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Mao Z, Zheng P, Zhu X, Wang L, Zhang F, Liu H, Li H, Zhou L, Liu W. Obstructive sleep apnea hypopnea syndrome and vascular lesions: An update on what we currently know. Sleep Med 2024; 119:296-311. [PMID: 38723575 DOI: 10.1016/j.sleep.2024.05.010] [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: 03/21/2024] [Revised: 04/23/2024] [Accepted: 05/02/2024] [Indexed: 06/18/2024]
Abstract
Obstructive sleep apnea-hypopnea syndrome (OSAHS) is the most prevalent sleep and respiratory disorder. This syndrome can induce severe cardiovascular and cerebrovascular complications, and intermittent hypoxia is a pivotal contributor to this damage. Vascular pathology is closely associated with the impairment of target organs, marking a focal point in current research. Vascular lesions are the fundamental pathophysiological basis of multiorgan ailments and indicate a shared pathogenic mechanism among common cardiovascular and cerebrovascular conditions, suggesting their importance as a public health concern. Increasing evidence shows a strong correlation between OSAHS and vascular lesions. Previous studies predominantly focused on the pathophysiological alterations in OSAHS itself, such as intermittent hypoxia and fragmented sleep, leading to vascular disruptions. This review aims to delve deeper into the vascular lesions affected by OSAHS by examining the microscopic pathophysiological mechanisms involved. Emphasis has been placed on examining how OSAHS induces vascular lesions through disruptions in the endothelial barrier, metabolic dysregulation, cellular phenotype alterations, neuroendocrine irregularities, programmed cell death, vascular inflammation, oxidative stress and epigenetic modifications. This review examines the epidemiology and associated risk factors for OSAHS and vascular diseases and subsequently describes the existing evidence on vascular lesions induced by OSAHS in the cardiovascular, cerebrovascular, retinal, renal and reproductive systems. A detailed account of the current research on the pathophysiological mechanisms mediating vascular lesions caused by OSAHS is provided, culminating in a discussion of research advancements in therapeutic modalities to mitigate OSAHS-related vascular lesions and the implications of these treatment strategies.
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Affiliation(s)
- Zhenyu Mao
- Department of Respiratory and Critical Care Medicine, National Health Committee (NHC) Key Laboratory of Respiratory Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Pengdou Zheng
- Department of Respiratory and Critical Care Medicine, National Health Committee (NHC) Key Laboratory of Respiratory Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoyan Zhu
- Department of Respiratory and Critical Care Medicine, National Health Committee (NHC) Key Laboratory of Respiratory Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lingling Wang
- Department of Respiratory and Critical Care Medicine, National Health Committee (NHC) Key Laboratory of Respiratory Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fengqin Zhang
- Department of Respiratory and Critical Care Medicine, National Health Committee (NHC) Key Laboratory of Respiratory Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huiguo Liu
- Department of Respiratory and Critical Care Medicine, National Health Committee (NHC) Key Laboratory of Respiratory Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hai Li
- Department of Geriatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China; Key Laboratory of Vascular Aging, Ministry of Education, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China
| | - Ling Zhou
- Department of Respiratory and Critical Care Medicine, National Health Committee (NHC) Key Laboratory of Respiratory Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Wei Liu
- Department of Geriatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China; Key Laboratory of Vascular Aging, Ministry of Education, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China.
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Ou YH, Colpani JT, Cheong CS, Loke W, Thant AT, Shih EC, Lee F, Chan SP, Sia CH, Koo CY, Wong S, Chua A, Khoo CM, Kong W, Chin CW, Kojodjojo P, Wong PE, Chan MY, Richards AM, Cistulli PA, Lee CH. Mandibular Advancement vs CPAP for Blood Pressure Reduction in Patients With Obstructive Sleep Apnea. J Am Coll Cardiol 2024; 83:1760-1772. [PMID: 38588926 DOI: 10.1016/j.jacc.2024.03.359] [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: 02/14/2024] [Revised: 03/04/2024] [Accepted: 03/04/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Hypertension guidelines recommend diagnosis and treatment of obstructive sleep apnea (OSA) in patients with hypertension. The mandibular advancement device (MAD) is an oral appliance therapy for patients who decline or cannot tolerate continuous positive airway pressure (CPAP). OBJECTIVES We compared the relative effectiveness of MAD vs CPAP in reducing 24-hour ambulatory blood pressure (BP). METHODS In an investigator-initiated, randomized, noninferiority trial (prespecified margin 1.5 mm Hg), 321 participants aged ≥40 years with hypertension and increased cardiovascular risk were recruited at 3 public hospitals for polysomnography. Of these, 220 participants with moderate-to-severe OSA (apnea-hypopnea index ≥15 events per hour) were randomized to either MAD or CPAP (1:1). The primary outcome was the difference between the 24-hour mean arterial BP at baseline and 6 months. RESULTS Compared with baseline, the 24-hour mean arterial BP decreased by 2.5 mm Hg (P = 0.003) at 6 months in the MAD group, whereas no change was observed in the CPAP group (P = 0.374). The between-group difference was -1.6 mm Hg (95% CI: -3.51 to 0.24, noninferiority P < 0.001). The MAD group demonstrated a larger between-group reduction in all secondary ambulatory BP parameters compared with the CPAP group, with the most pronounced effects observed in the asleep BP parameters. Both the MAD and CPAP improved daytime sleepiness, with the between-group difference similar (P = 0.384). There were no between-group differences in cardiovascular biomarkers. CONCLUSIONS MAD is noninferior to CPAP for reducing 24-hour mean arterial BP in participants with hypertension and increased cardiovascular risk. (Cardiosleep Research Program on Obstructive Sleep Apnea, Blood Pressure Control and Maladaptive Myocardial Remodeling-Non-inferiority Trial [CRESCENT]; NCT04119999).
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Affiliation(s)
- Yi-Hui Ou
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Juliana Tereza Colpani
- Department of Endodontics, Operative Dentistry and Prosthodontics, Faculty of Dentistry, National University of Singapore, Singapore
| | - Crystal S Cheong
- Department of Otolaryngology-Head & Neck Surgery, National University Hospital, Singapore, Singapore
| | - Weiqiang Loke
- Department of Endodontics, Operative Dentistry and Prosthodontics, Faculty of Dentistry, National University of Singapore, Singapore
| | - As Tar Thant
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - E' Ching Shih
- Department of Otolaryngology-Head & Neck Surgery, National University Hospital, Singapore, Singapore
| | - Frank Lee
- Department of Endodontics, Operative Dentistry and Prosthodontics, Faculty of Dentistry, National University of Singapore, Singapore
| | - Siew-Pang Chan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Cardiovascular Research Institute, National University Heart Centre, Singapore, Singapore; Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Chieh-Yang Koo
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Serene Wong
- Department of Medicine, Alexandra Hospital, Singapore
| | - Aiping Chua
- Department of Medicine, Ng Teng Fong General Hospital, Singapore
| | - Chin-Meng Khoo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - William Kong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Calvin W Chin
- Department of Cardiology, National Heart Centre Singapore, Singapore; Cardiovascular ACP, Duke-NUS Medical School, Singapore
| | - Pipin Kojodjojo
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | | | - Mark Y Chan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Cardiovascular Research Institute, National University Heart Centre, Singapore, Singapore; Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - A Mark Richards
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Cardiovascular Research Institute, National University Heart Centre, Singapore, Singapore; Department of Cardiology, National University Heart Centre, Singapore, Singapore; Christchurch Heart Institute, University of Otago, Dunedin, New Zealand
| | - Peter A Cistulli
- Sleep Research Group, Charles Perkins Centre and Northern Clinical School, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia; Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Chi-Hang Lee
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Cardiovascular Research Institute, National University Heart Centre, Singapore, Singapore; Department of Cardiology, National University Heart Centre, Singapore, Singapore.
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Panyarath P, Goldscher N, Pamidi S, Daskalopoulou SS, Gagnon R, Dayan N, Raiche K, Olha A, Geater SL, Benedetti A, Kimoff RJ. Positive Airway Pressure Treatment of Obstructive Sleep Apnea-Hypopnea in Hypertensive Disorders of Pregnancy: A Pilot Randomized Proof-of-Concept Clinical Trial. Ann Am Thorac Soc 2024; 21:803-813. [PMID: 38252423 DOI: 10.1513/annalsats.202310-863oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 01/19/2024] [Indexed: 01/23/2024] Open
Abstract
Rationale: Maternal obstructive sleep apnea-hypopnea (OSAH) is associated with hypertensive disorders of pregnancy (HDP). OSAH treatment with positive airway pressure (PAP) in the general population lowers blood pressure (BP). However, there are limited data on the effects of PAP therapy in maternal OSAH. Objectives: Our primary objective was to assess the feasibility of recruitment to a pilot randomized trial and adherence to PAP therapy for OSAH in women with HDP. Secondary objectives included assessment of PAP effects on 24-h BP, arterial stiffness, and maternal and fetal outcomes. Methods: Women with singleton pregnancies at ⩾12 weeks' gestation and hypertension underwent home level 2 polysomnography; those with mild to moderate OSAH (apnea-hypopnea index ⩾ 5 events/h; women with severe OSAH with apnea-hypopnea index > 30 events/h and oxygen desaturation index > 30 were excluded) were randomized to either PAP or nasal dilator strip (NDS; control) therapy. After PAP education, adherence was monitored online with episodic phone or in-person support by research personnel. Twenty-four-hour BP and arterial stiffness were assessed at baseline and before delivery. Maternal and fetal outcomes were also recorded. Results: Of 105 potentially eligible participants, 67 agreed to undergo screening for OSAH over 38 months; 48 women meeting OSAH inclusion criteria were randomized to PAP (n = 27) or NDS (n = 21) therapy. Of these, 14 PAP (52%) and 13 NDS (62%) participants completed all predelivery measurements, with lack of completion due to urgent delivery (19% in the PAP group, 14% in the NDS group), PAP intolerance at initiation (19%), or other factors. Mean PAP use was 3.1 ± 2.5 h/night, with use ⩾4 h/night on 38.4 ± 33.7% of nights during 9.6 ± 4.0 weeks of treatment. BP was controlled within the target range in most participants. There were no differences in mean change in 24-hour BP or arterial stiffness measurements or in adverse maternal and fetal outcomes between the PAP and NDS groups in either intention-to-treat or per-protocol analyses. Conclusions: PAP adherence was suboptimal in this HDP cohort despite education and troubleshooting. Further work is required to identify optimal OSAH treatment strategies during pregnancy. Clinical trial registered with www.clinicaltrials.gov (NCT03309826).
