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Holtstrand Hjälm H, Thunström E, Glantz H, Karlsson M, Celik Y, Peker Y. Obstructive sleep apnea severity and prevalent atrial fibrillation in a sleep clinic cohort with versus without excessive daytime sleepiness. Sleep Med 2023; 112:63-69. [PMID: 37806037 DOI: 10.1016/j.sleep.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 09/11/2023] [Accepted: 09/12/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is associated with atrial fibrillation (AF) in cardiac cohorts. Less is known regarding the magnitude of this association in a sleep clinic cohort with vs. without excessive daytime sleepiness (EDS). OBJECTIVES To explore the association of OSA severity with AF in a sleep clinic cohort stratified by EDS. PATIENTS AND METHODS All consecutive adults (n = 3814) admitted to the Skaraborg Hospital, Sweden between Jan 2005 and December 2011 were registered in a local database, and the follow-up ended in December 2018. OSA was defined as an apnea-hypopnea index (AHI) ≥5 events/h. Mild OSA was defined as AHI ≥5 & AHI<15 events/h; moderate OSA as AHI ≥15 & AHI<30 events/h; and severe OSA as AHI ≥30 events/h. EDS was defined as an Epworth Sleepiness Scale score ≥11. We conducted cross-sectional analyzes of the prevalent AF across the OSA severity categories and logistic regression analyzes stratified by EDS. RESULTS In all, 202 patients (5.3%) had AF at baseline, 1.6% in no-OSA, 3.9% in mild OSA, 5.2% in moderate OSA, and 7.6% in severe OSA, respectively (p < 0.001). The stratified analyzes revealed that patients with severe OSA without EDS had an increased risk for prevalent AF (OR 2.54, 95% CI 1.05-6.16; p = 0.039) independent of the confounding factors. CONCLUSIONS There was an independent dose-response relationship between OSA and prevalent AF among the non-sleepy phenotype in this sleep clinic cohort. Since adherence to OSA treatment is challenging in the absence of EDS, these patients may have increased risk for adverse cardiovascular outcomes.
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Affiliation(s)
- Henrik Holtstrand Hjälm
- Department of Molecular and Clinical Medicine/Cardiology, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Erik Thunström
- Department of Molecular and Clinical Medicine/Cardiology, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Helena Glantz
- Department of Internal Medicine, Skaraborg Hospital, Lidköping, Sweden
| | - Martin Karlsson
- Department of Internal Medicine, Skaraborg Hospital, Lidköping, Sweden
| | - Yeliz Celik
- Department of Pulmonary Medicine, Koc University School of Medicine & Koc University Research Center for Translational Medicine (KUTTAM), Istanbul, Turkey
| | - Yüksel Peker
- Department of Molecular and Clinical Medicine/Cardiology, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Pulmonary Medicine, Koc University School of Medicine & Koc University Research Center for Translational Medicine (KUTTAM), Istanbul, Turkey; Division of Sleep and Circadian Disorders, Brigham and Women's Hospital & Harvard Medical School, Boston, MA, USA; Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Clinical Sciences, Respiratory Medicine and Allergology, Faculty of Medicine, Lund University, Lund, Sweden
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Redline S, Azarbarzin A, Peker Y. Obstructive sleep apnoea heterogeneity and cardiovascular disease. Nat Rev Cardiol 2023; 20:560-573. [PMID: 36899115 DOI: 10.1038/s41569-023-00846-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2023] [Indexed: 03/12/2023]
Abstract
Obstructive sleep apnoea (OSA), characterized by recurrent periods of upper airway obstruction and intermittent hypoxaemia, is prevalent in patients with cardiovascular disease (CVD), and is therefore important to consider in the prevention and management of CVD. Observational studies indicate that OSA is a risk factor for incident hypertension, poorly controlled blood pressure, stroke, myocardial infarction, heart failure, cardiac arrhythmias, sudden cardiac death and all-cause death. However, clinical trials have not provided consistent evidence that treatment with continuous positive airway pressure (CPAP) improves cardiovascular outcomes. These overall null findings might be explained by limitations in trial design and low levels of adherence to CPAP. Studies have also been limited by the failure to consider OSA as a heterogeneous disorder that consists of multiple subtypes resulting from variable contributions from anatomical, physiological, inflammatory and obesity-related risk factors, and resulting in different physiological disturbances. Novel markers of sleep apnoea-associated hypoxic burden and cardiac autonomic response have emerged as predictors of OSA-related susceptibility to adverse health outcomes and treatment response. In this Review, we summarize our understanding of the shared risk factors and causal links between OSA and CVD and emerging knowledge on the heterogeneity of OSA. We discuss the varied mechanistic pathways that result in CVD that also vary across subgroups of OSA, as well as the potential role of new biomarkers for CVD risk stratification.
