AHI) and SYNTAX score between patients in the 22:00-5:59 and 6:00-13:59 groups. However, the AHI and SYNTAX scores in the 22:00-5:59 and 6:00-13:59 groups were higher than those in the 14:00-21:59 group, and the differences were statistically significant. In patients in the 22:00-5:59 group, the levels of serum D-dimer (DD), hemoglobin (Hb), and oxygen desaturation index (ODI3) were higher, the sleep mean oxygen saturation (MeanSaO2 ) was lower and the percentage of nighttime spent with oxygen saturation of less than 90% (Tsat90 ) and less than 85% (Tsat85 ) was longer.

CONCLUSION

The peak period for the onset of AMI in patients with OSA was 22:00-5:59, and the incidence of chest pain was high. During this period, patients had higher DD and Hb, higher ODI3, lower MeanSaO2 during sleep, and longer TSat90 and TSat85 . During the 22:00-5:59 and 6:00-13:59 periods, patients had higher AHI and a higher SYNTAX score.

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

BACKGROUND

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

METHODS AND RESULTS

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

CONCLUSIONS

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

Mandibular Advancement Device Therapy in Japanese Rugby Athletes with Poor Sleep Quality and Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) may contribute to poor sleep quality. This study assessed subjective sleep quality, the Respiratory Event Index (REI), reaction times, and the therapeutic effects of a custom-made mandibular advancement device (MAD) in male Japanese elite rugby athletes. The Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), and level III sleep test (REI and minimum oxygen saturation [SpO2 min]) were used to evaluate sleep quality. MAD therapy was used daily for 3 weeks. A telephone-based reaction time test of kinetic vision (the ability to identify moving objects) was recorded within 15 min of waking and over 5 days of pre- and post-MAD therapy. Differences in variables were evaluated using paired t-tests. Of the 42 players (mean age, 26.3 ± 3.7 years; mean body mass index, 28.7 ± 3.2 kg/m2) included in this study, 29 (69.0%) had poor sleep quality (PSQI > 5.5), and 27 were diagnosed with OSA (64.3%) (mild = 16/moderate = 9/severe = 2). Six were treated with MAD therapy, which significantly improved the REI (p < 0.01), SpO2 min (p < 0.001), ESS score (p < 0.001), reaction times (p < 0.01), and sleep quality. A significant reduction in reaction times suggests that OSA treatment can improve kinetic vision. Future studies should systematically evaluate the impact of sleep-disordered breathing on kinetic vision in athletes.

High adherence to continuous positive airway pressure (CPAP) in patients with obstructive sleep apnea (OSA) in Belgium: a narrative review

OBJECTIVES

Continuous positive airway pressure (CPAP) is the 'gold standard' treatment for moderate-to-severe obstructive sleep apnea (OSA); adherence is an important issue. The aim of this paper is to review Belgian data on CPAP users and their adherence over a period of 11 years.

METHODS

Data delivered annually by the CPAP centers to the Belgian National Institute for Health Insurance (RIZIV/INAMI) were studied. Comments on these results were embedded in a narrative review.

RESULTS

On 1 January 2008 27.266 Belgian patients were treated with CPAP, at the end of 2018 this number increased to 121.605. In 2018, the short-term adherence (≤3 months) to CPAP was at least twice as high compared to the United States: the CPAP termination rate in Belgium (mainly due to stop of reimbursement because adherence <4 h/night) was estimated to be 12.4%, considerably lower than the 31.1% of patients on CPAP in the United States using the device <4 h.

CONCLUSION

We speculate that this good adherence might be attributed to a stringent Belgian diagnostic and treatment convention model. This model uses 'gold standard' techniques (including in-hospital polysomnography), imposes a minimum capacity of medical doctors and paramedical collaborators, a strict follow-up of the patients, multidisciplinary care and proof of competency. Taking into account the increasing number of patients, a change in the Belgian care strategy is under consideration focusing on more out-of-centre patient's management; we propose a step-by step approach with careful monitoring of the impact of changing policy on adherence.

Can Weight Loss Improve the Cardiovascular Outcomes of Patients with Obesity and Obstructive Sleep Apnea?

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.