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Affiliation(s)
- Pattaraporn Panyarath
- Respiratory Division and Sleep Laboratory
- Division of Respiratory and Respiratory Critical Care Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand; and
| | | | - Sushmita Pamidi
- Respiratory Division and Sleep Laboratory
- Respiratory Epidemiology Research Unit, Center for Research Outcomes Evaluation
| | - Stella S Daskalopoulou
- Respiratory Epidemiology Research Unit, Center for Research Outcomes Evaluation
- Division of Internal Medicine, Department of Medicine, and
| | - Robert Gagnon
- Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Natalie Dayan
- Division of Internal Medicine, Department of Medicine, and
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Quebec, Canada
| | | | - Allen Olha
- Respiratory Division and Sleep Laboratory
| | - Sarayut L Geater
- Division of Respiratory and Respiratory Critical Care Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand; and
| | - Andrea Benedetti
- Respiratory Epidemiology Research Unit, Center for Research Outcomes Evaluation
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Quebec, Canada
| | - R John Kimoff
- Respiratory Division and Sleep Laboratory
- Respiratory Epidemiology Research Unit, Center for Research Outcomes Evaluation
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Lo Giudice A, La Rosa S, Ronsivalle V, Isola G, Cicciù M, Alessandri-Bonetti G, Leonardi R. Indications for Dental Specialists for Treating Obstructive Sleep Apnea with Mandibular Advancement Devices: A Narrative Review. Int J Dent 2024; 2024:1007237. [PMID: 38585252 PMCID: PMC10999292 DOI: 10.1155/2024/1007237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/20/2024] [Accepted: 03/21/2024] [Indexed: 04/09/2024] Open
Abstract
Obstructive sleep apnea (OSA) syndrome is characterized by repeated airway collapse during sleep. It determines cardiovascular, pulmonary, and neurocognitive consequences and is associated with several daytime and nighttime symptoms that influence the patient's quality of life. The contribution of the dental specialist in the clinical management of OSA patients entails participating in the screening process as diagnostic sentinels and providing adequate treatment using mandibular advancement devices (MADs). Since the treatment of OSA requires a multidisciplinary approach, including different medical specialists, dentists should have a comprehensive understanding of medical and dental factors that influence the strategy and effectiveness of OSA treatment with MAD. Such expertise is crucial in determining the appropriate treatment indications and helps clinicians establish a consolidated position within the multidisciplinary OSA team. In this regard, this review summarizes the evidence of the clinical indications for MAD treatment and provides the dental specialist with helpful information about medical, functional, and other relevant factors that should be considered during diagnosis, treatment plan, and follow-up stages. Information retrieved was organized and discussed, generating specific domains/queries oriented to the clinical management of OSA patients from the clinical perspective of dental specialists.
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Affiliation(s)
- Antonino Lo Giudice
- Department of General Surgery and Medical-Surgical Specialties, Section of Orthodontics, Policlinico Universitario “Gaspare Rodolico—San Marco”, University of Catania, Via Santa Sofia 78, Catania 95123, Italy
| | - Salvatore La Rosa
- Department of General Surgery and Medical-Surgical Specialties, Section of Orthodontics, Policlinico Universitario “Gaspare Rodolico—San Marco”, University of Catania, Via Santa Sofia 78, Catania 95123, Italy
| | - Vincenzo Ronsivalle
- Department of General Surgery and Medical-Surgical Specialties, Section of Oral Surgery, Policlinico Universitario “Gaspare Rodolico—San Marco”, University of Catania, Via Santa Sofia 78, Catania 95123, Italy
| | - Gaetano Isola
- Department of General Surgery and Medical-Surgical Specialties, Section of Periodontology, Policlinico Universitario “Gaspare Rodolico—San Marco”, University of Catania, Via Santa Sofia 78, Catania 95123, Italy
| | - Marco Cicciù
- Department of General Surgery and Medical-Surgical Specialties, Section of Oral Surgery, Policlinico Universitario “Gaspare Rodolico—San Marco”, University of Catania, Via Santa Sofia 78, Catania 95123, Italy
| | - Giulio Alessandri-Bonetti
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Section of Orthodontics, University of Bologna, Bologna, Italy
| | - Rosalia Leonardi
- Department of General Surgery and Medical-Surgical Specialties, Section of Orthodontics, Policlinico Universitario “Gaspare Rodolico—San Marco”, University of Catania, Via Santa Sofia 78, Catania 95123, Italy
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Grewal N, Gordon D, Bajaj S, Gyimah C, Hassan M, Fatima U, Mehrotra PP. Impact of Obstructive Sleep Apnea Treatment on Cardiovascular Disease Associated Mortality and Morbidity: A Systematic Review. Curr Probl Cardiol 2024; 49:102139. [PMID: 37863463 DOI: 10.1016/j.cpcardiol.2023.102139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 10/14/2023] [Indexed: 10/22/2023]
Abstract
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.
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Affiliation(s)
- Niyati Grewal
- Department of Internal Medicine, Howard University Hospital, Washington DC.
| | - Dominick Gordon
- Department of Internal Medicine, Howard University Hospital, Washington DC
| | - Siddharth Bajaj
- Department of Internal Medicine, Howard University Hospital, Washington DC
| | - Claudia Gyimah
- Department of Internal Medicine, Howard University Hospital, Washington DC
| | - Mubariz Hassan
- Department of Internal Medicine, Howard University Hospital, Washington DC
| | - Urooj Fatima
- Department of Cardiology, Howard University Hospital, Washington DC
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Johal A, Hamoda MM, Almeida FR, Marklund M, Tallamraju H. The role of oral appliance therapy in obstructive sleep apnoea. Eur Respir Rev 2023; 32:220257. [PMID: 37343962 DOI: 10.1183/16000617.0257-2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 04/12/2023] [Indexed: 06/23/2023] Open
Abstract
There is now widespread recognition within the world of sleep medicine of the increasing importance of dental sleep medicine and, in particular, the role of oral appliance therapy (OAT) in the management of adults with obstructive sleep apnoea (OSA). For the purpose of this review, the term OAT refers to a custom-made intra-oral appliance, which acts to posture the mandible in a forward and downward direction, away from its natural resting position. Whilst nasally applied continuous positive airway pressure remains the "gold standard" in nonsurgical OSA management, OAT remains the recognised alternative treatment.This review of OAT aims to provide an evidence-based update on our current understanding of their mode of action, exploring the potential anatomical and physiological impact of their use in preventing collapse of the upper airway; the current clinical practice guidelines, including the recently published National Institute of Clinical Excellence 2021 guidance, in conjunction with the American Academy of Sleep Medicine and American Academy of Dental Sleep Medicine; optimal design features, comparing the role of custom-made versus noncustom OAT devices and the importance of titration in achieving a dose-dependent effect; patient predictors, preference and adherence to OAT; its impact on a range of both patient- and clinician-centred health outcomes, with a comparison with CPAP; the limitations and side-effects of providing OAT; and, finally, a look at future considerations to help optimise the delivery and outcomes of OAT.
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Affiliation(s)
- Ama Johal
- Oral Bioengineering, Institute of Dentistry, Queen Mary, University of London, London, UK
| | - Mona M Hamoda
- Department of Oral Health Sciences, Faculty of Dentistry, University of British Columbia, Vancouver, BC, Canada
| | - Fernanda R Almeida
- Department of Oral Health Sciences, Faculty of Dentistry, University of British Columbia, Vancouver, BC, Canada
| | - Marie Marklund
- Department of Otontology, Medical Faculty, Umea University, Umea, Sweden
| | - Harishri Tallamraju
- Oral Bioengineering, Institute of Dentistry, Queen Mary, University of London, London, UK
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Long T, Li H, Shu Y, Li K, Xie W, Zeng Y, Huang L, Zeng L, Liu X, Peng D. Functional Connectivity Changes in the Insular Subregions of Patients with Obstructive Sleep Apnea after 6 Months of Continuous Positive Airway Pressure Treatment. Neural Plast 2023; 2023:5598047. [PMID: 36865671 PMCID: PMC9974286 DOI: 10.1155/2023/5598047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/21/2023] [Accepted: 01/31/2023] [Indexed: 02/25/2023] Open
Abstract
This study was aimed at investigating the functional connectivity (FC) changes between the insular subregions and whole brain in patients with obstructive sleep apnea (OSA) after 6 months of continuous positive airway pressure (CPAP) treatment and at exploring the relationship between resting-state FC changes and cognitive impairment in OSA patients. Data from 15 patients with OSA before and after 6 months of CPAP treatment were included in this study. The FC between the insular subregions and whole brain was compared between baseline and after 6 months of CPAP treatment in OSA. After 6 months of treatment, OSA patients had increased FC from the right ventral anterior insula to the bilateral superior frontal gyrus and bilateral middle frontal gyrus and increased FC from the left posterior insula to the left middle temporal gyrus and left inferior temporal gyrus. Hyperconnectivity was found from the right posterior insula to the right middle temporal gyrus, bilateral precuneus, and bilateral posterior cingulate cortex, which mainly involved the default mode network. There are changes in functional connectivity patterns between the insular subregions and whole brain in OSA patients after 6 months of CPAP treatment. These changes provide a better understanding of the neuroimaging mechanisms underlying the improvement in cognitive function and emotional impairment in OSA patients and can be used as potential biomarkers for clinical CPAP treatment.
