Effects of Ethnicity on the Prevalence of Obstructive Sleep Apnoea in Patients with Acute Coronary Syndrome: A Pooled Analysis of the ISAACC Trial and Sleep and Stent Study

The Long-Term Prognostic Role of Nighttime Resting Heart Rate in Obstructive Sleep Apnea in Patients with Acute Coronary Syndrome

AIM

A close relationship exists between resting heart rate (RHR) and obstructive sleep apnea (OSA). Still, the prognostic importance of nighttime RHR in patients with acute coronary syndrome (ACS) with or without OSA remains unclear.

METHODS

In this prospective cohort study, OSA was defined as an apnea-hypopnea index of ≥ 15 events/h, and the high nighttime RHR (HNRHR) was defined as a heart rate of ≥ 70 bpm. The primary endpoint was a major adverse cardiovascular and cerebrovascular event (MACCE), including cardiovascular death, myocardial infarction, stroke, ischemia-driven revascularization, or hospitalization for heart failure.

RESULTS

Among the 1875 enrolled patients, the mean patient age was 56.3±10.5 years, 978 (52.2%) had OSA, and 425 (22.7%) were in HNRHR. The proportion of patients with HNRHR is higher in the OSA population than in the non-OSA population (26.5% vs. 18.5%; P＜0.001). During 2.9 (1.5, 3.5) years of follow-up, HNRHR was associated with an increased risk of MACCE in patients with OSA (adjusted HR: 1.56, 95% CI: 1.09-2.23, P=0.014), but not in patients without OSA (adjust HR: 1.13, 95% CI: 0.69-1.84, P=0.63).

CONCLUSIONS

In patients with ACS, a nighttime RHR of ≥ 70 bpm was associated with a higher risk of MACCE in those with OSA but not in those without it. This identifies a potential high-risk subgroup where heart rate may interact with the prognosis of OSA. Further research is needed to determine causative relationships and confirm whether heart rate control impacts cardiovascular outcomes in patients with ACS-OSA.

Day-night pattern of acute ST-segment elevation myocardial infarction onset in patients with obstructive sleep apnea

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is associated with acute nocturnal hemodynamic and neurohormonal abnormalities that may increase the risk of coronary events, especially during the nighttime. This study sought to investigate the day-night pattern of acute ST-segment elevation myocardial infarction (STEMI) onset in patients with OSA and its impact on cardiovascular adverse events.

METHODS

We prospectively enrolled 397 patients with STEMI, for which the time of onset of chest pain was clearly identified. All participants were categorized into non-OSA (n = 280) and OSA (n = 117) groups. The association between STEMI onset time and major adverse cardiovascular and cerebrovascular events was estimated by Cox proportional hazards regression.

RESULTS

STEMI onset occurred from midnight to 5:59 am in 33% of patients with OSA, as compared with 15% in non-OSA patients (P < .01). For individuals with OSA, the relative risk of STEMI from midnight to 5:59 am was 2.717 [95% confidence interval (CI) 1.616 - 4.568] compared with non-OSA patients. After a median of 2.89 ± 0.78 years follow-up, symptom onset time was found to be significantly associated with risk of major adverse cardiovascular and cerebrovascular events in patients with OSA, while there was no significant association observed in non-OSA patients. Compared with STEMI presenting during noon to 5:59 pm, the hazard ratios for major adverse cardiovascular and cerebrovascular events in patients with OSA were 4.683 (95% CI 2.024 - 21.409, P = .027) for midnight to 5:59 am and 6.964 (95% CI 1.379 - 35.169, P = .019) for 6 pm to midnight, whereas the hazard ratios for non-OSA patients were 1.053 (95% CI 0.394 - 2.813, P = .917) for midnight to 5:59 am and 0.745 (95% CI 0.278 - 1.995, P = .558) for 6 pm to midnight.

CONCLUSIONS

Patients with OSA exhibited a peak incidence of STEMI between midnight and 5:59 am, which showed an independent association with cardiovascular adverse events.

CITATION

Wang Y, Buayiximu K, Zhu T, et al. Day-night pattern of acute ST-segment elevation myocardial infarction onset in patients with obstructive sleep apnea. J Clin Sleep Med. 2024;20(5):765-775.

