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Dedhia RC, Bliwise DL, Quyyumi AA, Thaler ER, Boon MS, Huntley CT, Seay EG, Tangutur A, Strollo PJ, Gurel N, Keenan BT. Hypoglossal Nerve Stimulation and Cardiovascular Outcomes for Patients With Obstructive Sleep Apnea: A Randomized Clinical Trial. JAMA Otolaryngol Head Neck Surg 2024; 150:39-48. [PMID: 38032624 PMCID: PMC10690581 DOI: 10.1001/jamaoto.2023.3756] [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: 06/19/2023] [Accepted: 10/09/2023] [Indexed: 12/01/2023]
Abstract
Importance Sham-controlled trials are needed to characterize the effect of hypoglossal nerve stimulation (HGNS) therapy on cardiovascular end points in patients with moderate-severe obstructive sleep apnea (OSA). Objective To determine the effect of therapeutic levels of HGNS, compared to sham levels, on blood pressure, sympathetic activity, and vascular function. Design, Setting, and Participants This double-blind, sham-controlled, randomized crossover therapy trial was conducted from 2018 to 2022 at 3 separate academic medical centers. Adult patients with OSA who already had an HGNS device implanted and were adherent and clinically optimized to HGNS therapy were included. Participants who had fallen asleep while driving within 1 year prior to HGNS implantation were excluded from the trial. Data analysis was performed from January to September 2022. Interventions Participants underwent a 4-week period of active HGNS therapy and a 4-week period of sham HGNS therapy in a randomized order. Each 4-week period concluded with collection of 24-hour ambulatory blood pressure monitoring (ABPM), pre-ejection period (PEP), and flow-mediated dilation (FMD) values. Main Outcomes and Measures The change in mean 24-hour systolic blood pressure was the primary outcome, with other ABPM end points exploratory, and PEP and FMD were cosecondary end points. Results Participants (n = 60) were older (mean [SD] age, 67.3 [9.9] years), overweight (mean [SD] body mass index, calculated as weight in kilograms divided by height in meters squared, 28.7 [4.6]), predominantly male (38 [63%]), and had severe OSA at baseline (mean [SD] apnea-hypopnea index, 33.1 [14.9] events/h). There were no differences observed between active and sham therapy in 24-hour systolic blood pressure (mean change on active therapy, -0.18 [95% CI, -2.21 to 1.84] mm Hg), PEP (mean change on active therapy, 0.11 [95% CI, -5.43 to 5.66] milliseconds), or FMD (mean change on active therapy, -0.17% [95% CI, -1.88% to 1.54%]). Larger differences between active and sham therapy were observed in a per-protocol analysis set (n = 20) defined as experiencing at least a 50% reduction in apnea-hypopnea index between sham and active treatment. Conclusions and Relevance In this sham-controlled HGNS randomized clinical trial, mean 24-hour systolic blood pressure and other cardiovascular measures were not significantly different between sham and active HGNS therapy. Several methodologic lessons can be gleaned to inform future HGNS randomized clinical trials. Trial Registration ClinicalTrials.gov Identifier: NCT03359096.