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Affiliation(s)
- Ting Long
- 1Medical Imaging Center, The First Affiliated Hospital of Nanchang University, Jiangxi Province, China
| | - Haijun Li
- 1Medical Imaging Center, The First Affiliated Hospital of Nanchang University, Jiangxi Province, China
- 2PET Center, The First Affiliated Hospital of Nanchang University, Jiangxi Province, China
| | - Yongqiang Shu
- 1Medical Imaging Center, The First Affiliated Hospital of Nanchang University, Jiangxi Province, China
| | - Kunyao Li
- 1Medical Imaging Center, The First Affiliated Hospital of Nanchang University, Jiangxi Province, China
| | - Wei Xie
- 1Medical Imaging Center, The First Affiliated Hospital of Nanchang University, Jiangxi Province, China
| | - Yaping Zeng
- 1Medical Imaging Center, The First Affiliated Hospital of Nanchang University, Jiangxi Province, China
| | - Ling Huang
- 1Medical Imaging Center, The First Affiliated Hospital of Nanchang University, Jiangxi Province, China
| | - Li Zeng
- 1Medical Imaging Center, The First Affiliated Hospital of Nanchang University, Jiangxi Province, China
| | - Xiang Liu
- 1Medical Imaging Center, The First Affiliated Hospital of Nanchang University, Jiangxi Province, China
| | - Dechang Peng
- 1Medical Imaging Center, The First Affiliated Hospital of Nanchang University, Jiangxi Province, China
- 2PET Center, The First Affiliated Hospital of Nanchang University, Jiangxi Province, China
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8
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Feltner C, Wallace IF, Aymes S, Cook Middleton J, Hicks KL, Schwimmer M, Baker C, Balio CP, Moore D, Voisin CE, Jonas DE. Screening for Obstructive Sleep Apnea in Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2022; 328:1951-1971. [PMID: 36378203 DOI: 10.1001/jama.2022.18357] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
IMPORTANCE Obstructive sleep apnea (OSA) is associated with adverse health outcomes. OBJECTIVE To review the evidence on screening for OSA in asymptomatic adults or those with unrecognized OSA symptoms to inform the US Preventive Services Task Force. DATA SOURCES PubMed/MEDLINE, Cochrane Library, Embase, and trial registries through August 23, 2021; surveillance through September 23, 2022. STUDY SELECTION English-language studies of screening test accuracy, randomized clinical trials (RCTs) of screening or treatment of OSA reporting health outcomes or harms, and systematic reviews of treatment reporting changes in blood pressure and apnea-hypopnea index (AHI) scores. DATA EXTRACTION AND SYNTHESIS Dual review of abstracts, full-text articles, and study quality. Meta-analysis of intervention trials. MAIN OUTCOMES AND MEASURES Test accuracy, excessive daytime sleepiness, sleep-related and general health-related quality of life (QOL), and harms. RESULTS Eighty-six studies were included (N = 11 051). No study directly compared screening with no screening. Screening accuracy of the Multivariable Apnea Prediction score followed by unattended home sleep testing for detecting severe OSA syndrome (AHI ≥30 and Epworth Sleepiness Scale [ESS] score >10) measured as the area under the curve in 2 studies (n = 702) was 0.80 (95% CI, 0.78 to 0.82) and 0.83 (95% CI, 0.77 to 0.90). Five studies assessing the accuracy of other screening tools were heterogeneous and results were inconsistent. Compared with inactive control, positive airway pressure was associated with a significant improvement in ESS score from baseline (pooled mean difference, -2.33 [95% CI, -2.75 to -1.90]; 47 trials; n = 7024), sleep-related QOL (standardized mean difference, 0.30 [95% CI, 0.19 to 0.42]; 17 trials; n = 3083), and general health-related QOL measured by the 36-Item Short Form Health Survey (SF-36) mental health component summary score change (pooled mean difference, 2.20 [95% CI, 0.95 to 3.44]; 15 trials; n = 2345) and SF-36 physical health component summary score change (pooled mean difference, 1.53 [95% CI, 0.29 to 2.77]; 13 trials; n = 2031). Use of mandibular advancement devices was also associated with a significantly larger ESS score change compared with controls (pooled mean difference, -1.67 [95% CI, 2.09 to -1.25]; 10 trials; n = 1540). Reporting of other health outcomes was sparse; no included trial found significant benefit associated with treatment on mortality, cardiovascular events, or motor vehicle crashes. In 3 systematic reviews, positive airway pressure was significantly associated with reduced blood pressure; however, the difference was relatively small (2-3 mm Hg). CONCLUSIONS AND RELEVANCE The accuracy and clinical utility of OSA screening tools that could be used in primary care settings were uncertain. Positive airway pressure and mandibular advancement devices reduced ESS score. Trials of positive airway pressure found modest improvement in sleep-related and general health-related QOL but have not established whether treatment reduces mortality or improves most other health outcomes.
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Affiliation(s)
- Cynthia Feltner
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Medicine, University of North Carolina at Chapel Hill
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Ina F Wallace
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Shannon Aymes
- Department of Medicine, University of North Carolina at Chapel Hill
| | - Jennifer Cook Middleton
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Kelli L Hicks
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill
| | - Manny Schwimmer
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Internal Medicine, The Ohio State University, Columbus
| | - Claire Baker
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Casey P Balio
- Center for Rural Health Research, Department of Health Services Management and Policy, College of Public Health, East Tennessee State University, Johnson City
| | - Daniel Moore
- Department of Medicine, University of North Carolina at Chapel Hill
| | - Christiane E Voisin
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Internal Medicine, The Ohio State University, Columbus
| | - Daniel E Jonas
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Internal Medicine, The Ohio State University, Columbus
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9
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Mecenas P, Miranda GHN, Fagundes NCF, Normando D, Ribeiro KCF. Effects of oral appliances on serum cytokines in adults with obstructive sleep apnea: a systematic review. Sleep Breath 2022; 26:1447-1458. [PMID: 34482502 DOI: 10.1007/s11325-021-02485-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/07/2021] [Accepted: 08/27/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE This review aimed to evaluate the effects of oral appliance (OA) therapy on serum inflammatory cytokines in adults diagnosed with obstructive sleep apnea (OSA). METHODS Seven electronic databases and partial gray literature were searched without restrictions through March 2021. Articles evaluating the levels of serum inflammatory cytokines in patients with OSA after OA treatment were included. The risk of bias (RoB) was assessed using the before-and-after tool or RoB 2.0. The level of certainty was assessed using the GRADE tool. RESULTS Five studies met the eligibility criteria. One was a randomized clinical trial (RCT), while four were non-randomized clinical trials (NRCTs). Among the studies, C-reactive protein (CRP), IL-6, IL-10, IL-1β, and tumor necrosis factor α (TNF-α) were investigated. The RCT reported no significant differences in marker levels after 2 months of OA therapy, while the NRCTs showed improvement on CRP, TNF-α, and IL-1β levels after longer follow-up periods. The RoB was evaluated as showing some concern in the RCT. Three NRCTs presented good RoB, and one showed a fair RoB. The level of certainty was graded as moderate quality for inflammatory marker levels assessed in the RCT The levels of certainty evaluated in NRCTs were classified as very low. CONCLUSIONS Although limited, existing scientific evidence showed that OA therapy may improve serum cytokine levels in adults with OSA. However, short treatment periods are not effective in reducing markers of systemic inflammation which may require extended time and a decrease of in apneic events to improve.
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Affiliation(s)
- Paulo Mecenas
- Department of Orthodontics, Faculdade Integrada Brasil Amazônia (FIBRA), Belém, Pará, Brazil.
| | | | | | - David Normando
- Faculty of Dentistry, Federal University of Pará (UFPA), Belém, Pará, Brazil
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10
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Kim HY, Jo JH, Chung JW, Park JW. The multisystemic effects of oral appliance therapy for obstructive sleep apnea: A narrative review. Medicine (Baltimore) 2022; 101:e29400. [PMID: 35866792 PMCID: PMC9302291 DOI: 10.1097/md.0000000000029400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Obstructive sleep apnea (OSA) is a chronic condition accompanied by repeated obstruction of the upper airway during sleep despite respiratory efforts, resulting in intermittent hypoxemia, altered sleep structure, and sympathetic activation. Previous studies have shown a significant association between OSA and general health issues such as cardiovascular diseases, endocrine disorders, neurocognitive function decline, and poor quality of life. Continuous positive airway pressure (CPAP) has been considered as the first line treatment for OSA. However, accumulating evidence supports the role of oral appliance (OA) therapy, including mandibular advancement devices, as an alternative option for snoring and OSA patients who do not comply with or refuse CPAP usage. Despite a generally favorable outcome of OA therapy for OSA related respiratory indices, studies focusing on the impact of systemic effects of OA therapy in OSA patients are relatively scarce compared with the extensive literature focusing on the systemic effects of CPAP. Therefore, this article aimed to provide an overview of the current evidence regarding the multisystemic effects of OA therapy for OSA.
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Affiliation(s)
- Hee Young Kim
- Department of Oral Medicine, Seoul National University Dental Hospital, Seoul, Republic of Korea
- Department of Oral Medicine and Oral Diagnosis, School of Dentistry, Seoul National University, Seoul, Republic of Korea
| | - Jung Hwan Jo
- Department of Oral Medicine, Seoul National University Dental Hospital, Seoul, Republic of Korea
- Department of Oral Medicine and Oral Diagnosis, School of Dentistry, Seoul National University, Seoul, Republic of Korea
| | - Jin Woo Chung
- Department of Oral Medicine, Seoul National University Dental Hospital, Seoul, Republic of Korea
- Department of Oral Medicine and Oral Diagnosis, School of Dentistry, Seoul National University, Seoul, Republic of Korea
- Dental Research Institute, Seoul National University, Seoul, Republic of Korea
| | - Ji Woon Park
- Department of Oral Medicine, Seoul National University Dental Hospital, Seoul, Republic of Korea
- Department of Oral Medicine and Oral Diagnosis, School of Dentistry, Seoul National University, Seoul, Republic of Korea
- Dental Research Institute, Seoul National University, Seoul, Republic of Korea
- *Correspondence: Ji Woon Park, Orofacial Pain Clinic, Department of Oral Medicine and Oral Diagnosis, School of Dentistry and Dental Research Institute, Seoul National University, 101 Yunkeun-Dong, Chongro-Ku, Seoul 03080, Republic of Korea (e-mail: )
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11
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POINT: Should Asymptomatic OSA Be Treated in Patients With Significant Cardiovascular Disease? Yes. Chest 2022; 161:605-607. [DOI: 10.1016/j.chest.2021.05.081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 04/14/2021] [Accepted: 05/04/2021] [Indexed: 11/21/2022] Open
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12
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Dieltjens M, Vanderveken OM, Shivalkar B, Van Haesendonck G, Kastoer C, Heidbuchel H, Braem MJ, Van De Heyning CM. Mandibular advancement device treatment and reverse left ventricular hypertrophic remodeling in patients with obstructive sleep apnea. J Clin Sleep Med 2022; 18:903-909. [PMID: 34728052 PMCID: PMC8883081 DOI: 10.5664/jcsm.9766] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) is associated with cardiovascular comorbidities such as left ventricular (LV) hypertrophy. Whether OSA is an independent etiological factor for this hypertrophic remodeling is yet unknown. Continuous positive airway pressure partially reverses this hypertrophy, but data regarding the effect of mandibular advancement devices on LV remodeling are scarce. The aim of this prospective trial is to evaluate the effect of mandibular advancement device therapy on LV geometry and function in patients with OSA. METHODS At baseline and 6-month follow-up, participants underwent a home sleep apnea test, 24-hour ambulatory blood pressure monitoring and a 2-dimensional Doppler and tissue Doppler echocardiography. RESULTS Sixty-three patients (age: 49 ± 11 years; body mass index: 27.0 ± 3.4 kg/m2; baseline apnea-hypopnea index home sleep apnea test: 11.7 [8.2; 24.9] events/h) completed the 6-month follow-up visit. Overall, blood pressure values and parameters of LV function were within normal ranges at baseline and did not change under mandibular advancement device therapy. In contrast, the interventricular septum thickness was at the upper limits of normal at baseline and showed a significant decrease at 6-month follow-up (11.1 ± 2.1 mm vs 10.6 ± 2.0 mm, P = .03). This significant improvement is only found in responders but not in nonresponders. There was no correlation between the decrease of interventricular septum thickness and the change in blood pressure. CONCLUSIONS In mildly obese, normotensive patients with OSA we observed significant reverse hypertrophic remodeling after 6 months of successful mandibular advancement device therapy, with maintained normotensive systemic blood pressure. This suggests that OSA is an independent factor in the pathophysiology of LV hypertrophy in these patients. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Name: Evaluation of the Cardiovascular Effects of the MAS in the Treatment of Obstructive Sleep Apnea; URL: https://clinicaltrials.gov/ct2/show/NCT02320877; Identifier: NCT02320877. CITATION Dieltjens M, Vanderveken OM, Shivalkar B, et al. Mandibular advancement device treatment and reverse left ventricular hypertrophic remodeling in patients with obstructive sleep apnea. J Clin Sleep Med. 2022;18(3):903-909.