Association of obstructive sleep apnoea with cardiovascular events in women and men with acute coronary syndrome

BACKGROUND

The impact of sex on the association of obstructive sleep apnoea (OSA) with recurrent cardiovascular events following acute coronary syndrome (ACS) remains uncertain. This study sought to examine the association between OSA and long-term cardiovascular outcomes in women and men with ACS.

METHODS

In this prospective cohort study, we recruited 2160 ACS patients undergoing portable sleep monitoring between June 2015 and January 2020. The primary end-point was major adverse cardiovascular and cerebrovascular event (MACCE), including cardiovascular death, myocardial infarction, stroke, ischaemia-driven revascularisation or hospitalisation for unstable angina or heart failure.

RESULTS

After exclusion of patients with failed sleep studies, central sleep apnoea, regular continuous positive airway pressure therapy and loss of follow-up, 1927 patients were enrolled. Among them, 298 (15.5%) were women and 1014 (52.6%) had OSA (apnoea-hypopnoea index ≥15 events·h^-1). The prevalence of OSA was 43.0% and 54.4% in women and men, respectively. In 4339 person-years (median 2.9 years, interquartile range 1.5-3.6 years), the cumulative incidence of MACCE was significantly higher in OSA versus non-OSA groups in the overall population (22.4% versus 17.7%; adjusted hazard ratio (HR) 1.29, 95% CI 1.04-1.59; p=0.018). OSA was associated with greater risk of MACCE in women (28.1% versus 18.8%; adjusted HR 1.68, 95% CI 1.02-2.78; p=0.042), but not in men (21.6% versus 17.5%; adjusted HR 1.22, 95% CI 0.96-1.54; p=0.10). No significant interaction was noted between sex and OSA for MACCE (interaction p=0.32). The incremental risk in women was attributable to higher rates of hospitalisation for unstable angina and ischaemia-driven revascularisation.

CONCLUSIONS

In hospitalised ACS patients, OSA was associated with increased risk of subsequent events, particularly among women. Female patients with ACS should not be neglected for OSA screening and dedicated intervention studies focusing on women with ACS and comorbid OSA should be prioritised.

Association of Homocysteine and Risks of Long-Term Cardiovascular Events and All-Cause Death among Older Patients with Obstructive Sleep Apnea: A Prospective Study

OBJECTIVES

This study aimed to assess whether raised baseline plasma tHcy concentrations increased the risks of major adverse cardiovascular events (MACE) and all-cause death outcomes in older patients with obstructive sleep apnea (OSA).

DESIGN

A multicenter, prospective, observational study.

SETTING

Beijing, Shandong Province, Gansu Province of China.

PARTICIPANTS

A total of 1, 290 OSA patients aged 60 to 96 years from sleep centers of six hospitals in China consecutively recruited between January 2015 and October 2017.

MEASUREMENTS

Cox proportional models assessed the association between tHcy and the risk of new-onset all events among Chinese older OSA patients.

RESULTS

The final analysis (60.1% male; median age, 66 years) used data from 1, 100 subjects during a median follow-up of 42 months, a total of 105 (9.5%) patients developed MACE and 42 (3.8%) patients died. Multivariable Cox regression analysis showed higher adjusted hazard ratios (aHRs) of MACE, myocardial infarction (MI), hospitalization for unstable angina, and composite of all events with tHcy levels in the 4th quartile (HR=5.93, 95% CI: 2.79-12.59; HR=4.72, 95% CI:1.36-4.61; HR=4.26, 95% CI:1.62-5.71; HR=4.17, 95% CI:2.23-7.81) and the 3rd quartile (HR=3.79, 95% CI:1.76-8.20; HR=3.65, 95% CI:1.04-2.98; HR=2.75, 95% CI:1.08-3.76; HR=2.51, 95% CI:1.31-4.83) compared to reference tHcy levels in quartile 1, respectively, while the aHRs (95% CIs) of all-cause death showed significantly higher only in the highest tHcy level quartile than in the lowest quartile (HR=3.20, 95% CI=1.16-8.84, P=0.025) with no significant differences in risks of cardiovascular death and hospitalisation for heart failure among groups (P>0.05).

CONCLUSIONS

tHcy, a marker of prognosis for older OSA patients, was significantly associated with the increased risk of MACE and all-cause death in this population independent of BMI, smoking status, and other potential risk factors, but not all clinical components events of MACE. New therapeutic approaches for older patients with OSA should mitigate tHcy-associated risks of MACE, and even all-cause death.