Obstructive sleep apnea: transition from pathophysiology to an integrative disease model

Obstructive sleep apnea (OSA) is characterised by recurring episodes of upper airway obstruction during sleep and the fundamental abnormality reflects the inability of the upper airway dilating muscles to withstand the negative forces generated within the upper airway during inspiration. Factors that result in narrowing of the oropharynx such as abnormal craniofacial anatomy, soft tissue accumulation in the neck, and rostral fluid shift in the recumbent position increase the collapsing forces within the airway. The counteracting forces of upper airway dilating muscles, especially the genioglossus, are negatively influenced by sleep onset, inadequacy of the genioglossus responsiveness, ventilatory instability, especially post arousal, and loop gain. OSA is frequently associated with comorbidities that include metabolic, cardiovascular, renal, pulmonary, and neuropsychiatric, and there is growing evidence of bidirectional relationships between OSA and comorbidity, especially for heart failure, metabolic syndrome, and stroke. A detailed understanding of the complex pathophysiology of OSA encourages the development of therapies targeted at pathophysiological endotypes and facilitates a move towards precision medicine as a potential alternative to continuous positive airway pressure therapy in selected patients.

VEGF Receptor 1 Promotes Hypoxia-Induced Hematopoietic Progenitor Proliferation and Differentiation

Although it is well known that hypoxia incites unleashed cellular inflammation, the mechanisms of exaggerated cellular inflammation in hypoxic conditions are not known. We observed augmented proliferation of hematopoietic stem and progenitor cells (HSPC), precursors of inflammatory leukocytes, in mice under hypoxia. Consistently, a transcriptomic analysis of human HSPC exposed to hypoxic conditions revealed elevated expression of genes involved in progenitor proliferation and differentiation. Additionally, bone marrow cells in mice expressed high amount of vascular endothelial growth factor (VEGF), and HSPC elevated VEGF receptor 1 (VEGFr1) and its target genes in hypoxic conditions. In line with this, VEGFr1 blockade in vivo and in vitro decreased HSPC proliferation and attenuated inflammation. In silico and ChIP experiments demonstrated that HIF-1α binds to the promoter region of VEGFR1. Correspondingly, HIF1a silencing decreased VEGFr1 expression in HSPC and diminished their proliferation. These results indicate that VEGF signaling in HSPC is an important mediator of their proliferation and differentiation in hypoxia-induced inflammation and represents a potential therapeutic target to prevent aberrant inflammation in hypoxia-associated diseases.

Continuous positive airway pressure and adverse cardiovascular events in obstructive sleep apnea: are participants of randomized trials representative of sleep clinic patients?

STUDY OBJECTIVES

Randomized controlled trials (RCTs) have shown no reduction in adverse cardiovascular (CV) events in patients randomized to continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea (OSA). This study examined whether randomized study populations were representative of OSA patients attending a sleep clinic.

METHODS

Sleep clinic patients were 3,965 consecutive adults diagnosed with OSA by in-laboratory polysomnography from 2006 to 2010 at a tertiary hospital sleep clinic. Characteristics of these patients were compared with participants of five recent RCTs examining the effect of CPAP on adverse CV events in OSA. The percentage of patients with severe (apnea-hypopnea index, [AHI] ≥ 30 events/h) or any OSA (AHI ≥ 5 events/h) who met the eligibility criteria of each RCT was determined, and those criteria that excluded the most patients identified.

RESULTS

Compared to RCT participants, sleep clinic OSA patients were younger, sleepier, more likely to be female and less likely to have established CV disease. The percentage of patients with severe or any OSA who met the RCT eligibility criteria ranged from 1.2% to 20.9% and 0.8% to 21.9%, respectively. The eligibility criteria that excluded most patients were preexisting CV disease, symptoms of excessive sleepiness, nocturnal hypoxemia and co-morbidities.

CONCLUSIONS

A minority of sleep clinic patients diagnosed with OSA meet the eligibility criteria of RCTs of CPAP on adverse CV events in OSA. OSA populations in these RCTs differ considerably from typical sleep clinic OSA patients. This suggests that the findings of such OSA treatment-related RCTs are not generalizable to sleep clinic OSA patients.Randomized Intervention with Continuous Positive Airway Pressure in CAD and OSA (RICCADSA) trial, https://clinicaltrials.gov/ct2/show/NCT00519597, ClinicalTrials.gov number, NCT00519597.Usefulness of Nasal Continuous Positive Airway Pressure (CPAP) Treatment in Patients with a First Ever Stroke and Sleep Apnea Syndrome, https://clinicaltrials.gov/ct2/show/NCT00202501, ClinicalTrials.gov number, NCT00202501.Effect of Continuous Positive Airway Pressure (CPAP) on Hypertension and Cardiovascular Morbidity-Mortality in Patients with Sleep Apnea and no Daytime Sleepiness, https://clinicaltrials.gov/ct2/show/NCT00127348, ClinicalTrials.gov number, NCT00127348.Continuous Positive Airway Pressure (CPAP) in Patients with Acute Coronary Syndrome and Obstructive Sleep Apnea (OSA) (ISAACC), https://clinicaltrials.gov/ct2/show/NCT01335087, ClinicalTrials.gov number, NCT01335087.