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Affiliation(s)
- Marijke Dieltjens
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium,Otolaryngology and Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium,Address correspondence to: Marijke Dieltjens, PhD, Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1–D.T.493, 2610 Wilrijk, Belgium;
| | - Olivier M. Vanderveken
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium,Otolaryngology and Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Bharati Shivalkar
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium,Department of Cardiology, Delta (CHIREC) Hospital, Brussels, Belgium,Pfizer Biopharmaceuticals, Brussels, Belgium
| | - Gilles Van Haesendonck
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium,Otolaryngology and Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Chloé Kastoer
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium,Otolaryngology and Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Hein Heidbuchel
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium,Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
| | - Marc J. Braem
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium,Otolaryngology and Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Caroline M. Van De Heyning
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium,Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
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13
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Venema JAMU, Vries GEKD, van Goor H, Westra J, Hoekema A, Wijkstra PJ. Cardiovascular and metabolic effects of a mandibular advancement device and continuous positive airway pressure in moderate obstructive sleep apnea: a randomized controlled trial. J Clin Sleep Med 2022; 18:1547-1555. [PMID: 35088708 DOI: 10.5664/jcsm.9908] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
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.
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Affiliation(s)
- Julia A M Uniken Venema
- Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Department of Oral and Maxillofacial Surgery, Amsterdam University Medical Centre, location Academic Medical Center (AMC), and Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Grietje E Knol-de Vries
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Harry van Goor
- Department of Pathology and Medical Biology, University Medical Center Groningen, Groningen, the Netherlands
| | - Johanna Westra
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, the Netherlands
| | - Aarnoud Hoekema
- Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Department of Oral and Maxillofacial Surgery, Amsterdam University Medical Centre, location Academic Medical Center (AMC), and Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Department of Oral and Maxillofacial Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Oral and Maxillofacial Surgery, Tjongerschans Hospital, Heerenveen, The Netherlands
| | - Peter J Wijkstra
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Center for Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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14
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Lai S, Chen L, Zhan P, Lin G, Lin H, Huang H, Chen Q. Circular RNA Expression Profiles and Bioinformatic Analysis in Mouse Models of Obstructive Sleep Apnea-Induced Cardiac Injury: Novel Insights Into Pathogenesis. Front Cell Dev Biol 2021; 9:767283. [PMID: 34820383 PMCID: PMC8606653 DOI: 10.3389/fcell.2021.767283] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 10/25/2021] [Indexed: 01/22/2023] Open
Abstract
Circular RNAs (circRNAs) participate in the development of various kinds of diseases. However, the function and roles of circRNAs in obstructive sleep apnea (OSA)-induced cardiovascular disease remain poorly understood. Therefore, we sought to explore the circRNA expression profiles and predict their functions in OSA-induced cardiac injury with the use of bioinformatics analysis. The model of OSA was established in mouse treated by chronic intermittent hypoxia (CIH) exposure. Then, we screened the circRNA profile using circRNA microarray. By comparing circRNA expression in three matched pairs of CIH-treated cardiac tissues and controls, differentially expressed circRNAs were identified in the CIH groups. Comparison of the selected circRNAs expression levels was performed between qRT-PCR and microarray. Meanwhile, we employed Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses to predict the functions of these selected circRNAs. Finally, we constructed a circRNA-miRNA-mRNA network based on the target prediction. It was found that a total of 124 circRNAs were differentially expressed in CIH-treated cardiac tissues (p ≤ 0.05, fold-change ≥ 1.5). Among them, 23 circRNAs were significantly down-regulated, and the other 101 were up-regulated. Then, ten circRNAs were randomly selected to validate the reliability of the microarray results by using qRT-PCR. Next, we conducted the GO and KEGG pathway analysis to explore the parental genes functions of differentially expressed circRNA. Finally, two significantly differentially expressed circRNAs (mmu_circRNA_014309 and mmu_circRNA_21856) were further selected to create a circRNA-miRNA-mRNA regulation network. Our study did first reveal that the differentially expressed circRNAs played a vital role in the pathogenesis of OSA-induced cardiac damage. Thus, our findings bring us closer to unraveling the pathophysiologic mechanisms and eliciting novel therapeutic targets for the treatment of OSA-associated cardiovascular diseases.
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Affiliation(s)
- Suxian Lai
- Department of Neonatology, The First Hospital of Quanzhou Affiliated to Fujian Medical University, Quanzhou, China
| | - Lijun Chen
- Department of Endocrinology and Metabolism, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Pingyun Zhan
- Department of Cardiology, Haidu Hospital, Quanzhou, China
| | - Guofu Lin
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Hai Lin
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Huibin Huang
- Department of Endocrinology and Metabolism, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Qingshi Chen
- Department of Endocrinology and Metabolism, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
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15
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Khurana S, Soda N, Shiddiky MJA, Nayak R, Bose S. Current and future strategies for diagnostic and management of obstructive sleep apnea. Expert Rev Mol Diagn 2021; 21:1287-1301. [PMID: 34747304 DOI: 10.1080/14737159.2021.2002686] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Obstructive sleep apnea (OSA) is a common sleep disorder with multiple comorbidities including hypertension, diabetes, and cardiovascular disorders. Detected based on an overnight sleep study is called polysomnography (PSG); OSA still remains undiagnosed in majority of the population mainly attributed to lack of awareness. To overcome the limitations posed by PSG such as patient discomfort and overnight hospitalization, newer technologies are being explored. In addition, challenges associated with current management of OSA using continuous positive airway pressure (CPAP), etc. presents several pitfalls. AREAS COVERED Conventional and modern detection/management techniques including PSG, CPAP, smart wearable/pillows, bio-motion sensors, etc., have both pros and cons. To fulfill the limitations in OSA diagnostics, there is an imperative need for new technology for screening of symptomatic and more importantly asymptomatic OSA patients to reduce the risk of several associated life-threatening comorbidities. In this line, molecular marker-based diagnostics have shown great promises. EXPERT OPINION A detailed overview is presented on the OSA management and diagnostic approaches and recent advances in the molecular screening methods. The potentials of biomarker-based detection and its limitations are also portrayed and a comparison between the standard, current modern approaches, and promising futuristic technologies for OSA diagnostics and management is set forth.ABBREVIATIONS AHI: Apnea hypopnea index; AI: artificial intelligence; CAM: Cell adhesion molecules; CPAP: Continuous Positive Airway Pressure; COVID-19: Coronavirus Disease 2019; CVD: Cardiovascular disease; ELISA: Enzyme linked immunosorbent assay; HSAT: Home sleep apnea testing; IR-UWB: Impulse radio-ultra wideband; MMA: maxillomandibular advancement; PSG: Polysomnography; OSA: Obstructive sleep apnea; SOD: Superoxide dismutase; QD: Quantum dot.
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Affiliation(s)
- Sartaj Khurana
- Amity Institute of Biotechnology, Amity University Uttar Pradesh, Noida, India.,Amity Institute of Molecular Medicine and Stem Cell Research, Amity University Uttar Pradesh, Noida, India
| | - Narshone Soda
- Queensland Micro- and Nanotechnology Centre (Qmnc) and School of Environment and Science (ESC), Griffith University, Brisbane, Australia
| | - Muhammad J A Shiddiky
- Queensland Micro- and Nanotechnology Centre (Qmnc) and School of Environment and Science (ESC), Griffith University, Brisbane, Australia
| | - Ranu Nayak
- Amity Institute of Nanotechnology, Amity University Uttar Pradesh, Noida, India
| | - Sudeep Bose
- Amity Institute of Biotechnology, Amity University Uttar Pradesh, Noida, India.,Amity Institute of Molecular Medicine and Stem Cell Research, Amity University Uttar Pradesh, Noida, India
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16
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The role of sleep disorders in cardiovascular diseases: Culprit or accomplice? Life Sci 2021; 283:119851. [PMID: 34324916 DOI: 10.1016/j.lfs.2021.119851] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 07/02/2021] [Accepted: 07/20/2021] [Indexed: 11/24/2022]
Abstract
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.
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17
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Choi JH. Treatments for Adult Obstructive Sleep Apnea. SLEEP MEDICINE RESEARCH 2021. [DOI: 10.17241/smr.2021.00913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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18
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Guimarães TM, Poyares D, Oliveira E Silva L, Luz G, Coelho G, Dal Fabbro C, Tufik S, Bittencourt L. The treatment of mild OSA with CPAP or mandibular advancement device and the effect on blood pressure and endothelial function after one year of treatment. J Clin Sleep Med 2021; 17:149-158. [PMID: 32964829 DOI: 10.5664/jcsm.8822] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
STUDY OBJECTIVES To evaluate and compare the effects of continuous positive airway pressure (CPAP), use of a mandibular advancement device (MAD), and no treatment on 24-hour ambulatory blood pressure monitoring and peripheral arterial tonometry at 6 and 12 months follow-up in individuals with mild obstructive sleep apnea (OSA), and in a subgroup who had an apnea-hypopnea index of < 5 events/h and adherence of ≥ 4 hours per night (effective-treatment subgroups). METHODS The inclusion criteria were individuals with mild obstructive sleep apnea, any sex, age between 18 and 65 years, and a body mass index of ≤ 35 kg/m². Patients were randomized into CPAP, MAD, and no-treatment groups. The evaluations included physical examination, full polysomnography, 24-hour ambulatory blood pressure monitoring, and peripheral arterial tonometry at baseline and after 6 and 12 months. A generalized linear mixed model was used for comparisons. RESULTS The CPAP and MAD groups had lower apnea-hypopnea indexes than the control group at 6 and 12 months, and the CPAP group had higher blood oxygen levels (SpO₂) than the MAD group. The MAD group had more hours of treatment per night and better adaptation to treatment than the CPAP group (MAD: 5.7 ± 2.7 h/night; CPAP: 3.8 ± 3.4 h/night; MAD: 16% did not adapt; CPAP: 42% did not adapt). No differences were found in the total sample and effective treatment in relation to peripheral arterial tonometry or 24-hour ambulatory blood pressure monitoring outcomes. CONCLUSIONS Treatment of mild obstructive sleep apnea with CPAP or MAD did not improve blood pressure or endothelial function after 1 year, even in patients with effective treatment. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Name: Continuous Positive Airway Pressure and Oral Appliances Treatments in Mild Obstructive Sleep Apnea; URL: https://clinicaltrials.gov/ct2/show/NCT01461486; Identifier: NCT01461486.