Integrative analysis of key candidate genes and signaling pathways in acute coronary syndrome related to obstructive sleep apnea by bioinformatics

Although obstructive sleep apnea (OSA) has been clinically reported to be associated with acute coronary syndrome (ACS), the pathogenesis between the two is unclear. Herein, we analyzed and screened out the prospective molecular marker. To explore the candidate genes, as well as signaling cascades involved in ACS related to OSA, we extracted the integrated differentially expressed genes (DEGs) from the intersection of genes from the Gene Expression Omnibus (GEO) cohorts and text mining, followed by enrichment of the matching cell signal cascade through DAVID analysis. Moreover, the MCODE of Cytoscape software was employed to uncover the protein-protein interaction (PPI) network and the matching hub gene. A total of 17 and 56 integrated human DEGs in unstable angina (UA) and myocardial infarction (MI) group associated with OSAs that met the criteria of |log2 fold change (FC)|≥ 1, adjusted P < 0.05, respectively, were uncovered. After PPI network construction, the top five hub genes associated with UA were extracted, including APP, MAPK3, MMP9, CD40 and CD40LG, whereas those associated with MI were PPARG, MAPK1, MMP9, AGT, and TGFB1. The establishment of the aforementioned candidate key genes, as well as the enriched signaling cascades, provides promising molecular marker for OSA-related ACS, which will to provide a certain predictive value for the occurrence of ACS in OSA patients in the future.

Chronic Intermittent Hypoxia Participates in the Pathogenesis of Atherosclerosis and Perturbs the Formation of Intestinal Microbiota

Chronic intermittent hypoxia (CIH) is the prominent signature of highly prevalent obstructive sleep apnea (OSA) pathophysiology, which leads to increased risk and aggravation of atherosclerotic cardiovascular diseases. However, whether intestinal microbiota is implicated in the mechanisms linking CIH to arteriosclerosis (AS) pathogenesis remains unclear. The association of CIH with the development of altered gut microbiota (GM) may provide the opportunity to develop preventive strategies for atherosclerotic cardiovascular risk reduction. Animal models of apolipoprotein E-deficient (apoE^-/-) mice treated with high-fat diet (HFD) and subjected to CIH conditions was applied to mimic the AS observed in patients with OSA. The physiological status and atherosclerotic lesion formation were confirmed by histological analysis. 16S rDNA sequencing of fecal samples was conducted to determine the changes in gut microbial composition. Morphometric analysis demonstrated that CIH caused aggravated atherosclerotic lesions and facilitated AS in apoE^-/- mice treated with HFD. The gut bacteria was significantly varied in AS and AS+CIH mice compared with that in the control mice. Significantly perturbed GM profiles were detected in AS mice with and without CIH, with altered microbial α- and β- diversity and shifts in bacterial compositions at phylum and genus levels. While the difference between AS and AS+CIH was observed at different bacteria taxa levels. Aggravation of reduced Sutterella and increased Halomonas, Halomonadaceae and Oceanospirillales was noted in CIH-treated AS mice. The correlation of intestinal bacterial parameters with pathological changes in artery indicated complicated interactions under CIH-induced GM dysbiosis. Furthermore, the gut microbial functions in the potential ability of replication recombination and repair proteins, glycan biosynthesis and metabolism, as well as metabolism of cofactors and vitamins were identified to be further suppressed by CIH. Our findings demonstrated a causal effect of CIH on GM alterations in AS mice and suggested that the disordered GM features in AS development were deteriorated by CIH, which may be associated with AS aggravation. Preventative strategies targeting gut microbiome are highly recommended for intervention of OSA-related AS.

Association of Obstructive Sleep Apnea With Cardiovascular Outcomes in Patients With Acute Coronary Syndrome

Background

The prognostic significance of obstructive sleep apnea (OSA) in patients with acute coronary syndrome (ACS) in the contemporary era is unclear. We performed a large, prospective cohort study and did a landmark analysis to delineate the association of OSA with subsequent cardiovascular events after ACS onset.