Moderate obstructive sleep apnea and cardiovascular outcomes in older adults: a propensity score-matched multicenter study (CPAGE-MODE study)

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) has been associated with cardiovascular events (CVEs), although recent randomized controlled trials have not demonstrated that long-term continuous positive airway pressure (CPAP) prevents CVEs. Our objective was to determine the effect of CPAP on older adults with moderate OSA regarding CVE reduction.

METHODS

An observational and multicenter study of a cohort of older adults (> 70 years of age) diagnosed with moderate OSA (apnea-hypopnea index 15.0-29.9 events/h) was conducted. Two groups were formed: (1) CPAP treatment and (2) standard of care. The primary endpoint was CVE occurrence after OSA diagnosis. Association with CPAP treatment was assessed by propensity score matching and inverse weighting probability. Secondary endpoints were incidence of CVE separately and time to first CVE.

RESULTS

A total of 614 patients were included. After matching, 236 older adults (111 men, mean age 75.9 ± 4.7 years) with a follow-up of 47 months (interquartile range: 29.6-64.0 months) were considered for primary and secondary endpoint evaluations. Forty-one patients presented at least 1 CVE (17.4%): 20 were in the standard-of-care group (16.9%) and 21 were in the CPAP group (17.8%), with a relative risk of 1.05 (95% confidence interval [CI], 0.60-1.83; P = .43) for CPAP treatment. Inverse probability weighting of the initial 614 patients determined an adjusted relative risk of 1.24 (95% CI, 0.79-1.96; P = .35) for CPAP treatment. No statistical differences were found in secondary endpoint analyses.

CONCLUSIONS

CPAP should not be prescribed to reduce CVE probability in older adults with moderate OSA.

CITATION

López-Padilla D, Terán-Tinedo J, Cerezo-Lajas A, et al. Moderate obstructive sleep apnea and cardiovascular outcomes in older adults: a propensity score-matched multicenter study (CPAGE-MODE study). J Clin Sleep Med. 2022;18(2):553-561.

Cardiovascular and metabolic effects of a mandibular advancement device and continuous positive airway pressure in moderate obstructive sleep apnea: a randomized controlled trial

STUDY OBJECTIVES

It has been suggested that treatment for obstructive sleep apnea (OSA) reduces cardiovascular risk. So far, knowledge is limited about the difference in the reduction of this risk between mandibular advancement device (MAD) and continuous positive airway pressure (CPAP) therapy. The aim of this study was to compare the cardiovascular effects of MAD versus CPAP therapy in patients with moderate OSA.

METHODS

Patients with an apnea-hypopnea index (AHI) of 15-30 events/h were randomized to either MAD or CPAP therapy. At baseline and after 12-months follow-up, 24-hour ambulant blood pressure measurements (ABPM) and laboratory measurements were performed. ABPM consisted of 24-hour, daytime and night-time systolic (SBP) and diastolic blood pressure (DBP), and heart rate (HR) measurements. Laboratory measurements consisted of serum lipid values, creatinine, high-sensitivity c-reactive protein, plasma glucose, hemoglobin A1c (HbA1c), proinflammatory cytokines, soluble receptor for advanced glycation end products (sRAGE), chemokines and adhesion molecules.

RESULTS

Of the 85 randomized patients with moderate OSA, data were available for 54 patients (n=24 MAD, n=30 CPAP) at 12-month follow-up and showed that AHI significantly decreased with either therapy. In the MAD group, sRAGE and HbA1c were significantly higher after 12 months follow-up compared to baseline. No significant changes were found between MAD and CPAP treatment for all outcomes.

CONCLUSIONS

Treatment of patients with moderate OSA with either MAD or CPAP therapy had no profound effects on major cardiovascular risk factors after 12-months.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Title: MRA Therapy Versus CPAP Therapy in Moderate OSAS; Identifier: NCT01588275; URL: https://clinicaltrials.gov/ct2/show/NCT01588275.