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Affiliation(s)
| | - Dalva Poyares
- Departamento de Psicobiologia, Universidade Federal de Sao Paulo, São Paulo, Brasil
| | | | - Gabriela Luz
- Departamento de Pneumologia, Universidade Federal de Sao Paulo, São Paulo, Brasil
| | - Glaury Coelho
- Departamento de Psicobiologia, Universidade Federal de Sao Paulo, São Paulo, Brasil
| | - Cibele Dal Fabbro
- Departamento de Psicobiologia, Universidade Federal de Sao Paulo, São Paulo, Brasil
| | - Sergio Tufik
- Departamento de Psicobiologia, Universidade Federal de Sao Paulo, São Paulo, Brasil
| | - Lia Bittencourt
- Departamento de Psicobiologia, Universidade Federal de Sao Paulo, São Paulo, Brasil
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19
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Kirk VG, Edgell H, Joshi H, Constantin E, Katz SL, MacLean JE. Cardiovascular changes in children with obstructive sleep apnea and obesity after treatment with noninvasive ventilation. J Clin Sleep Med 2021; 16:2063-2071. [PMID: 32808921 DOI: 10.5664/jcsm.8760] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
STUDY OBJECTIVES Adults with obesity and obstructive sleep apnea (OSA) are at risk for cardiometabolic disease, and this risk likely extends to children with both conditions. Noninvasive ventilation (NIV; including continuous and bilevel positive airway pressure) is often used to treat OSA in children with obesity. The aim of this study was to examine the impact of NIV treatment on heart rate variability (HRV), as a marker of cardiovascular risk, in children with obesity and newly diagnosed OSA. METHODS A prospective multicenter cohort study was conducted in children with obesity prescribed NIV therapy for newly diagnosed moderate-severe OSA. Measurements of HRV were derived from polysomnography recordings at baseline and after 12 months of treatment. HRV parameters were examined by sleep stage, before and after arousal and oxygen desaturation events. HRV parameters were compared between time points using pair t tests as well as mixed model analysis. RESULTS Twelve children had appropriate data for analysis at baseline and 12 months. Heart rate decreased by 4.5 beats/min after NIV treatment, with no change in HRV parameters. HRV parameters differed by sleep stage and showed an increase in arousal-related sympathetic-parasympathetic balance after 12 months of NIV treatment. HRV parameters did not differ before and after oxygen desaturation events. CONCLUSIONS NIV for the treatment in children with obesity and OSA resulted in a small decrease in heart rate and an increase in arousal-related sympathetic-parasympathetic balance. These findings suggest small, potentially positive impacts of NIV on cardiovascular risk in children with concurrent obesity and OSA.
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Affiliation(s)
- Valerie G Kirk
- Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | | | | | - Evelyn Constantin
- Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Sherri L Katz
- Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Joanna E MacLean
- Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
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20
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Clinical and Research Solutions to Manage Obstructive Sleep Apnea: A Review. SENSORS 2021; 21:s21051784. [PMID: 33806496 PMCID: PMC7961570 DOI: 10.3390/s21051784] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 02/24/2021] [Accepted: 02/26/2021] [Indexed: 12/13/2022]
Abstract
Obstructive sleep apnea (OSA), a common sleep disorder disease, affects millions of people. Without appropriate treatment, this disease can provoke several health-related risks including stroke and sudden death. A variety of treatments have been introduced to relieve OSA. The main present clinical treatments and undertaken research activities to improve the success rate of OSA were covered in this paper. Additionally, guidelines on choosing a suitable treatment based on scientific evidence and objective comparison were provided. This review paper specifically elaborated the clinically offered managements as well as the research activities to better treat OSA. We analyzed the methodology of each diagnostic and treatment method, the success rate, and the economic burden on the world. This review paper provided an evidence-based comparison of each treatment to guide patients and physicians, but there are some limitations that would affect the comparison result. Future research should consider the consistent follow-up period and a sufficient number of samples. With the development of implantable medical devices, hypoglossal nerve stimulation systems will be designed to be smart and miniature and one of the potential upcoming research topics. The transcutaneous electrical stimulation as a non-invasive potential treatment would be further investigated in a clinical setting. Meanwhile, no treatment can cure OSA due to the complicated etiology. To maximize the treatment success of OSA, a multidisciplinary and integrated management would be considered in the future.
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Peng L, Li Y, Li X, Du Y, Li L, Hu C, Zhang J, Qin Y, Wei Y, Zhang H. Extracellular Vesicles Derived from Intermittent Hypoxia-Treated Red Blood Cells Impair Endothelial Function Through Regulating eNOS Phosphorylation and ET-1 Expression. Cardiovasc Drugs Ther 2020; 35:901-913. [PMID: 33242203 DOI: 10.1007/s10557-020-07117-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/18/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE Intermittent hypoxia (IH), a main characteristic of obstructive sleep apnea (OSA) syndrome, has been known as a dominant cause of OSA-related endothelial dysfunction and hypertension. However, the underlying mechanism still remains unclear. Extracellular vesicles (EVs), small vesicles secreted by various cells, can be absorbed by endothelial cells and then influence vascular function. The aim of this research is to clarify whether and how EVs shedding from red blood cells (RBCs) are involved in IH-induced endothelial dysfunction. METHODS EVs were extracted by ultracentrifugation. After the identification of property and purity, EVs from IH-exposed RBCs (IH REVs) and normoxia-exposed RBCs (NOR REVs) or from OSA and non-OSA patient RBCs were utilized to treat C57BL/6 mouse aortas or human umbilical vein endothelial cells (HUVECs) for mechanistic exploration. RESULTS Functional results demonstrated that REVs from OSA patients dramatically impaired endothelium-dependent relaxations (EDRs). Similarly, in vivo and ex vivo studies showed that IH REVs caused significant endothelial dysfunction compared to control group. Further results presented that IH REVs blocked endothelial nitric oxide synthase (eNOS) phosphorylation through inhibiting PI3K/Akt pathway and enhanced endothelin-1 (ET-1) expression through activating Erk1/2 pathway in endothelial cells. Meanwhile, endothelial dysfunction caused by IH REVs was reversed by Akt activator SC79 as well as Erk kinase inhibitor PD98059, suggesting that PI3K/Akt/eNOS and Erk1/2/ET-1 pathways were implicated in IH REV-induced impaired EDRs. CONCLUSIONS This study reveals a novel role of REVs in endothelial dysfunction under IH and dissects the relevant mechanism involved in this process, which will help to establish a comprehensive understanding of OSA or IH-related endothelial dysfunction from a new scope.
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Affiliation(s)
- Lu Peng
- Key Laboratory of Upper Airway Dysfunction-related Cardiovascular Diseases, Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Road, Beijing, 100029, China
| | - Yu Li
- Key Laboratory of Upper Airway Dysfunction-related Cardiovascular Diseases, Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Road, Beijing, 100029, China
| | - Xinwei Li
- Key Laboratory of Upper Airway Dysfunction-related Cardiovascular Diseases, Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Road, Beijing, 100029, China
| | - Yunhui Du
- Key Laboratory of Upper Airway Dysfunction-related Cardiovascular Diseases, Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Road, Beijing, 100029, China
| | - Linyi Li
- Key Laboratory of Upper Airway Dysfunction-related Cardiovascular Diseases, Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Road, Beijing, 100029, China
| | - Chaowei Hu
- Key Laboratory of Upper Airway Dysfunction-related Cardiovascular Diseases, Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Road, Beijing, 100029, China
| | - Jing Zhang
- Key Laboratory of Upper Airway Dysfunction-related Cardiovascular Diseases, Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Road, Beijing, 100029, China
| | - Yanwen Qin
- Key Laboratory of Upper Airway Dysfunction-related Cardiovascular Diseases, Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Road, Beijing, 100029, China
| | - Yongxiang Wei
- Department of Otolaryngology-Head and Neck Surgery, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Road, Beijing, 100029, China.
| | - Huina Zhang
- Key Laboratory of Upper Airway Dysfunction-related Cardiovascular Diseases, Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Road, Beijing, 100029, China.
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Incerti Parenti S, Aroni E, Laffranchi L, Paganelli C, Alessandri-Bonetti G. The effectiveness of mandibular advancement devices in the treatment of obstructive sleep apnoea in adults: a methodological quality assessment of systematic reviews. Eur J Orthod 2020; 42:483-493. [PMID: 31504379 DOI: 10.1093/ejo/cjz065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND AND OBJECTIVES There is growing interest in the use of mandibular advancement devices (MADs) for the treatment of obstructive sleep apnoea (OSA). Many systematic reviews (SRs) have investigated their effectiveness, but the applicability of SR results is affected by their methodological quality. This study critically appraises the methodological quality of SRs on this topic using a more detailed and updated version of A MeaSurement Tool to Assess systematic Reviews (AMSTAR). MATERIALS AND METHODS The literature was searched for SRs on MAD effectiveness in adults (≥18 years of age) for OSA treatment as compared with other non-surgical or surgical interventions or no intervention. Any objective or subjective measures of treatment outcome were considered eligible. AMSTAR2 was used to assess methodological quality. RESULTS The literature search yielded 64 potential reports; 10 met the eligibility criteria. All SRs had more than one critical flaw in AMSTAR2, so their methodological quality was rated as critically low. The most common issues included non-registration of study protocol, absence of list of excluded studies, no acknowledgment of fundings of included studies, no impact of risk of bias on SR results or interpretation and discussion of results, and data extraction not in duplicate. LIMITATIONS If a SR was not clearly identified by title or abstract as a SR or meta-analysis, it may have been missed during the screening process. CONCLUSIONS The methodological quality of SRs was suboptimal and warrants further improvement in order to provide strong evidence of MAD effectiveness and increase applicability of SR results for clinical decision-making.
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Affiliation(s)
- Serena Incerti Parenti
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Section of Orthodontics, University of Bologna, Bologna, Italy
| | - Elena Aroni
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Section of Orthodontics, University of Bologna, Bologna, Italy
| | | | | | - Giulio Alessandri-Bonetti
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Section of Orthodontics, University of Bologna, Bologna, Italy
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Abstract
Obstructive sleep apnea (OSA) telehealth management may improve initial and chronic care access, time to diagnosis and treatment, between-visit care, e-communications and e-education, workflows, costs, and therapy outcomes. OSA telehealth options may be used to replace or supplement none, some, or all steps in the evaluation, testing, treatments, and management of OSA. All telehealth steps must adhere to OSA guidelines. OSA telehealth may be adapted for continuous positive airway pressure (CPAP) and non-CPAP treatments. E-data collection enhances uses for individual and group analytics, phenotyping, testing and treatment selections, high-risk identification and targeted support, and comparative and multispecialty therapy studies.