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Affiliation(s)
- Raj C. Dedhia
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia
- Department of Sleep Medicine, University of Pennsylvania, Philadelphia
| | | | - Arshed A. Quyyumi
- Division of Cardiology, Department of Medicine, Emory University, Atlanta, Georgia
| | - Erica R. Thaler
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia
| | - Maurits S. Boon
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Colin T. Huntley
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Everett G. Seay
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia
| | - Akshay Tangutur
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia
| | - Patrick J. Strollo
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Nil Gurel
- Reality Labs, Meta, Menlo Park, California
| | - Brendan T. Keenan
- Department of Sleep Medicine, University of Pennsylvania, Philadelphia
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Chang JL, Goldberg AN, Alt JA, Alzoubaidi M, Ashbrook L, Auckley D, Ayappa I, Bakhtiar H, Barrera JE, Bartley BL, Billings ME, Boon MS, Bosschieter P, Braverman I, Brodie K, Cabrera-Muffly C, Caesar R, Cahali MB, Cai Y, Cao M, Capasso R, Caples SM, Chahine LM, Chang CP, Chang KW, Chaudhary N, Cheong CSJ, Chowdhuri S, Cistulli PA, Claman D, Collen J, Coughlin KC, Creamer J, Davis EM, Dupuy-McCauley KL, Durr ML, Dutt M, Ali ME, Elkassabany NM, Epstein LJ, Fiala JA, Freedman N, Gill K, Boyd Gillespie M, Golisch L, Gooneratne N, Gottlieb DJ, Green KK, Gulati A, Gurubhagavatula I, Hayward N, Hoff PT, Hoffmann OM, Holfinger SJ, Hsia J, Huntley C, Huoh KC, Huyett P, Inala S, Ishman SL, Jella TK, Jobanputra AM, Johnson AP, Junna MR, Kado JT, Kaffenberger TM, Kapur VK, Kezirian EJ, Khan M, Kirsch DB, Kominsky A, Kryger M, Krystal AD, Kushida CA, Kuzniar TJ, Lam DJ, Lettieri CJ, Lim DC, Lin HC, Liu SY, MacKay SG, Magalang UJ, Malhotra A, Mansukhani MP, Maurer JT, May AM, Mitchell RB, Mokhlesi B, Mullins AE, Nada EM, Naik S, Nokes B, Olson MD, Pack AI, Pang EB, Pang KP, Patil SP, Van de Perck E, Piccirillo JF, Pien GW, Piper AJ, Plawecki A, Quigg M, Ravesloot MJ, Redline S, Rotenberg BW, Ryden A, Sarmiento KF, Sbeih F, Schell AE, Schmickl CN, Schotland HM, Schwab RJ, Seo J, Shah N, Shelgikar AV, Shochat I, Soose RJ, Steele TO, Stephens E, Stepnowsky C, Strohl KP, Sutherland K, Suurna MV, Thaler E, Thapa S, Vanderveken OM, de Vries N, Weaver EM, Weir ID, Wolfe LF, Tucker Woodson B, Won CH, Xu J, Yalamanchi P, Yaremchuk K, Yeghiazarians Y, Yu JL, Zeidler M, Rosen IM. International Consensus Statement on Obstructive Sleep Apnea. Int Forum Allergy Rhinol 2023; 13:1061-1482. [PMID: 36068685 PMCID: PMC10359192 DOI: 10.1002/alr.23079] [Citation(s) in RCA: 53] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 08/12/2022] [Accepted: 08/18/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA). METHODS Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus. RESULTS The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated. CONCLUSION This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.
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Affiliation(s)
- Jolie L. Chang
- University of California, San Francisco, California, USA
| | | | | | | | - Liza Ashbrook
- University of California, San Francisco, California, USA
| | | | - Indu Ayappa
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | - Maurits S. Boon
- Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Pien Bosschieter
- Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | - Itzhak Braverman
- Hillel Yaffe Medical Center, Hadera Technion, Faculty of Medicine, Hadera, Israel
| | - Kara Brodie
- University of California, San Francisco, California, USA
| | | | - Ray Caesar
- Stone Oak Orthodontics, San Antonio, Texas, USA
| | | | - Yi Cai
- University of California, San Francisco, California, USA
| | | | | | | | | | | | | | | | | | - Susmita Chowdhuri
- Wayne State University and John D. Dingell VA Medical Center, Detroit, Michigan, USA
| | - Peter A. Cistulli
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - David Claman
- University of California, San Francisco, California, USA
| | - Jacob Collen
- Uniformed Services University, Bethesda, Maryland, USA
| | | | | | - Eric M. Davis
- University of Virginia, Charlottesville, Virginia, USA
| | | | | | - Mohan Dutt
- University of Michigan, Ann Arbor, Michigan, USA
| | - Mazen El Ali
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | | | | | - Kirat Gill
- Stanford University, Palo Alto, California, USA
| | | | - Lea Golisch
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | | | | | - Arushi Gulati
- University of California, San Francisco, California, USA
| | | | | | - Paul T. Hoff
- University of Michigan, Ann Arbor, Michigan, USA
| | - Oliver M.G. Hoffmann
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | - Jennifer Hsia
- University of Minnesota, Minneapolis, Minnesota, USA
| | - Colin Huntley
- Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | | | - Sanjana Inala
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | | | | | | | | | | | - Meena Khan
- Ohio State University, Columbus, Ohio, USA
| | | | - Alan Kominsky
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | - Meir Kryger
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Derek J. Lam
- Oregon Health and Science University, Portland, Oregon, USA
| | | | | | | | | | | | | | - Atul Malhotra
- University of California, San Diego, California, USA
| | | | - Joachim T. Maurer