Stratifying the Risk of Cardiovascular Disease in Obstructive Sleep Apnea Using Machine Learning

OBJECTIVES/HYPOTHESIS

Obstructive sleep apnea (OSA) is associated with higher risk of morbidity and mortality related to cardiovascular disease (CVD). Due to overlapping clinical risk factors, identifying high-risk patients with OSA who are likely to develop CVD remains challenging. We aimed to identify baseline clinical factors associated with the future development of CVD in patients with OSA.

STUDY DESIGN

Retrospective analysis of prospectively collected data.

METHODS

We performed a retrospective analysis of 967 adults aged 45 to 84 years and enrolled in the Multi-Ethnic Study of Atherosclerosis. Six machine learning models were created using baseline clinical factors initially identified by stepwise variable selection. The performance of these models for the prediction of additional risk of CVD in OSA was calculated. Additionally, these models were evaluated for interpretability using locally interpretable model-agnostic explanations.

RESULTS

Of the 967 adults without baseline OSA or CVD, 116 were diagnosed with OSA and CVD and 851 with OSA alone 10 years after enrollment. The best performing models included random forest (sensitivity 84%, specificity 99%, balanced accuracy 91%) and bootstrap aggregation (sensitivity 84%, specificity 100%, balanced accuracy 92%). The strongest predictors of OSA and CVD versus OSA alone were fasting glucose >91 mg/dL, diastolic pressure >73 mm Hg, and age >59 years.

CONCLUSION

In the selected study population of adults without OSA or CVD at baseline, the strongest predictors of CVD in patients with OSA include fasting glucose, diastolic pressure, and age. These results may shape a strategy for cardiovascular risk stratification in patients with OSA and early intervention to mitigate CVD-related morbidity.

LEVEL OF EVIDENCE

3 Laryngoscope, 132:234-241, 2022.

OSA Treatment on Cardio- and Cerebrovascular Comorbidities: A Long-term Nationwide Cohort Study

OBJECTIVE

To compare the cardio- and cerebrovascular outcomes and survival rates of surgical and nonsurgical interventions for patients with obstructive sleep apnea (OSA) based on a national population-based database.

STUDY DESIGN

Retrospective cohort study.

SETTING

Taiwan National Health Insurance Research Database.

METHODS

We analyzed all cases of OSA among adults (age >20 years and confirmed with ICD-9-CM) from January 2001 to December 2013. We compared the patients with OSA who received upper airway surgery with age-, sex-, and comorbidity index-matched controls with continuous positive airway pressure (CPAP) treatment. The risk of myocardial infarction (MI) or stroke after treatment of OSA-related surgery versus CPAP was investigated.

RESULTS

During follow-up, 112 and 92 incident cases of MI occurred in the OSA surgery and CPAP treatment groups, respectively (rates of 327 and 298 per 100,000 person-years). Furthermore, 50 and 39 cases were newly diagnosed with stroke in the OSA surgery and CPAP treatment groups (rates of 144 and 125 per 100,000 person-years). Cox proportional hazard regressions showed that the OSA treatment groups (OSA surgery vs CPAP) were not significantly related to MI (hazard ratio, 1.03 [95% CI, 0.781-1.359]; P = .833) and stroke (hazard ratio, 1.12 [95% CI, 0.736-1.706]; P = .596) at follow-up, after adjustment for sex, age at index date, days from diagnosis to treatment, and comorbidities.

CONCLUSION

Our study demonstrated that there was no difference of cardio- and cerebrovascular results between CPAP and surgery for patients with OSA in a 13-year follow-up.

LEVEL OF EVIDENCE

3.

Obstruktive Schlafapnoe: Klug entscheiden, das Richtige tun

Die obstruktive Schlafapnoe (OSA) kann zu einer erheblichen Einschränkung der Lebensqualität führen, und eine nicht behandelte mittel- bis schwergradige OSA (Apnoe-Hypopnoe-Index ≥ 15/h) erhöht das Risiko vieler – überwiegend kardiovaskulärer – Erkrankungen deutlich. In Anbetracht der Häufigkeit des Krankheitsbilds und der damit verbundenen Beeinträchtigungen ist eine effektive Diagnostik und Therapie der OSA von besonderer Bedeutung.

Die Deutsche Gesellschaft für Schlafforschung und Schlafmedizin (DGSM) hat daher jeweils fünf praxisnahe Positiv- und Negativempfehlungen zusammengestellt, die das diagnostische und therapeutische Vorgehen bei OSA erleichtern sollen. Sie beziehen sich insbesondere auf die Indikationen zur schlafmedizinischen Diagnostik und zu spezifischen Therapieoptionen unter Berücksichtigung von Alter, Klinik, Risikofaktoren und Komorbiditäten.