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Affiliation(s)
- Susan Redline
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Yüksel Peker
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA, USA
- Koc University School of Medicine, Istanbul, Turkey
- University of Gothenburg, Gothenburg, Sweden
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Lund University School of Medicine, Lund, Sweden
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Gervès-Pinquié C, Bailly S, Goupil F, Pigeanne T, Launois S, Leclair-Visonneau L, Masson P, Bizieux-Thaminy A, Blanchard M, Sabil A, Jaffuel D, Racineux JL, Trzepizur W, Gagnadoux F. Positive Airway Pressure Adherence, Mortality, and Cardiovascular Events in Patients with Sleep Apnea. Am J Respir Crit Care Med 2022; 206:1393-1404. [PMID: 35816570 DOI: 10.1164/rccm.202202-0366oc] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Rationale: Randomized controlled trials showed no effect of positive airway pressure (PAP) therapy for obstructive sleep apnea (OSA) on cardiovascular (CV) risk. However, patient selection and low PAP adherence preclude the generalization of their data to clinical samples. Objectives: To evaluate the association between hours of PAP use, mortality, and CV morbidity in real-life conditions. Methods: Data from the Pays de la Loire Cohort were linked to health administrative data to identify incident major adverse cardiovascular events (MACEs; a composite outcome of mortality, stroke, and cardiac diseases) in patients with OSA who were prescribed PAP. Cox proportional hazards analyses were conducted to evaluate the association between MACEs and quartiles of average daily PAP use over the study period. Measurements and Main Results: After a median follow-up of 6.6 years, 961 of 5,138 patients experienced MACEs. Considering nonadherent patients (0-4 h/night) as the reference group, adjusted hazard ratios (95% confidence intervals) for MACEs were 0.87 (0.73-1.04) for the 4-6 h/night group, 0.75 (0.62-0.92) for the 6-7 h/night group, and 0.78 (0.65-0.93) for the ⩾7 h/night group (P = 0.0130). Sensitivity analyses using causal inference approaches confirmed the association of PAP use with MACEs. The association was stronger in male patients (P value for interaction = 0.0004), patients without overt CV disease at diagnosis (P < 0.0001), and those belonging to the excessively sleepy symptom subtype (P = 0.060). Conclusions: These real-life clinical data demonstrate a dose-response relationship between PAP adherence and incident MACEs in OSA. Patient support programs may help improve PAP adherence and CV outcomes in patients with OSA.
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Affiliation(s)
| | - Sebastien Bailly
- Hypoxia Physiopathology (HP2) Laboratory, Grenoble Alpes University, Grenoble, France
| | - François Goupil
- Department of Respiratory Diseases, Le Mans General Hospital, Le Mans, France
| | | | - Sandrine Launois
- Bioserenity Paris Jean-Jaurès, Hôpital Jean-Jaurès, Paris, France
| | | | - Philippe Masson
- Department of Respiratory Diseases, Cholet General Hospital, Cholet, France
| | - Acya Bizieux-Thaminy
- Department of Respiratory Diseases, La Roche sur Yon General Hospital, La Roche sur Yon, France
| | - Margaux Blanchard
- Ecole Supérieur D'Electronique de l'Ouest, Angers, France.,Laboratoire d'Acoustique de l'Université du Mans, Unité Mixte de Recherche, Centre National de la Recherche Scientifique 6613, Le Mans, France
| | - AbdelKebir Sabil
- Pays de la Loire Respiratory Health Research Institute, Beaucouzé, France.,Cloud Sleep Lab, Paris, France
| | - Dany Jaffuel
- Department of Respiratory Diseases, Montpellier University Hospital, Montpellier, France
| | | | - Wojciech Trzepizur
- Department of Respiratory and Sleep Medicine, Angers University Hospital, Angers, France; and.,National Institute for Health and Medical Research (INSERM) Unit, Mitochondrial and Cardiovascular Physiopathology (MitoVasc), University of Angers, Angers, France
| | - Frédéric Gagnadoux
- Department of Respiratory and Sleep Medicine, Angers University Hospital, Angers, France; and.,National Institute for Health and Medical Research (INSERM) Unit, Mitochondrial and Cardiovascular Physiopathology (MitoVasc), University of Angers, Angers, France
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The Link between Obstructive Sleep Apnea and Neurocognitive Impairment: An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2022; 19:1245-1256. [PMID: 35913462 PMCID: PMC9353960 DOI: 10.1513/annalsats.202205-380st] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
There is emerging evidence that obstructive sleep apnea (OSA) is a risk factor for preclinical Alzheimer's disease (AD). An American Thoracic Society workshop was convened that included clinicians, basic scientists, and epidemiologists with expertise in OSA, cognition, and dementia, with the overall objectives of summarizing the state of knowledge in the field, identifying important research gaps, and identifying potential directions for future research. Although currently available cognitive screening tests may allow for identification of cognitive impairment in patients with OSA, they should be interpreted with caution. Neuroimaging in OSA can provide surrogate measures of disease chronicity, but it has methodological limitations. Most data on the impact of OSA treatment on cognition are for continuous positive airway pressure (CPAP), with limited data for other treatments. The cognitive domains improving with CPAP show considerable heterogeneity across studies. OSA can negatively influence risk, manifestations, and possibly progression of AD and other forms of dementia. Sleep-dependent memory tasks need greater incorporation into OSA testing, with better delineation of sleep fragmentation versus intermittent hypoxia effects. Plasma biomarkers may prove to be sensitive, feasible, and scalable biomarkers for use in clinical trials. There is strong biological plausibility, but insufficient data, to prove bidirectional causality of the associations between OSA and aging pathology. Engaging, recruiting, and retaining diverse populations in health care and research may help to decrease racial and ethnic disparities in OSA and AD. Key recommendations from the workshop include research aimed at underlying mechanisms; longer-term longitudinal studies with objective assessment of OSA, sensitive cognitive markers, and sleep-dependent cognitive tasks; and pragmatic study designs for interventional studies that control for other factors that may impact cognitive outcomes and use novel biomarkers.