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - Anna M. May
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Ron B. Mitchell
- University of Texas, Southwestern and Children’s Medical Center Dallas, Texas, USA
| | | | | | | | | | - Brandon Nokes
- University of California, San Diego, California, USA
| | | | - Allan I. Pack
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | | | | | | | | | | | | | - Mark Quigg
- University of Virginia, Charlottesville, Virginia, USA
| | | | - Susan Redline
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Armand Ryden
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | | | - Firas Sbeih
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | | | | | | | | | - Jiyeon Seo
- University of California, Los Angeles, California, USA
| | - Neomi Shah
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | - Ryan J. Soose
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Erika Stephens
- University of California, San Francisco, California, USA
| | | | | | | | | | - Erica Thaler
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sritika Thapa
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Nico de Vries
- Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | | | - Ian D. Weir
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Josie Xu
- University of Toronto, Ontario, Canada
| | | | | | | | | | | | - Ilene M. Rosen
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Altay S, Fırat S, Peker Y. A Narrative Review of the Association of Obstructive Sleep Apnea with Hypertension: How to Treat Both When They Coexist? J Clin Med 2023; 12:4144. [PMID: 37373837 DOI: 10.3390/jcm12124144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 06/07/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
Hypertension (HT) is a worldwide public health issue and an essential risk factor for cardiovascular and cerebrovascular diseases. Obstructive sleep apnea (OSA) is a condition characterized by recurrent episodes of apnea and hypopnea as a consequence of partial or complete obstruction of the upper airways due to anatomic and/or functional disturbances. There is mounting evidence of a relationship between OSA and HT. In patients with OSA, HT is predominantly nocturnal and characterized by high diastolic blood pressure and usually by a nondipping pattern. Optimizing the blood pressure control is recommended in the current guidelines as the first treatment option in hypertensive patients with OSA. Continuous positive airway pressure (CPAP) therapy may reduce blood pressure, albeit only slightly as a stand-alone treatment. CPAP, as an add-on treatment to antihypertensive medication, appears to be an efficient treatment modality when both conditions coexist. This narrative review aims to summarize the current perspectives on the association of OSA with HT and the treatment options available for adults with OSA-related HT.
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Affiliation(s)
- Servet Altay
- Department of Cardiology, Trakya University School of Medicine, Edirne 22030, Turkey
| | - Selma Fırat
- Department of Pulmonary Medicine, University of Health Sciences, Atatürk Sanatorium Education and Research Hospital, Ankara 06280, Turkey
| | - Yüksel Peker
- Department of Pulmonary Medicine, Koç University School of Medicine, Istanbul 34450, Turkey
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA 02115, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
- Department of Clinical Sciences, Respiratory Medicine and Allergology, Faculty of Medicine, Lund University, 22002 Lund, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 40530 Gothenburg, Sweden
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Abstract
OBJECTIVE Obstructive sleep apnoea (OSA) is a common cause of secondary hypertension. This network meta-analysis (NMA) assessed the effect of different OSA treatments on lowering blood pressure. METHODS PubMed, EMBASE, Web of Science, and Cochrane Library databases were searched for relevant randomized controlled trials. The search strategies included the concepts of OSA, blood pressure, hypertension, and blood pressure-reducing treatments without language or data restriction (from inception to 1 June 2021). The outcomes included office SBP, office DBP, daytime SBP (dSBP) and DBP (dDBP), and night-time SBP (nSBP) and DBP (nDBP). A Bayesian network meta-analysis was performed, and mean differences with 95% credibility intervals were calculated. RESULTS We reviewed 49 randomized controlled trials involving 4893 patients and the following interventions: continuous positive-airway pressure (CPAP), mandibular advancement devices, nocturnal supplemental oxygen, surgery, β-blocker, angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs), renal sympathetic denervation (RDN), mineralocorticoid receptor antagonists (MRAs), calcium channel blockers. MRAs were significantly associated with blood pressure reduction followed by ACEI/ARB. RDN could reduce office SBP, office DBP, 24-h SBP, 24-h DBP, dSBP, and dDBP. CPAP also demonstrated modest blood pressure lowering. CONCLUSION MRAs and ACEIs/ARBs can reduce blood pressure effectively in patients with OSA. RDN is a novel hypertension treatment that lowered blood pressure in such patients. CPAP was associated with mild but stable blood pressure reduction, and it might be helpful as an adjunctive therapy in OSA patients with hypertension. REVIEW REGISTRATION This systematic review and meta-analysis was registered in PROSPERO: CRD42021240891.