Die Auswahl der Empfehlungen orientiert sich an der klinischen Relevanz, an bestehenden Defiziten im Sinne einer Über- oder Unterversorgung und an der Stärke der Empfehlungen in der aktuellen S3-Leitlinie der DGSM zu den schlafbezogenen Atmungsstörungen.

Impact of continuous positive airway pressure ventilation on cardiovascular outcomes among patients with obstructive sleep apnea: A meta-analysis of randomized trials

Background

The impact of continuous positive airway pressure (CPAP) on cardiovascular outcomes among patients with obstructive sleep apnea (OSA) is controversial.

Objective

To evaluate the impact of CPAP on reducing cardiovascular outcomes in patients with OSA.

Methods

We performed a computerized search of MEDLINE, EMBASE and COCHRANE databases through April 2021 for randomized trials evaluating the impact of CPAP versus control on cardiovascular outcomes in patients with OSA. Summary estimates were reported using both fixed and random effects model. The main study outcome was major adverse cardiac events (MACE).

Results

The final analysis included 8 randomized trials with total of 5684 patients. The weighted mean follow-up was 42.6 months. There was no difference between the CPAP and control groups in the risk of MACE (14.4% versus 14.8%, risk ratio [RR]: 0.97; 95% confidence interval [CI]: 0.85 to 1.10; p = 0.60; I2 = 21%). Subgroup analysis suggested that CPAP was associated with lower MACE (by 36%) in CPAP-adherent patients (≥4 h/night) (Pinteraction = 0.08). There was no difference between the CPAP and control groups in the risk of all-cause mortality, cardiovascular mortality, acute stroke, acute myocardium infarction or hospitalizations for angina.

Conclusions and relevance

CPAP use might not be associated with lower cardiovascular events among patients with OSA. However, patients adherent to CPAP (≥4 h/night) might derive a benefit on cardiovascular outcomes. Future studies are warranted to evaluate the impact of CPAP in reducing cardiovascular events among patients with severe OSA and with optimal adherence rates to CPAP therapy.

Association of Systemic Diseases With Surgical Treatment for Obstructive Sleep Apnea Compared With Continuous Positive Airway Pressure

Importance

The efficacy of surgical treatments for obstructive sleep apnea (OSA) is variable when considering only the Apnea Hypopnea Index as the treatment end point. However, only a few studies have shown an association between these procedures and improved clinically relevant outcomes, such as cardiovascular, endocrine, and neurological sequelae of OSA.

Objective

To evaluate the association of surgery for OSA with clinically relevant outcomes.

Design, Setting, and Participants

This retrospective cohort study used the Truven MarketScan Database from January 1, 2007, to December 31, 2015, to identify all patients diagnosed with OSA who received a prescription of continuous positive airway pressure (CPAP), were 40 to 89 years of age, and had at least 3 years of data on file. Data were analyzed September 19, 2019.

Interventions

Soft tissue and skeletal surgical procedures for the treatment of OSA.

Main Outcomes and Measures

The occurrence of cardiovascular, neurological, and endocrine complications was compared in patients who received CPAP alone and those who received surgery. High-dimensionality propensity score matching was used to adjust the models for confounders. Kaplan-Meier survival analysis with a log-rank test was used to compare differences in survival curves.

Findings

A total of 54 224 patients were identified (33 405 men [61.6%]; mean [SD] age, 55.1 [9.2] years), including a cohort of 49 823 patients who received CPAP prescription alone (mean [SD] age, 55.5 [9.4] years) and 4269 patients who underwent soft tissue surgery (mean [SD] age, 50.3 [7.0] years). The median follow-up time was 4.47 (interquartile range, 3-8) years after the index CPAP prescription. In the unadjusted model, soft tissue surgery was associated with decreased cardiovascular (hazard ratio [HR], 0.92; 95% CI, 0.86-0.98), neurological (HR, 0.49; 95% CI, 0.39-0.61), and endocrine (HR, 0.80; 95% CI, 0.74-0.86) events. This finding was maintained in the adjusted model (HR for cardiovascular events, 0.91 [95% CI, 0.83-1.00]; HR for neurological events, 0.67 [95% CI, 0.51-0.89]; HR for endocrine events, 0.82 [95% CI, 0.74-0.91]). Skeletal surgery (n = 114) and concomitant skeletal and soft tissue surgery (n = 18) did not demonstrate significant differences in rates of development of systemic complications.