Methods and Results

Between June 2015 and May 2017, consecutive eligible patients admitted for ACS underwent cardiorespiratory polygraphy during hospitalization. OSA was defined as an apnea‐hypopnea index ≥15 events·h⁻¹. The primary end point was major adverse cardiovascular and cerebrovascular event (MACCE), including cardiovascular death, myocardial infarction, stroke, ischemia‐driven revascularization, or hospitalization for unstable angina or heart failure. OSA was present in 403 of 804 (50.1%) patients. During median follow‐up of 1 year, cumulative incidence of MACCE was significantly higher in the OSA group than in the non‐OSA group (log‐rank, P=0.041). Multivariate analysis showed that OSA was nominally associated with incidence of MACCE (adjusted hazard ratio, 1.55; 95% CI, 0.94–2.57; P=0.085). In the landmark analysis, patients with OSA had 3.9 times the risk of incurring a MACCE after 1 year (adjusted hazard ratio, 3.87; 95% CI, 1.20–12.46; P=0.023), but no increased risk was found within 1‐year follow‐up (adjusted hazard ratio, 1.18; 95% CI, 0.67–2.09; P=0.575). No significant differences were found in the incidence of cardiovascular death, myocardial infarction, and ischemia‐driven revascularization, except for a higher rate of hospitalization for unstable angina in the OSA group than in the non‐OSA group (adjusted hazard ratio, 2.10; 95% CI, 1.09–4.05; P=0.027).

Conclusions

There was no independent correlation between OSA and 1‐year MACCE after ACS. The increased risk associated with OSA was only observed after 1‐year follow‐up. Efficacy of OSA treatment as secondary prevention after ACS requires further investigation.

Effects of bicuspid extractions and incisor retraction on upper airway of Asian adults and late adolescents: A systematic review

OBJECTIVES

This systematic review aimed to assess the effects of bicuspid extractions and incisor retraction on airway dimension, hyoid position and breathing of adults and late adolescents.

METHODS

The review was conducted according to PRISMA guidelines. Eight databases including PubMed, EMBASE, Web of Science and Scopus were searched to August 2018. Minimum age of participants was 16 years. The intervention was dual-arch bicuspid extractions with incisor retraction. Outcomes were airway dimension, hyoid position and breathing assessment.

RESULTS

All nine publications meeting inclusion criteria were from Asia. They were divided into three Asian subregions. All East Asian lateral cephalometric studies reported anteroposterior airway narrowing at the oropharynx and sometimes the hypopharynx. However, the narrowing was small, comparable to measurement errors, and highly variable. Two out of three East Asian computed tomography (CT) studies described reductions in airway dimensions. The single functional breathing study showed increased simulated flow resistance after incisor retraction in East Asians. South Asian studies had mixed findings, with some reporting significant airway narrowing. The single study from West Asia found no significant airway or hyoid changes.

CONCLUSIONS

Airway response to bicuspid extractions and incisor retraction varied substantially when assessed with cephalometry. CT measurements present larger effect sizes and smaller variations, providing stronger evidence of airway narrowing. Orthodontic extractions for incisor retraction may be more frequently indicated in Asia, and East Asians seem particularly susceptible to airway narrowing and postero-inferior hyoid movement with incisor retraction. Better designed CT studies are needed for confirmation due to small effect size and large variability.

Clinical significance of obstructive sleep apnea in patients with acute coronary syndrome in relation to diabetes status

OBJECTIVE

The prognostic significance of obstructive sleep apnea (OSA) in patients with acute coronary syndrome (ACS) according to diabetes mellitus (DM) status remains unclear. We aimed to elucidate the association of OSA with subsequent cardiovascular events in patients with ACS with or without DM.

RESEARCH DESIGN AND METHODS

In this prospective cohort study, consecutive eligible patients with ACS underwent cardiorespiratory polygraphy between June 2015 and May 2017. OSA was defined as an Apnea Hypopnea Index ≥15 events/hour. The primary end point was major adverse cardiovascular and cerebrovascular events (MACCEs), including cardiovascular death, myocardial infarction, stroke, ischemia-driven revascularization, or hospitalization for unstable angina or heart failure.