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Martinez-Garcia MA, Oscullo G, Gomez-Olivas JD. Representativeness of randomized controlled trials participants on the effect of continuous positive airway pressure on cardiovascular outcomes: caution is needed. Sleep 2022; 45:6510875. [DOI: 10.1093/sleep/zsac021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Miguel Angel Martinez-Garcia
- Pneumology Department, University and Polytechnic la Fe Hospital, Valencia, Spain
- CIBERES in Pulmonary Diseases, Instituto de Salud Carlos III, Madrid, Spain
| | - Grace Oscullo
- Pneumology Department, University and Polytechnic la Fe Hospital, Valencia, Spain
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Schiza S, Lévy P, Martinez-Garcia MA, Pepin JL, Simonds A, Randerath W. The search for realistic evidence on the outcomes of obstructive sleep apnoea. Eur Respir J 2021; 58:58/4/2101963. [PMID: 34620678 DOI: 10.1183/13993003.01963-2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 07/30/2021] [Indexed: 01/21/2023]
Affiliation(s)
- Sophia Schiza
- Sleep Disorders Center, Dept of Respiratory Medicine, Medical School, University of Crete, Heraklion, Greece
| | - Patrick Lévy
- Univ. Grenoble Alpes, Inserm, HP2 Laboratory, Grenoble, France.,Grenoble University Hospital, Sleep Laboratory, EFCR, Grenoble, France
| | - Miguel Angel Martinez-Garcia
- Pneumology Dept, University and Politechnic La Fe Hospital, Valencia, Spain.,CIBERES de enfermedades respiratorias, ISCIII, Madrid, Spain
| | - Jean-Louis Pepin
- Univ. Grenoble Alpes, Inserm, HP2 Laboratory, Grenoble, France.,Grenoble University Hospital, Sleep Laboratory, EFCR, Grenoble, France
| | - Anita Simonds
- Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Winfried Randerath
- Bethanien Hospital, Clinic of Pneumology and Allergology, Center for Sleep Medicine and Respiratory Care, Institute of Pneumology at the University of Cologne, Solingen, Germany
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Abstract
Adequate sleep is an important component of cardiovascular health. Due to circadian misalignment and irregular shifts, inadequate sleep is common in shift workers. Adverse consequences include daytime sleepiness, decreased cognitive performance, increased sympathetic tone, inflammation, impaired glucose tolerance, and altered leptin and ghrelin levels. When circadian adjustment has not occurred, daytime sleepers often experience decreased sleep duration and increased wakefulness during displaced sleep; additionally, skipping sleep is common in shift workers, further contributing to sleep deprivation. Habitual decreased sleep duration and physiological changes contribute to obesity, diabetes, hypertension, and increased cardiovascular disease risk in shift workers. Shift workers with obstructive sleep apnea (OSA), the most common sleep-related breathing disorder, can experience more frequent sleep disruptions than non-shift workers with OSA. Furthermore, shift work-induced circadian misalignment may potentiate cardiometabolic risk in OSA patients through autonomic nervous system dysfunction and other mechanisms.
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Affiliation(s)
- Amir Gohari
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Darrin Wiebe
- Department of Medicine, University of British Columbia, Vancouver, Canada.,Leon Judah Blackmore Centre for Sleep Disorders, University of British Columbia Hospital, Vancouver, Canada
| | - Najib Ayas
- Department of Medicine, University of British Columbia, Vancouver, Canada.,Leon Judah Blackmore Centre for Sleep Disorders, University of British Columbia Hospital, Vancouver, Canada
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