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Abstract
Obstructive sleep apnea (OSA) is a multifactorial condition, and an interdisciplinary approach to diagnosis forms the basis for effective treatment planning. Craniofacial structure and attached soft tissues and muscles play a central role in OSA. Evidence-based studies demonstrate the effectiveness of oral appliances for mandibular advancement and tongue stabilization in managing OSA, and current clinical standards of practice recommend the use of oral appliances to treat OSA when patients cannot tolerate continuous positive airway pressure (CPAP). Although effective, oral appliances are less predictable in managing OSA compared with CPAP therapy. Measures can be taken to improve predictability of oral appliance treatment.
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Affiliation(s)
- Jing Hao Ng
- Department of Orthodontics, National Dental Centre Singapore, 5 Second Hospital Avenue, Singapore 168938, Singapore.
| | - Mimi Yow
- Department of Orthodontics, National Dental Centre Singapore, 5 Second Hospital Avenue, Singapore 168938, Singapore
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Mysliwiec V, Martin JL, Ulmer CS, Chowdhuri S, Brock MS, Spevak C, Sall J. The Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines. Ann Intern Med 2020; 172:325-336. [PMID: 32066145 DOI: 10.7326/m19-3575] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
DESCRIPTION In September 2019, the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) approved a new joint clinical practice guideline for assessing and managing patients with chronic insomnia disorder and obstructive sleep apnea (OSA). This guideline is intended to give health care teams a framework by which to screen, evaluate, treat, and manage the individual needs and preferences of VA and DoD patients with either of these conditions. METHODS In October 2017, the VA/DoD Evidence-Based Practice Work Group initiated a joint VA/DoD guideline development effort that included clinical stakeholders and conformed to the Institute of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions, systematically searched and evaluated the literature, created three 1-page algorithms, and advanced 41 recommendations using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. RECOMMENDATIONS This synopsis summarizes the key recommendations of the guideline in 3 areas: diagnosis and assessment of OSA and chronic insomnia disorder, treatment and management of OSA, and treatment and management of chronic insomnia disorder. Three clinical practice algorithms are also included.
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Affiliation(s)
- Vincent Mysliwiec
- University of Texas Health Science Center at San Antonio, San Antonio, Texas (V.M.)
| | - Jennifer L Martin
- David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, California (J.L.M.)
| | - Christi S Ulmer
- Durham VA Healthcare System and Duke University School of Medicine, Durham, North Carolina (C.S.U.)
| | - Susmita Chowdhuri
- John D. Dingell VA Sleep Wake Disorders Center and Wayne State University, Detroit, Michigan (S.C.)
| | - Matthew S Brock
- U.S. Army SAMHS Sleep Medicine Service, San Antonio, Texas, and Wilford Hall Ambulatory Surgical Center, Lackland Air Force Base, Texas (M.S.B.)
| | - Christopher Spevak
- Walter Reed National Military Medical Center/Defense Health Agency, Bethesda, Maryland (C.S.)
| | - James Sall
- Department of Veterans Affairs, Washington, DC (J.S.)
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Liu C, Kang W, Zhang S, Qiao X, Yang X, Zhou Z, Lu H. Mandibular Advancement Devices Prevent the Adverse Cardiac Effects of Obstructive Sleep Apnea-Hypopnea Syndrome (OSAHS). Sci Rep 2020; 10:3394. [PMID: 32098974 PMCID: PMC7042252 DOI: 10.1038/s41598-020-60034-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 02/03/2020] [Indexed: 01/21/2023] Open
Abstract
Although considerable research highlights the interactions between obstructive sleep apnea-hypopnea syndrome (OSAHS) and cardiovascular diseases, the effect of mandibular advancement device (MAD) treatment on cardiovascular complications in OSAHS patients remains unclear. We evaluated the effect of OSAHS treatment with MADs on the myocardium. All methods in this study were in accordance with relevant guidelines and regulations of the medical ethics committee in Hospital of Stomatology, Hebei Medical University approved the work. Thirty New Zealand rabbits were randomized into three groups: the control group, Group OSAHS, and Group MAD. Hydrophilic polyacrylamide gel was injected into the soft palate of the rabbits to induce OSAHS. In Group MAD, a MAD was positioned after OSAHS induction. All animals were induced to sleep in a supine position for 4–6 h/day for 8 weeks. Echocardiography was used to determine the structure and function of the heart. The histological changes were detected by optical microscopy and transmission electron microscopy (TEM). The levels of ET-1(endothelin-1) and Ang II (Angiotensin II) in the plasma were measured by an enzyme-linked immunosorbent assay (ELISA). The expression of ET-1 mRNA in heart tissue was detected by RT-PCR. Histological abnormalities, left ventricular hypertrophy, and left ventricular dysfunctions were demonstrated in Group OSAHS, and the abnormities were rescued with MAD treatment. Higher levels of plasma ET-1 and Ang II and elevated expression of ET-1 mRNA in cardiac tissue were detected in Group OSAHS compared with Group MAD and the control group. The blood oxygen saturation was negatively correlated with the levels of ET-1 and Ang II. OSAHS-induced elevated levels of ET-1 and Ang II may be attributed to myocardial structural abnormalities and dysfunction. Early treatment of MADs may play an important role in preventing myocardial damage in OSAHS rabbit model.
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Affiliation(s)
- Chunyan Liu
- Department of Orthodontics, School and Hospital of Stomatology, Hebei Medical University & Hebei Key Laboratory of Stomatology, Shijiazhuang, 050017, P.R. China.,Department of Periodontology and Dental Hygiene, School of Dentistry, University of Detroit Mercy, Detroit, MI, USA
| | - Wenjing Kang
- Department of Orthodontics, School and Hospital of Stomatology, Hebei Medical University & Hebei Key Laboratory of Stomatology, Shijiazhuang, 050017, P.R. China
| | - Shilong Zhang
- Department of Orthodontics, School and Hospital of Stomatology, Hebei Medical University & Hebei Key Laboratory of Stomatology, Shijiazhuang, 050017, P.R. China
| | - Xing Qiao
- Department of Orthodontics, School and Hospital of Stomatology, Hebei Medical University & Hebei Key Laboratory of Stomatology, Shijiazhuang, 050017, P.R. China
| | - Xiuchun Yang
- Department of Cardiology, The Second Hospital of Hebei Medical University; Hebei Province, Shijiazhuang, China
| | - Zheng Zhou
- Department of Periodontology and Dental Hygiene, School of Dentistry, University of Detroit Mercy, Detroit, MI, USA.
| | - Haiyan Lu
- Department of Orthodontics, School and Hospital of Stomatology, Hebei Medical University & Hebei Key Laboratory of Stomatology, Shijiazhuang, 050017, P.R. China.
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Salman LA, Shulman R, Cohen JB. Obstructive Sleep Apnea, Hypertension, and Cardiovascular Risk: Epidemiology, Pathophysiology, and Management. Curr Cardiol Rep 2020; 22:6. [PMID: 31955254 DOI: 10.1007/s11886-020-1257-y] [Citation(s) in RCA: 131] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Given the rising prevalence of obstructive sleep apnea (OSA), we aimed to review the epidemiologic and pathophysiologic relationship of OSA, hypertension, and cardiovascular disease, and to summarize recent advances in the treatment of OSA. RECENT FINDINGS OSA is associated with an elevated risk of hypertension and cardiovascular disease. Several pathophysiologic factors contribute to the relationship between OSA and vascular risk, including neurohormonal dysregulation, endothelial dysfunction, and inflammation. While CPAP reduces blood pressure, it has not been demonstrated to reduce cardiovascular risk. The combination of CPAP and weight loss has a synergistic effect on blood pressure and several metabolic parameters. Adherence to CPAP is poor across studies, potentially contributing to the attenuation of perceived cardiovascular benefit from CPAP therapy. A greater emphasis on adherence to CPAP and the combination of CPAP and weight loss are central to reducing cardiovascular risk among individuals with OSA.
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Affiliation(s)
- Liann Abu Salman
- Department of Internal Medicine, Lankenau Medical Center, Wynnewood, PA, USA
| | - Rachel Shulman
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jordana B Cohen
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, 831 Blockley, Philadelphia, PA, 19104, USA.
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Collen J, Lettieri C, Wickwire E, Holley A. Obstructive sleep apnea and cardiovascular disease, a story of confounders! Sleep Breath 2020; 24:1299-1313. [PMID: 31919716 DOI: 10.1007/s11325-019-01945-w] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 09/10/2019] [Accepted: 09/13/2019] [Indexed: 12/18/2022]
Abstract
Obstructive sleep apnea (OSA) syndrome is increasingly common among middle aged and older adults and is frequently linked to most cardiovascular diseases (CVD). Sleep-disordered breathing and CVD share a number of common risk factors and comorbid conditions including obesity, male gender, advancing age, metabolic syndrome, and hypertension. OSA appears to be associated with worsened CVD outcomes, sleep-related symptoms, quality of life, and risk of motor vehicle accidents. Demonstrating a cause-and-effect relationship between CVD and OSA has been challenging due to shared comorbidities. Strong evidence demonstrating clinically significant benefit for OSA treatments on OSA-related CVD outcomes are limited. In this review, we evaluate potential pathophysiologic mechanisms that link OSA to CVD and focus on specific treatments for OSA, including positive airway pressure (PAP), dental devices, and surgeries with regard to OSA-related CVD outcomes.
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Affiliation(s)
- Jacob Collen
- Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA.
| | | | - Emerson Wickwire
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
- Sleep Disorders Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Aaron Holley
- Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
- Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD, 20889, USA
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Review of systematic reviews on mandibular advancement oral appliance for obstructive sleep apnea: The importance of long-term follow-up. JAPANESE DENTAL SCIENCE REVIEW 2019; 56:32-37. [PMID: 31871511 PMCID: PMC6909077 DOI: 10.1016/j.jdsr.2019.10.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 05/23/2019] [Accepted: 10/27/2019] [Indexed: 12/11/2022] Open
Abstract
The purpose of this review was to present the currently available information on oral appliance (OA) therapy for dentists, especially clinic-based dentists, to aid them in performing this treatment for the management of symptoms of obstructive sleep apnea (OSA). The clinical research evidence comprised of systematic reviews concerned with the mandibular advancement oral appliance (OAm). Continuous positive airway pressure (CPAP) is superior to OA therapy in improving OSA symptoms. It is necessary to survey the adherence of patients who stopped CPAP therapy to OAm therapy. There is little evidence supporting the theory that OAm therapy prevents cardiovascular disease or improves prognosis. There is still room to investigate the types of OAm. OAm therapy has clear dental and skeletal side effects with long-term use, and these are important for dentists. However, a certain percentage of patients discontinue consultations. Regarding consultation rate for follow-up and repair/adjustments of OAm, there are advantages for the clinic-based dentists treating OSA with OAm. We believe that enhancing under-graduate and post-graduate education on sleep medicine, and establishing a specialist system could be the strategies for enabling the dentists to handle OAm therapy in dental clinics.