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Ee JS, Pham CK, Shaha DP, Rogers MC, Cacace GS, Mounts CW. Soldiers' Perception of a Behavioral Intervention for Positive Airway Pressure Therapy Adherence in a Military Treatment Facility. Mil Med 2021; 186:239-245. [PMID: 33499498 DOI: 10.1093/milmed/usaa306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 07/14/2020] [Accepted: 09/02/2020] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION The incidence of obstructive sleep apnea in military personnel has increased over 500% since the early 2000s. Adherence to continuous positive airway pressure (PAP), an efficacious treatment, has been suboptimal. This article presents a behavioral intervention model for enhancing PAP therapy adherence and describes how the model was received by military personnel. MATERIALS AND METHODS The study population comprised 254 out of 280 military personnel (93% men, mean age 39 years) who attended a 90-minute behavioral intervention class within the first 8 weeks of PAP use. They were coached on the Knowledge, Skills, Attitudes (KSA) model of PAP therapy success: Knowledge about obstructive sleep apnea and PAP treatment; Skills to develop a habitual loop for nightly PAP use; and Attitudes that address readiness, barriers, and solutions for sustaining PAP use. Participants completed a voluntary, anonymous postclass survey that inquired of their perception of various elements of the class. Data were analyzed using descriptive statistics and a paired sample t-test. RESULTS In participants' self-rating of how much they know about PAP treatment before and after the class, their ratings indicated that they experienced a significant increase in knowledge (P < 0.0001). On the postclass survey, 77% of the participants (N = 195/254) "agree a lot" or "strongly agree" that the class gave them tools to have a successful treatment and 78% (N = 198/254) noted that it was a valuable educational experience. The Knowledge portion was rated by 79% (N = 201/254) of the participants as "quite a lot" or "extremely" beneficial. The Skills segment was rated as "quite a lot" or "extremely" beneficial by 72% (N = 183/254) of the participants. The Attitudes discussion was perceived as "quite a lot" or "extremely" beneficial by 70% (N = 178/254) of the participants. Participants' free-text responses to "what was most helpful" were generally positive. CONCLUSIONS A KSA model of behavioral intervention for enhancing PAP therapy adherence was well received by participants. Future research will assess the impact of this intervention on adherence as measured by objective indicators.
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Affiliation(s)
- Juliana S Ee
- Department of Family Medicine, Womack Army Medical Center, NC, 28310, USA
| | | | - David P Shaha
- Department of Medicine, Womack Army Medical Center, NC, 28310, USA
| | - Mary C Rogers
- Department of Medicine, Womack Army Medical Center, NC, 28310, USA
| | - Gregory S Cacace
- Department of Medicine, Womack Army Medical Center, NC, 28310, USA
| | - Charles W Mounts
- Department of Family Medicine, Womack Army Medical Center, NC, 28310, USA
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Baran R, Grimm D, Infanger M, Wehland M. The Effect of Continuous Positive Airway Pressure Therapy on Obstructive Sleep Apnea-Related Hypertension. Int J Mol Sci 2021; 22:ijms22052300. [PMID: 33669062 PMCID: PMC7956605 DOI: 10.3390/ijms22052300] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/18/2021] [Accepted: 02/21/2021] [Indexed: 01/02/2023] Open
Abstract
Obstructive sleep apnea (OSA) is a common disease, with approximately 3-7% of men and 2-5% of women worldwide suffering from symptomatic OSA. If OSA is left untreated, hypoxia, microarousals and increased chemoreceptor stimulation can lead to complications like hypertension (HT). Continuous positive airway pressure (CPAP) is the most common treatment for OSA, and it works by generating airway patency, which will counteract the apnea or hypopnea. More than one billion people in the world suffer from HT, and the usual treatment is pharmacological with antihypertensive medication (AHM). The focus of this review will be to investigate whether the CPAP therapy for OSA affects HT.