Conclusions and Relevance

In this cohort study, soft tissue surgery for OSA was associated with lower rates of development of cardiovascular, neurological, and endocrine systemic complications compared with CPAP prescription in a large convenience sample of the working insured US adult population. These findings suggest that surgery should be part of the early treatment algorithm in patients at high risk of CPAP failure or nonadherence.

The role of sleep disorders in cardiovascular diseases: Culprit or accomplice?

Sleep disorders frequently comorbid with several cardiovascular diseases (CVDs), attracting increasing scientific attention and interest. Sleep disorders include insomnia, sleep-disordered breathing, restless legs syndrome, etc. It is well known that inflammation, sympathetic activation, and endothelial dysfunction play critical roles in sleep disorders, all of which are predisposing factors for CVDs. The comorbidity of sleep disorders and CVDs may have a bidirectional relationship. Patients with CVDs may have a high incidence of sleep disorders and vice versa. This review focused on the comorbidity of sleep disorders and CVDs and discussed the potential pathophysiological mechanisms and therapeutic strategies. In addition to the existing mechanisms, this review summarized novel potential mechanisms underlying comorbidities, such as gut microbiota, orexin, and extracellular vesicles, which may provide a theoretical basis for further basic research and clinical investigations on improving therapeutic outcomes.

Does continuous positive airway pressure therapy benefit patients with coronary artery disease and obstructive sleep apnea? A systematic review and meta-analysis

The prevalent co‐morbidity of coronary artery disease (CAD) and obstructive sleep apnea (OSA) has attracted great interest. However, effects of continuous positive airway pressure (CPAP) in patients with OSA and CAD for cardiovascular outcomes and deaths are still controversial. Usage of CPAP among patients with CAD and OSA could decrease the risk of cardiovascular events and death in adults. PubMed, EMBASE, Web of science, and Cochrane Library were systematically searched. Studies that described association of CPAP treatment with cardiovascular events in CAD and OSA patients were included. The main outcome was the major adverse cardiovascular events (MACE), including all‐cause death, cardiovascular death, myocardial infarction (MI), stroke, and repeat revascularization. Summary relative risks (risk ratios [RRs]) and 95% confidence intervals (CIs) of outcomes were pooled and heterogeneity was assessed with the I² statistic. Nine studies enrolling 2590 participants with OSA and CAD were included and extracted data. There was significant association of CPAP with reduced risk of MACE (RR, 0.73, 95% CI [0.55, 0.96]), particularly among those with AHI less than 30 events/h (RR, 0.43, 95% CI [0.22, 0.84]). Similarly, the same result was found in all‐cause death (RR, 0.66, 95% CI, [0.46, 0.94]) and cardiovascular death (RR, 0.495, 95% CI [0.292, 0.838]). Our data suggested that CPAP usage, compared to usual care, was associated with reduced risks of cardiovascular outcomes or death in patients with OSA and CAD, particularly in the subgroup with AHI less than 30 events/h, which still needs further studies to confirm.

Cardiovascular Disease in Patients with Chronic Obstructive Pulmonary Disease, Obstructive Sleep Apnoea Syndrome and Overlap Syndrome

Chronic obstructive pulmonary disease (COPD) and obstructive sleep apnoea syndrome (OSAS) are among the most prevalent chronic respiratory disorders. Accumulating data suggest that there is a significant burden of cardiovascular disease (CVD) in patients with COPD and OSAS, affecting negatively patients' quality of life and survival. Overlap syndrome (OS), i.e. the co-existence of both COPD and OSAS in the same patient, has an additional impact on the cardiovascular system multiplying the risk of morbidity and mortality. The underlying mechanisms for the development of CVD in patients with either OSAS or COPD and OS are not entirely elucidated. Several mechanisms, in addition to smoking and obesity, may be implicated, including systemic inflammation, increased sympathetic activity, oxidative stress and endothelial dysfunction. Early diagnosis and proper management of these patients might reduce cardiovascular risk and improve patients' survival. In this review, we summarize the current knowledge regarding epidemiological aspects, pathophysiological mechanisms and present point-to-point specific associations between COPD, OSAS, OS and components of CVD, namely, pulmonary hypertension, coronary artery disease, peripheral arterial disease and stroke.