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30
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Sutherland K, Cistulli PA. Oral Appliance Therapy for Obstructive Sleep Apnoea: State of the Art. J Clin Med 2019; 8:jcm8122121. [PMID: 31810332 PMCID: PMC6947472 DOI: 10.3390/jcm8122121] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 11/26/2019] [Accepted: 11/27/2019] [Indexed: 12/17/2022] Open
Abstract
Obstructive sleep apnoea (OSA) represents a significant global health burden, with impact on cardiometabolic health, chronic disease, productivity loss and accident risk. Oral appliances (OA) are an effective therapy for OSA and work by enlarging and stabilising the pharyngeal airway to prevent breathing obstructions during sleep. Although recommended in clinical guidelines for OSA therapy, they are often considered only as second-line therapy following positive airway pressure (PAP) therapy failure. There has been a long-standing barrier to selecting OA over PAP therapy due to the inability to be certain about the level of efficacy in individual OSA patients. A range of methods to select OSA patients for OA therapy, based on the outcome of a single sleep study night, have been proposed, although none has been widely validated for clinical use. Emergent health outcome data suggest that equivalent apnoea–hypopnea index reduction may not be necessary to produce the same health benefits of PAP. This may be related to the more favourable adherence to OA therapy, which can now be objectively verified. Data on longer term health outcomes are needed, and there are additional opportunities for device improvement and combination therapy approaches. OAs have an important role in precision care of OSA as a chronic disorder through a multi-disciplinary care team. Future studies on real-world health outcomes following OA therapy are needed.
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Affiliation(s)
- Kate Sutherland
- Sleep Research Group, Charles Perkins Centre and Northern Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia;
- Department of Respiratory Medicine, Royal North Shore Hospital, Sydney, NSW 2065, Australia
- Correspondence:
| | - Peter A. Cistulli
- Sleep Research Group, Charles Perkins Centre and Northern Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia;
- Department of Respiratory Medicine, Royal North Shore Hospital, Sydney, NSW 2065, Australia
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31
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de Vries GE, Hoekema A, Claessen JQPJ, Stellingsma C, Stegenga B, Kerstjens HAM, Wijkstra PJ. Long-Term Objective Adherence to Mandibular Advancement Device Therapy Versus Continuous Positive Airway Pressure in Patients With Moderate Obstructive Sleep Apnea. J Clin Sleep Med 2019; 15:1655-1663. [PMID: 31739856 PMCID: PMC6853388 DOI: 10.5664/jcsm.8034] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 07/17/2019] [Accepted: 07/17/2019] [Indexed: 02/07/2023]
Abstract
STUDY OBJECTIVES Comparable health effects of mandibular advancement device (MAD) and continuous positive airway pressure (CPAP) therapy have been attributed to higher adherence with MAD compared with CPAP therapy. The objective of this study was to make a direct comparison of the objective adherence between MAD and CPAP in patients with moderate obstructive sleep apnea (OSA). METHODS Adherence was monitored for 12 months in 59 patients with moderate OSA (apnea-hypopnea index 15-30 events/h) as part of a randomized controlled trial. Objective adherence with MAD was assessed using the TheraMon microsensor. Objective adherence with CPAP was assessed using the built-in registration software with readout on SD card. Self-reported adherence with both therapies was assessed using a questionnaire. RESULTS Forty patients (68%) completed the study with the therapy to which they were randomly assigned. Median (interquartile range) objective adherence (h/night) in the 3rd month was 7.4 (5.2-8.2) for MAD and 6.8 (5.7-7.6) for CPAP (P = .41), compared to 6.9 (3.5-7.9) with MAD and 6.8 (5.2-7.6) with CPAP (P = .85) in the 12th month. There were no significant changes between the 3rd and 12th month for both MAD (P = .21) and CPAP (P = .46). Changes in adherence were not significantly different between MAD and CPAP (P = .51). Self-reported adherence was significantly higher with MAD than CPAP at all follow-ups. Self-reported adherence with CPAP was lower than objective CPAP adherence at the 6th and 12th month (P = .02). CONCLUSIONS Objective adherence with MAD and CPAP is comparable and consistent over time. Self-reported adherence is higher with MAD than with CPAP giving rise to interesting discrepancy between objective and self-reported adherence with CPAP. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Identifier: NCT01588275.
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Affiliation(s)
- Grietje E de Vries
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Aarnoud Hoekema
- Department of Oral and Maxillofacial Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Oral Kinesiology, Academic Center for Dentistry Amsterdam, MOVE Research Institute Amsterdam, University of Amsterdam and VU University Amsterdam, Amsterdam, The Netherlands
- Department of Oral and Maxillofacial Surgery, Academic Medical Center, Amsterdam, The Netherlands
- Department of Oral and Maxillofacial Surgery, Tjongerschans Hospital, Heerenveen, The Netherlands
| | | | - Cornelis Stellingsma
- Department of Oral and Maxillofacial Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Boudewijn Stegenga
- Department of Oral and Maxillofacial Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Deceased October 27, 2018
| | - Huib A M Kerstjens
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter J Wijkstra
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Center for Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Affiliation(s)
| | - Naima Covassin
- Department of Cardiovascular Diseases (N.C., V.K.S.), Mayo Clinic, Rochester, MN
| | - Virend K Somers
- Department of Cardiovascular Diseases (N.C., V.K.S.), Mayo Clinic, Rochester, MN
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33
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Dieltjens M, Vanderveken OM. Oral Appliances in Obstructive Sleep Apnea. Healthcare (Basel) 2019; 7:healthcare7040141. [PMID: 31717429 PMCID: PMC6956298 DOI: 10.3390/healthcare7040141] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 10/29/2019] [Accepted: 11/01/2019] [Indexed: 12/25/2022] Open
Abstract
Oral appliance therapy is increasingly prescribed as a non-invasive treatment option for patients diagnosed with obstructive sleep apnea. The custom-made titratable mandibular advancement devices (MAD) are the recommended type of oral appliances. Mandibular advancement devices are efficacious in reducing the severity of obstructive sleep apnea, however, only to a lesser extent than standard therapy using continuous positive airway pressure (CPAP). Although oral appliance therapy is known to reduce the severity of obstructive sleep apnea in most of the patients, one out of three patients still show negligible improvement under MAD therapy. Therefore, the selection of the appropriate candidates for this therapy is imperative and several upfront prediction tools are described. Overall, the health outcome of mandibular advancement device therapy is similar to that of CPAP, probably due to the inferior compliance of CPAP compared to MAD therapy, resulting in similar clinical effectiveness.
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Affiliation(s)
- Marijke Dieltjens
- Department of Translational neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Wilrijk, Belgium;
- Special Dentistry Care, Antwerp University Hospital, 2650 Edegem, Belgium
- ENT, Head and Neck Surgery, Antwerp University Hospital, 2650 Edegem, Belgium
| | - Olivier M. Vanderveken
- Department of Translational neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Wilrijk, Belgium;
- ENT, Head and Neck Surgery, Antwerp University Hospital, 2650 Edegem, Belgium
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, 2650 Edegem, Belgium
- Correspondence:
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34
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Lavigne G, Herrero Babiloni A, Beetz G, Dal Fabbro C, Sutherland K, Huynh N, Cistulli P. Critical Issues in Dental and Medical Management of Obstructive Sleep Apnea. J Dent Res 2019; 99:26-35. [DOI: 10.1177/0022034519885644] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
This critical review focuses on obstructive sleep apnea (OSA) and its management from a dental medicine perspective. OSA is characterized by ≥10-s cessation of breathing (apnea) or reduction in airflow (hypopnea) ≥5 times per hour with a drop in oxygen and/or rise in carbon dioxide. It can be associated with sleepiness and fatigue, impaired mood and cognition, cardiometabolic complications, and risk for transportation and work accidents. Although sleep apnea is diagnosed by a sleep physician, its management is interdisciplinary. The dentist’s role includes 1) screening patients for OSA risk factors (e.g., retrognathia, high arched palate, enlarged tonsils or tongue, enlarged tori, high Mallampati score, poor sleep, supine sleep position, obesity, hypertension, morning headache or orofacial pain, bruxism); 2) referring to an appropriate health professional as indicated; and 3) providing oral appliance therapy followed by regular dental and sleep medical follow-up. In addition to the device features and provider expertise, anatomic, behavioral, demographic, and neurophysiologic characteristics can influence oral appliance effectiveness in managing OSA. Therefore, OSA treatment should be tailored to each patient individually. This review highlights some of the putative action mechanisms related to oral appliance effectiveness and proposes future research directions.
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Affiliation(s)
- G.J. Lavigne
- Faculté de médicine dentaire, Université de Montréal, Montréal, Canada
- Research Center, CIUSSS du Nord-de-l’Île-de-Montréal, Montréal, Canada
- Division of Experimental Medicine, McGill University, Montréal, Canada
| | - A. Herrero Babiloni
- Faculté de médicine dentaire, Université de Montréal, Montréal, Canada
- Research Center, CIUSSS du Nord-de-l’Île-de-Montréal, Montréal, Canada
- Division of Experimental Medicine, McGill University, Montréal, Canada
| | - G. Beetz
- Research Center, CIUSSS du Nord-de-l’Île-de-Montréal, Montréal, Canada
| | | | - K. Sutherland
- Charles Perkins Centre and Sydney Medical School, University of Sydney, and Royal North Shore Hospital, Sydney, Australia
| | - N. Huynh
- Faculté de médicine dentaire, Université de Montréal, Montréal, Canada
| | - P.A. Cistulli
- Charles Perkins Centre and Sydney Medical School, University of Sydney, and Royal North Shore Hospital, Sydney, Australia
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Chan ASL, Sutherland K, Cistulli PA. Mandibular advancement splints for the treatment of obstructive sleep apnea. Expert Rev Respir Med 2019; 14:81-88. [PMID: 31663416 DOI: 10.1080/17476348.2020.1686978] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Introduction: Obstructive sleep apnea (OSA) is a chronic condition which requires a comprehensive chronic disease management model, rather than a device-focused approach, so as to achieve the best possible health outcomes. Oral appliances are the main alternative to continuous positive airway pressure (CPAP) for the treatment of OSA. There has been an expansion of the research evidence to support the use of oral appliances in clinical practice and the clinical use of oral appliances for the treatment of OSA has become a mainstream practice.Areas covered: This review summarizes the evidence base for the use of oral appliances for the treatment of OSA. The types of oral appliances; their mechanism of action and clinical efficacy for the treatment of OSA; adverse effects, and the impact on patient acceptability and treatment adherence; and clinical effectiveness and health outcomes are discussed.Expert opinion: Personalization of treatment is vitally important in OSA and is a pre-requisite for optimizing adherence with treatment which, in turn, is a key determinant of clinical effectiveness. Treatment of OSA with mandibular advancement splints could provide an equivalent health benefit to CPAP despite not achieving a complete normalization of polysomnographic indices, mediated by differences in adherence profiles.