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Affiliation(s)
- Ronni Baran
- Department of Biomedicine, Aarhus University, 8000 Aarhus, Denmark;
| | - Daniela Grimm
- Department of Biomedicine, Aarhus University, 8000 Aarhus, Denmark;
- Department for Microgravity Research and Translational Regenerative Medicine, Otto-von-Guericke University, D-39106 Magdeburg, Germany;
- Correspondence: (D.G.); (M.W.)
| | - Manfred Infanger
- Department for Microgravity Research and Translational Regenerative Medicine, Otto-von-Guericke University, D-39106 Magdeburg, Germany;
| | - Markus Wehland
- Department for Microgravity Research and Translational Regenerative Medicine, Otto-von-Guericke University, D-39106 Magdeburg, Germany;
- Correspondence: (D.G.); (M.W.)
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Cruz FC, Drager LF, Queiróz DB, Souza GA, Pedrosa RP, Patriota TLC, Dórea EL, Vieira MLC, Righi CG, Martinez D, da Silva GA, Silva GV, Pio-Abreu A, Lotufo PA, Benseãor IM, Bortolotto LA, Fuchs FD, Lorenzi-Filho G. The effect of continuous positive airway pressure on blood pressure in patients with obstructive sleep apnea and uncontrolled hypertension - Study design and challenges during the COVID-19 pandemic. Clinics (Sao Paulo) 2021; 76:e2926. [PMID: 34495079 PMCID: PMC8382149 DOI: 10.6061/clinics/2021/e2926] [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] [Received: 03/11/2021] [Accepted: 06/15/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To describe the MORPHEOS (Morbidity in patients with uncontrolled HTN and OSA) trial, and describe the challenges imposed by the COVID-19 pandemic. METHODS MORPHEOS is a multicenter (n=6) randomized controlled trial designed to evaluate the blood pressure (BP) lowering effects of treatment with continuous positive airway pressure (CPAP) or placebo (nasal strips) for 6 months in adult patients with uncontrolled hypertension (HTN) and moderate-to-severe obstructive sleep apnea (OSA). Patients using at least one antihypertensive medication were included. Uncontrolled HTN was confirmed by at least one abnormal parameter in the 24-hour ABPM and ≥80% medication adherence evaluated by pill counting after the run-in period. OSA was defined by an apnea-hypopnea index ≥15 events/hours. The co-primary endpoints are brachial BP (office and ambulatory BP monitoring, ABPM) and central BP. Secondary outcomes include hypertension-mediated organ damage (HMOD) to heart, aorta, eye, and kidney. We pre-specified several sub-studies from this investigation. Visits occur once a week in the first month and once a month thereafter. The programmed sample size was 176 patients but the pandemic prevented this final target. A post-hoc power analysis will be calculated from the final sample. ClinicalTrials.gov: NCT02270658. RESULTS The first 100 patients are predominantly males (n=69), age: 52±10 years, body mass index: 32.7±3.9 kg/m2 with frequent co-morbidities. CONCLUSIONS The MORPHEOS trial has a unique study design including a run-in period; pill counting, and detailed analysis of hypertension-mediated organ damage in patients with uncontrolled HTN that will allow clarification of the impact of OSA treatment with CPAP.
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Affiliation(s)
- Fernanda C.S.G. Cruz
- Laboratorio de Sono, Divisao de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Luciano F. Drager
- Unidade de Hipertensao, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Unidade de Hipertensao, Divisao Renal, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Hospital Universitario, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Daniel B.C. Queiróz
- Laboratorio de Sono, Divisao de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Gabriela A. Souza
- Laboratorio de Sono, Divisao de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Rodrigo P. Pedrosa
- Laboratorio do Sono e Coracao, Pronto-Socorro Cardiologico de Pernambuco (PROCAPE), Universidade de Pernambuco, Recife, PE, BR
| | - Tarcya L.G Couto Patriota
- Laboratorio do Sono e Coracao, Pronto-Socorro Cardiologico de Pernambuco (PROCAPE), Universidade de Pernambuco, Recife, PE, BR
| | - Egidio L. Dórea
- Hospital Universitario, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Marcelo Luiz C. Vieira
- Unidade de Ecocardiografia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Camila G. Righi
- Laboratorio Interdisciplinar de Pesquisa em Sono, Hospital de Clinicas de Porto Alegre (LIPES-HCPA), Porto Alegre, RS, BR
| | - Denis Martinez
- Laboratorio Interdisciplinar de Pesquisa em Sono, Hospital de Clinicas de Porto Alegre (LIPES-HCPA), Porto Alegre, RS, BR