RESULTS

Among 804 patients, 248 (30.8%) had DM and 403 (50.1%) had OSA. OSA was associated with 2.5 times the risk of 1 year MACCE in patients with DM (22.3% vs 7.1% in the non-OSA group; adjusted HR (HR)=2.49, 95% CI 1.16 to 5.35, p=0.019), but not in patients without DM (8.5% vs 7.7% in the non-OSA group, adjusted HR=0.94, 95% CI 0.51 to 1.75, p=0.85). Patients with DM without OSA had a similar 1 year MACCE rate as patients without DM. The increased risk of events was predominately isolated to patients with OSA with baseline glucose or hemoglobin A1c levels above the median. Combined OSA and longer hypoxia duration (time with arterial oxygen saturation <90%>22 min) further increased the MACCE rate to 31.0% in patients with DM.

CONCLUSIONS

OSA was associated with increased risk of 1 year MACCE following ACS in patients with DM, but not in non-DM patients. Further trials exploring the efficacy of OSA treatment in high-risk patients with ACS and DM are warranted.

Syndrome 'Z': A Predictor of Angiographic Severity of Coronary Artery Disease in Patients of Acute Coronary Syndrome

BACKGROUND

Owing to the growing evidence that the pathophysiology of obstructive sleep apnoea (OSA) and metabolic syndrome (MS) overlap considerably and both adversely impact cardiovascular health, we hypothesised that the presence of OSA with MS additively and adversely affect the severity of coronary artery disease (CAD). Exploration and understanding of this may have direct implications for the development of targeted, preventive strategies for CAD. Thus, this prospective study was aimed to determine the prevalence of 'Syndrome Z' in patients of MS who present with an acute coronary event and to correlate it with the angiographic severity of CAD in these patients.

METHODS

The present study was a single centre, cross sectional study conducted in a university teaching hospital. In a span of 6 months, 922 patients with acute coronary syndromes (ACS) were screened for the study. Among these, 861 patients had no evidence of MS. The remaining 61 patients who were diagnosed to have MS were then subjected to an overnight sleep study. Only 58 had good sleep data so were included for further analysis. Angiographic parameters in terms of number of vessels involved and culprit lesions were noted and correlated with presence and absence of OSA and also with its severity based on the Apnoea/Hypopnoea Index (AHI).

RESULTS

The prevalence of OSA positivity in patients with MS who presented with ACS was 34.5% (n=20). Most of the patients in the OSA negative group (78.9%, n=30) had disease limited to only one vessel while in the OSA positive group only a minority (15%, n=3) of patients had their disease limited to a single vessel (p=0.001). The number of lesions in the culprit vessel was also significantly less in the OSA negative group compared to the OSA positive group. While in the OSA negative group 68.4% (n=26) patients had a solitary lesion, followed by two and three lesions in 15.8% (n=6) of the patients each, multiple lesions were more common in OSA positive patients, involving 80% of cases (45.0%, n=9 with two lesions; 35.0%, n=7 with three lesions; only 20%, n=4 had a solitary lesion).

CONCLUSIONS

Prevalence of 'Syndrome Z' is high in patients having MS presenting with ACS and it correlates with the angiographic severity of CAD.

Patients with symptoms and characteristics consistent with obstructive sleep apnea are at a higher risk for acute and subacute stent thrombosis after percutaneous coronary stent implantation: a single-center case-control study

Background

To determine if obstructive sleep apnea (OSA) is a risk factor for early stent thrombosis (EST; within 30 days) after percutaneous coronary intervention (PCI).

Methods

This case–control study involved 23 patients with angiographically confirmed EST after PCI (case group) and 92 PCI patients (control group) who did not develop stent thrombosis during a 2-year follow-up. Patients with symptoms and characteristics consistent with OSA (hereinafter referred to as OSA) were identified using the Berlin questionnaire, and the general characteristics of the patients and their treatments as well as outcomes were recorded. The odds ratios (ORs) for OSA were calculated. Additionally, the association between OSA and EST in patients with different conventional cardiovascular risk factors was analyzed.

Results

The crude OR for OSA was 4.17 (95% confidence interval [CI]: 1.60–10.84, P = 0.003). After adjusting for other risk factors of EST, the OR for OSA remained significant. In participants with no or one conventional cardiovascular disease risk factor, we found a significant association between OSA and EST (OR: 17.00, 95% CI: 2.33–124.19, P = 0.005).

Conclusion

OSA is an independent risk factor for EST. This conclusion was further supported by the finding that in patients with few conventional cardiovascular risk factors, the contribution of OSA to EST was more obvious.