Personalized and Patient-Centered Strategies to Improve Positive Airway Pressure Adherence in Patients with Obstructive Sleep Apnea

Obstructive sleep apnea (OSA), a common sleep disorder characterized by repeated pauses in breathing during sleep, is effectively treated with positive airway pressure (PAP) therapy. The magnitude of improvements in daily functioning and reduced negative health risks are dependent on maintaining PAP adherence, which is a significant challenge. Evidence-based interventions to improve PAP use are not easily translated to clinical practice because they are labor-intensive and require specialty expertise. Further, to date, individualized care, inclusive of personalized medicine and patient- and person-centered care have been marginally incorporated in the field's understanding of OSA and PAP adherence. This integrative review describes current PAP adherence assessment processes, interventions to improve adherence, and outlines future opportunities to advance the field, particularly as it relates to individualizing care and the use of implementation science to apply evidence to practice.

Patterns of nightly CPAP usage in OSA patients with suboptimal treatment adherence

BACKGROUND AND OBJECTIVES

Low adherence impairs the effectiveness of continuous positive airway pressure (CPAP) therapy in patients with obstructive sleep apnoea (OSA), but knowledge on CPAP usage micro-patterns is mostly lacking. Thus, the aim of this study was to analyse usage micro-patterns among patients with suboptimal CPAP adherence.

METHODS

We analysed CPAP usage datasets comprising the initial 31 nights of therapy. By employing a threshold of 4 h usage in at least 70% of nights, we subdivided the patients into suboptimal and optimal users. We investigated single CPAP start- and stop-points, and introduced the parameter "interruption-rate", by dividing the amount of therapy interruptions per night by the usage duration per night. This parameter represents the amount of interruptions per 1 h of CPAP usage. Group comparison analysis was performed via t-test, Wilcoxon rank sum-test, and via Chi²-test.

RESULTS

We included datasets of 48 suboptimal and 48 optimal users (55.9 ± 11.3 years, 83.3% men) in the analysis. Interruption-rate was significantly higher among suboptimal users, when compared with optimal users (median (quartiles) 0.24 (0.14/0.45) versus 0.15 (0.05/0.28), p < 0.001∗). Suboptimal users were more likely to report that CPAP reduced their sleep quality, waked them up at night, and that CPAP side effects or problems with the device impaired their adherence.

CONCLUSIONS

CPAP usage micro-patterns are more fragmented among OSA patients with lower overall adherence. These patterns might result from impaired sleep quality, due to CPAP side effects, and device-associated problems.

Impact of Snoring on the Cardiovascular System and its Treatment: Positive and Negative Effects of Continuous Positive Airway Pressure in Sleep Apnea

Obstructive sleep apnea (OSA) is a common condition, and if not treated can be a significant risk factor for multiple comorbidities like hypertension (HTN), coronary artery disease (CAD), and congestive heart failure (CHF). The underlying pathophysiology involves coagulation and inflammatory pathways, including an overactive sympathetic nervous system. This ultimately causes hemodynamic changes and subclinical myocardial injuries. We reviewed the published literature about the impact of continuous positive airway pressure (CPAP) when used as a mode of treatment to reduce the OSA effects on cardiomyocytes. We found that the results were mixed, including both ill and good effects. The cardiac markers like N-terminal pro-brain natriuretic peptide (NT-proBNP) and atrial natriuretic peptide (ANP) were reduced, implying the decrease in the incidence of heart failure with CPAP treatment in a few of the studies. They also proved a significant decrease in harmful cardiovascular (CV) outcomes, while others concluded that CPAP therapy might be stressful on the heart, causing an elevation in cardiac troponin T levels. However, the impact on inflammatory markers is still indeterminate and needs more research in future.

Continuous positive pressure therapy usage and incident stroke in patients with obstructive sleep apnea: A nationwide population-based cohort study

INTRODUCTION

Continuous positive airway pressure (CPAP) is the main treatment for obstructive sleep apnea (OSA). To date, the link between CPAP usage and incident stroke has been inconsistent.

OBJECTIVE

This nationwide population study is designed to examine the effect of CPAP on stroke incidence in OSA patients.

METHODS

Using Taiwan's National Health Insurance Research Database (NHIRD), this study collected data from 4275 OSA patients diagnosed between 2000 and 2011 and divided them into two groups according to whether they received CPAP treatment. After matching baseline demographics and comorbidities, both cohorts contained 959 OSA patients and were followed to a newly diagnosed stroke or until the end of 2013. Cox regression analysis was performed to examine the incidence of stroke between patients with OSA receiving CPAP or no CPAP treatment.