| | - Geruza A. da Silva
- Faculdade de Medicina de Ribeirao Preto, Universidade de Sao Paulo, Ribeirao Preto, SP, BR
| | - Giovanio V. Silva
- Hospital Universitario, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Andrea Pio-Abreu
- Hospital Universitario, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Paulo A. Lotufo
- Hospital Universitario, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Isabela M. Benseãor
- Hospital Universitario, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Luiz A. Bortolotto
- Unidade de Hipertensao, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Flávio D. Fuchs
- Divisao de Cardiologia, Hospital de Clinicas de Porto Alegre, Porto Alegre, RS, BR
| | - Geraldo Lorenzi-Filho
- Laboratorio de Sono, Divisao de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Corresponding author. E-mail:
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Chalegre ST, Lins-Filho OL, Lustosa TC, França MV, Couto TLG, Drager LF, Lorenzi-Filho G, Bittencourt MS, Pedrosa RP. Impact of CPAP on arterial stiffness in patients with obstructive sleep apnea: a meta-analysis of randomized trials. Sleep Breath 2020; 25:1195-1202. [PMID: 33094411 DOI: 10.1007/s11325-020-02226-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 10/05/2020] [Accepted: 10/13/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE This study aimed to perform a systematic review and meta-analysis of randomized trials investigating the effect of continuous positive airway pressure (CPAP) on non-invasive markers of arterial stiffness in patients with OSA. METHODS The purpose of the study was to evaluate the effect of CPAP on markers of arterial stiffness (pulse wave velocity (PWV) and augmentation index (Aix)) in patients with OSA. The study adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We systematically reviewed MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, and LILACS databases for randomized trials (RT) evaluating the changes in markers of arterial stiffness (pulse wave velocity (PWV) and augmentation index (Aix) comparing CPAP vs. controls in patients with OSA. Reviewer Manager version 5.3 (R Foundation for Statistical Computing, Vienna, Austria) was used to perform meta-analysis. Risk of bias analysis was performed using the Cochrane tool. RESULTS Of the 464 studies initially retrieved, 9 relevant studies with 685 participants were included in the analysis. The studies presented moderate risk of bias. CPAP did not significantly reduce Aix (mean difference, - 1.96 (95% confidence interval (CI) - 5.25 to 1.33), p = 0.24), whereas it significantly changed PWV (mean difference, - 0.44 (95% confidence interval (CI) - 0.76 to - 0.12), p = 0.00). CONCLUSION CPAP treatment was effective in improving arterial stiffness by reducing PWV in patients with OSA. Additional randomized trials, however, should be performed to confirm these findings.
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Affiliation(s)
- Sintya T Chalegre
- Sleep and Heart Laboratory, Pronto Socorro Cardiológico de Pernambuco (PROCAPE), University of Pernambuco, Rua dos Palmares, SN, Recife, Pernambuco, Brazil
| | - Ozeas L Lins-Filho
- Sleep and Heart Laboratory, Pronto Socorro Cardiológico de Pernambuco (PROCAPE), University of Pernambuco, Rua dos Palmares, SN, Recife, Pernambuco, Brazil.
| | - Thais C Lustosa
- Sleep and Heart Laboratory, Pronto Socorro Cardiológico de Pernambuco (PROCAPE), University of Pernambuco, Rua dos Palmares, SN, Recife, Pernambuco, Brazil
| | - Marcus V França
- Sleep and Heart Laboratory, Pronto Socorro Cardiológico de Pernambuco (PROCAPE), University of Pernambuco, Rua dos Palmares, SN, Recife, Pernambuco, Brazil
| | - Tarcya L G Couto
- Sleep and Heart Laboratory, Pronto Socorro Cardiológico de Pernambuco (PROCAPE), University of Pernambuco, Rua dos Palmares, SN, Recife, Pernambuco, Brazil
| | - Luciano F Drager
- Hypertension Unit, Heart Institute (InCor) and Renal Division, University Hospital, Faculdade de Medicina, University of São Paulo, Sao Paulo, Brazil
| | - Geraldo Lorenzi-Filho
- Sleep Laboratory, Pulmonary Division, Heart Institute (InCor), University Hospital, University of São Paulo, Sao Paulo, Brazil
| | - Marcio S Bittencourt
- Division of Internal Medicine, University Hospital, University of São Paulo, São Paulo, Brazil.,Hospital Israelita Albert Einstein & Faculdade Israelita de Ciências da Saúde Albert Einstein, Sao Paulo, Brazil
| | - Rodrigo P Pedrosa
- Sleep and Heart Laboratory, Pronto Socorro Cardiológico de Pernambuco (PROCAPE), University of Pernambuco, Rua dos Palmares, SN, Recife, Pernambuco, Brazil