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Affiliation(s)
- Andrew S L Chan
- Centre for Sleep Health and Research, Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, St Leonards, Australia.,Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Australia
| | - Kate Sutherland
- Centre for Sleep Health and Research, Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, St Leonards, Australia.,Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Australia.,Charles Perkins Centre, Faculty of Medicine and Health, The University of Sydney, Australia
| | - Peter A Cistulli
- Centre for Sleep Health and Research, Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, St Leonards, Australia.,Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Australia.,Charles Perkins Centre, Faculty of Medicine and Health, The University of Sydney, Australia
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de Vries GE, Hoekema A, Vermeulen KM, Claessen JQPJ, Jacobs W, van der Maten J, van der Hoeven JH, Stegenga B, Kerstjens HAM, Wijkstra PJ. Clinical- and Cost-Effectiveness of a Mandibular Advancement Device Versus Continuous Positive Airway Pressure in Moderate Obstructive Sleep Apnea. J Clin Sleep Med 2019; 15:1477-1485. [PMID: 31596213 PMCID: PMC6778341 DOI: 10.5664/jcsm.7980] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 06/07/2019] [Accepted: 06/07/2019] [Indexed: 12/29/2022]
Abstract
STUDY OBJECTIVES Limited evidence exists on the cost-effectiveness of mandibular advancement device (MAD) compared to continuous positive airway pressure (CPAP) therapy in moderate obstructive sleep apnea (OSA). Therefore, this study compares the clinical and cost-effectiveness of MAD therapy with CPAP therapy in moderate OSA. METHODS In a multicentre randomized controlled trial, patients with an apnea-hypopnea index (AHI) of 15 to 30 events/h were randomized to either MAD or CPAP. Incremental cost-effectiveness and cost-utility ratios (ICER/ICUR, in terms of AHI reduction and quality-adjusted life-years [QALYs, based on the EuroQol Five-Dimension Quality of Life questionnaire]) were calculated after 12 months, all from a societal perspective. RESULTS In the 85 randomized patients (n = 42 CPAP, n = 43 MAD), AHI reduction was significantly greater with CPAP (median reduction AHI 18.3 [14.8-22.6] events/h) than with MAD therapy (median reduction AHI 13.5 [8.5-18.4] events/h) after 12 months. Societal costs after 12 months were higher for MAD than for CPAP (mean difference €2.156). MAD was less cost-effective than CPAP after 12 months (ICER -€305 [-€3.003 to €1.572] per AHI point improvement). However, in terms of QALY, MAD performed better than CPAP after 12 months (€33.701 [-€191.106 to €562.271] per QALY gained). CONCLUSIONS CPAP was more clinically effective (in terms of AHI reduction) and cost-effective than MAD. However, costs per QALY was better with MAD as compared to CPAP. Therefore, CPAP is the first-choice treatment option in moderate OSA and MAD may be a good alternative. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Identifier: NCT01588275.
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Affiliation(s)
- Grietje E de Vries
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, The Netherlands
- Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Aarnoud Hoekema
- Department of Oral and Maxillofacial Surgery, University of Groningen, University Medical Center Groningen, The Netherlands
- Department of Oral Kinesiology, Academic Center for Dentistry Amsterdam, MOVE Research Institute Amsterdam, University of Amsterdam and VU University Amsterdam, The Netherlands
- Department of Oral and Maxillofacial Surgery, Academic Medical Center, Amsterdam, The Netherlands
- Department of Oral and Maxillofacial Surgery, Tjongerschans Hospital Heerenveen, The Netherlands
| | - Karin M Vermeulen
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, The Netherlands
| | | | - Wouter Jacobs
- Department of Pulmonary Diseases, Martini Hospital Groningen, The Netherlands
| | - Jan van der Maten
- Department of Pulmonary Diseases, Medical Center Leeuwarden, The Netherlands
| | - Johannes H van der Hoeven
- Department of Clinical Neurophysiology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Boudewijn Stegenga
- Department of Oral and Maxillofacial Surgery, University of Groningen, University Medical Center Groningen, The Netherlands
- Deceased October 27, 2018
| | - Huib A M Kerstjens
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, The Netherlands
- Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Peter J Wijkstra
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, The Netherlands
- Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, The Netherlands
- Center for Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, The Netherlands
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Abstract
PURPOSE OF REVIEW Obstructive sleep apnea (OSA) is increasing in prevalence. The intermittent hypoxia of OSA has wide-ranging effects on a patient's general health outcomes. However, gold-standard investigations and treatment are expensive and a significant burden on patients. Therefore, OSA research remains focused on improving the means of diagnosing and treating OSA, in high-risk-associated conditions. This review is to provide an update on the advances in the field of OSA. RECENT FINDINGS There has been recent debate about the best practice for diagnosis and treatment of OSA. Further work has been done on conditions associated with OSA including hypertension, atherosclerosis, various types of dementia and intracranial aneurysms. Inflammatory and vascular risk factors associated with OSA increase stroke risk and alter outcomes for recovery. OSA should definitely be considered in patients presenting with nonarteritic anterior ischemic optic neuropathy, and perhaps those with intracranial hypertension. SUMMARY Newer home-based sleep-apnea testing can be implemented via physician clinics, with oversight by a certified sleep physician. Although continuous positive airway pressure (CPAP) is the gold-standard, management should include diet and exercise. It is important to test for, and treat OSA in patients with a range of neurological diseases. However, further studies into the long-term impact of CPAP on health outcomes are still needed.
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Salsone M, Marelli S, Vescio B, Quattrone A, Gambardella A, Castelnuovo A, Quattrone A, Ferini Strambi L. Usefulness of cardiac parasympathetic index in CPAP-treated patients with obstructive sleep apnea: A preliminary study. J Sleep Res 2019; 29:e12893. [PMID: 31368146 DOI: 10.1111/jsr.12893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 06/06/2019] [Accepted: 06/15/2019] [Indexed: 12/16/2022]
Abstract
Cardiac autonomic indexes, including cardiac parasympathetic index and cardiac sympathetic index, have been reported to accurately identify patients with sleep disorders such as obstructive sleep apnea. Our study aimed to assess cardiac autonomic indexes in patients with obstructive sleep apnea before and during a single full-night continuous positive airway pressure therapy using a combined approach. Our simultaneous heart rate variability-polysomnographic study included 16 never-treated obstructive sleep apnea patients. Two patients dropped out. Patients underwent combined recordings in two consecutive days, at baseline and during a single full-night of acute continuous positive airway pressure treatment. We calculated cardiac parasympathetic index and cardiac sympathetic index as night/day ratio for high-frequency and low-frequency heart rate variability spectral components, respectively. Continuous positive airway pressure treatment significantly reduced cardiac autonomic indexes values in comparison with baseline values (cardiac parasympathetic index: p < .0001; cardiac sympathetic index: p = .001). After acute continuous positive airway pressure treatment, the percentage of decrease of cardiac parasympathetic index was greater than that of cardiac sympathetic index (51.02 ± 15.72 versus 34.64 ± 26.93). A positive statistical correlation was also found between decrease of cardiac parasympathetic index and decrease of apnea-hypopnea index after continuous positive airway pressure (p < .001). This study improves the knowledge on cardiac autonomic modulation during acute continuous positive airway pressure therapy in obstructive sleep apnea. Our results demonstrate that both autonomic indexes decreased significantly after a single-night of acute continuous positive airway pressure therapy. Cardiac parasympathetic index more than cardiac sympathetic index was related to decrease of apnea-hypopnea index after continuous positive airway pressure therapy, thus representing a potential help in everyday clinical practice.
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Affiliation(s)
- Maria Salsone
- Institute of Molecular Bioimaging and Physiology, National Research Council, Catanzaro, Italy
| | - Sara Marelli
- Faculty of Psychology, 'Vita-Salute' San Raffaele University, Milan, Italy.,Department of Clinical Neurosciences, Neurology-Sleep Disorder Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Andrea Quattrone
- Institute of Neurology, University 'Magna Graecia', Catanzaro, Italy
| | | | - Alessandra Castelnuovo
- Faculty of Psychology, 'Vita-Salute' San Raffaele University, Milan, Italy.,Department of Clinical Neurosciences, Neurology-Sleep Disorder Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Aldo Quattrone
- Institute of Neurology, University 'Magna Graecia', Catanzaro, Italy.,Neuroscience Center, University 'Magna Graecia', Catanzaro, Italy
| | - Luigi Ferini Strambi
- Faculty of Psychology, 'Vita-Salute' San Raffaele University, Milan, Italy.,Department of Clinical Neurosciences, Neurology-Sleep Disorder Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Abstract
Obstructive sleep apnea (OSA) is a multifactorial condition, and an interdisciplinary approach to diagnosis forms the basis for effective treatment planning. Craniofacial structure and attached soft tissues and muscles play a central role in OSA. Evidence-based studies demonstrate the effectiveness of oral appliances for mandibular advancement and tongue stabilization in managing OSA, and current clinical standards of practice recommend the use of oral appliances to treat OSA when patients cannot tolerate continuous positive airway pressure (CPAP). Although effective, oral appliances are less predictable in managing OSA compared with CPAP therapy. Measures can be taken to improve predictability of oral appliance treatment.
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Peker Y, Balcan B. Cardiovascular outcomes of continuous positive airway pressure therapy for obstructive sleep apnea. J Thorac Dis 2018; 10:S4262-S4279. [PMID: 30687542 DOI: 10.21037/jtd.2018.11.48] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Obstructive sleep apnea is a common disorder with increased risk for cardiovascular morbidity and mortality. The first choice of treatment of obstructive sleep apnea is continuous positive airway pressure, which reduces excessive daytime sleepiness and improves quality of life in sleep clinic cohorts. Nevertheless, the majority of patients with cardiovascular disease and concomitant obstructive sleep apnea do not report daytime sleepiness, and adherence to treatment is insufficient particularly in this group. The current article aims to give an updated overview of the impact of continuous positive airway pressure therapy on cardiovascular outcomes mainly based on the observational studies and the recent randomized controlled trials.
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Affiliation(s)
- Yüksel Peker
- Department of Pulmonary Medicine, School of Medicine, Koc University, Istanbul, Turkey.,Department of Clinical Sciences, Respiratory Medicine and Allergology, Faculty of Medicine, Lund University, Lund, Sweden.,Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Baran Balcan
- Department of Pulmonary Medicine, School of Medicine, Marmara University, Istanbul, Turkey
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Herrero Babiloni A, De Beaumont L, Lavigne GJ. Transcranial Magnetic Stimulation. Sleep Med Clin 2018; 13:571-582. [DOI: 10.1016/j.jsmc.2018.07.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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