RESULTS

CPAP treatment for OSA patients predicted a lower incidence rate (3.41 vs 5.43 per 1000 person-years) and tended to protect against the development of stroke (hazard ratio (HR): 0.68, 95% confidence interval (95% CI): 0.38-1.23) compared to those without CPAP treatment, but the estimate was not statistically significant. Similar results were also observed by dividing stroke into ischemic (2.65 vs 4.30 per 1000 person-years; HR: 0.67, 95% CI: 0.35-1.31) or hemorrhagic origin (0.76 vs 1.12 per 1000 person-years; HR: 0.67, 95% CI: 0.19-2.40).

CONCLUSIONS

It is possible that treatment with CPAP might be beneficial for protection against stroke, but this conclusion should be interpreted with caution. Future studies with satisfactory CPAP quality and duration are needed to validate this observation.

EAN/ERS/ESO/ESRS statement on the impact of sleep disorders on risk and outcome of stroke

Sleep disorders are highly prevalent in the general population and may be linked in a bidirectional fashion to stroke, which is one of the leading causes of morbidity and mortality.Four major scientific societies established a task force of experts in neurology, stroke, respiratory medicine, sleep medicine and methodology, to critically evaluate the evidence regarding potential links and the impact of therapy. 13 research questions were evaluated in a systematic literature search using a stepwise hierarchical approach: first, systematic reviews and meta-analyses; second, primary studies post-dating the systematic reviews/meta-analyses. A total of 445 studies were evaluated and 88 included. Statements were generated regarding current evidence and clinical practice.Severe obstructive sleep apnoea (OSA) doubles the risk for incident stroke, especially in young to middle-aged patients. Continuous positive airway pressure (CPAP) may reduce stroke risk, especially in treatment-compliant patients. The prevalence of OSA is high in stroke patients and can be assessed by polygraphy. Severe OSA is a risk factor for recurrence of stroke and may be associated with stroke mortality, while CPAP may improve stroke outcome. It is not clear if insomnia increases stroke risk, while pharmacotherapy of insomnia may increase it. Periodic limb movements in sleep (PLMS), but not restless limb syndrome (RLS), may be associated with an increased risk of stroke. Preliminary data suggest a high frequency of post-stroke insomnia and RLS and their association with a less favourable stroke outcome, while treatment data are scarce.Overall, the evidence base is best for OSA relationship with stroke and supports active diagnosis and therapy. Research gaps remain especially regarding insomnia and RLS/PLMS relationships with stroke.

Auto positive airway pressure therapy reduces pulmonary pressures in adults admitted for acute heart failure with pulmonary hypertension and obstructive sleep apnea. The ASAP-HF Pilot Trial

OBJECTIVES

Pulmonary hypertension (PH) is extremely common in acute decompensated heart failure (ADHF) patients and predicts increased mortality. Obstructive sleep apnea (OSA), highly prevalent in congestive heart failure patients, may contribute to further elevated pulmonary pressures. This study evaluates the impact of positive airway pressure (PAP) therapy on PH in patients admitted for ADHF with OSA.

METHODS

A two-center randomized control trial comparing standard of care (SOC) therapy for ADHF versus addition of PAP therapy in patients with concomitant OSA.

RESULTS

Twenty-one consecutive patients were enrolled with 1:1 randomization to SOC versus SOC plus 48-hour PAP therapy protocol. In the intervention arm, the mean pulmonary artery systolic pressure (PASP) difference before therapy and after 48 hours of PAP therapy was -15.8 ± 3.2 (58.6 ± 2.5 mm Hg to 42.8 ± 2.7) versus the SOC arm where the mean PASP difference was -5.2 ± 2.6 (62.7 ± 3.3 mm Hg reduced to 57.5 ± 3.9) (p = 0.025). In addition, ejection fraction in the intervention arm improved (3.4 ± 1.5% versus -0.5 ± 0.5 %) (p = 0.01). Significant improvement was also noted in tricuspid annular plane systolic excursion (TAPSE) and right ventricular systolic area in the intervention arm but not in NT-pro-BNP or 6-minute walk distance.

CONCLUSIONS

In patients with ADHF and OSA, addition of 48 hours of PAP therapy to SOC treatment significantly reduced PH. In addition, PAP therapy was able to improve right and left ventricular function. ClinicalTrials.gov identifier: NCT02963597.