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9
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Pengo MF, Soranna D, Giontella A, Perger E, Mattaliano P, Schwarz EI, Lombardi C, Bilo G, Zambon A, Steier J, Parati G, Minuz P, Fava C. Obstructive sleep apnoea treatment and blood pressure: which phenotypes predict a response? A systematic review and meta-analysis. Eur Respir J 2020; 55:13993003.01945-2019. [PMID: 32079643 DOI: 10.1183/13993003.01945-2019] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 02/06/2020] [Indexed: 11/05/2022]
Abstract
The treatment for obstructive sleep apnoea (OSA) with continuous positive airway pressure (CPAP) or mandibular advancement devices (MADs) is associated with blood pressure (BP) reduction; however, the overall effect is modest. The aim of this systematic review and meta-analysis of randomised controlled trials (RCTs) comparing the effect of such treatments on BP was to identify subgroups of patients who respond best to treatment.The article search was performed in three different databases with specific search terms and selection criteria. From 2289 articles, we included 68 RCTs that compared CPAP or MADs with either passive or active treatment. When all the studies were pooled together, CPAP and MADs were associated with a mean BP reduction of -2.09 (95% CI -2.78- -1.40) mmHg for systolic BP and -1.92 (95% CI -2.40- -1.43) mmHg for diastolic BP and -1.27 (95% CI -2.34- -0.20) mmHg for systolic BP and -1.11 (95% CI -1.82- -0.41) mmHg for diastolic BP, respectively. The subgroups of patients who showed a greater response were those aged <60 years (systolic BP -2.93 mmHg), with uncontrolled BP at baseline (systolic BP -4.14 mmHg) and with severe oxygen desaturations (minimum arterial oxygen saturation measured by pulse oximetry <77%) at baseline (24-h systolic BP -7.57 mmHg).Although this meta-analysis shows that the expected reduction of BP by CPAP/MADs is modest, it identifies specific characteristics that may predict a pronounced benefit from CPAP in terms of BP control. These findings should be interpreted with caution; however, they are particularly important in identifying potential phenotypes associated with BP reduction in patients treated for OSA.
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Affiliation(s)
- Martino F Pengo
- Dept of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Davide Soranna
- Dept of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy.,These authors are joint co-authors
| | - Alice Giontella
- Section of General Medicine and Hypertension, Dept of Medicine, University of Verona, Verona, Italy.,These authors are joint co-authors
| | - Elisa Perger
- Dept of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Paola Mattaliano
- Dept of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Esther Irene Schwarz
- Dept of Pulmonology and Sleep Disorders Centre, University Hospital of Zurich, Zurich, Switzerland
| | - Carolina Lombardi
- Dept of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Grzegorz Bilo
- Dept of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Antonella Zambon
- Dept of Statistics and Quantitative Methods, Università di Milano-Bicocca, Milan, Italy
| | - Joerg Steier
- CHAPS, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Gianfranco Parati
- Dept of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy.,Dept of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Pietro Minuz
- Section of General Medicine and Hypertension, Dept of Medicine, University of Verona, Verona, Italy
| | - Cristiano Fava
- Section of General Medicine and Hypertension, Dept of Medicine, University of Verona, Verona, Italy
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10
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Cardoso CRL, Roderjan CN, Cavalcanti AH, Cortez AF, Muxfeldt ES, Salles GF. Effects of continuous positive airway pressure treatment on aortic stiffness in patients with resistant hypertension and obstructive sleep apnea: A randomized controlled trial. J Sleep Res 2020; 29:e12990. [DOI: 10.1111/jsr.12990] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 01/06/2020] [Accepted: 01/16/2020] [Indexed: 12/18/2022]
Affiliation(s)
- Claudia R. L. Cardoso
- Department of Internal Medicine School of Medicine University Hospital Clementino Fraga Filho Universidade Federal do Rio de Janeiro Rio de Janeiro Brasil
| | - Christian N. Roderjan
- Department of Internal Medicine School of Medicine University Hospital Clementino Fraga Filho Universidade Federal do Rio de Janeiro Rio de Janeiro Brasil
| | - Aline H. Cavalcanti
- Department of Internal Medicine School of Medicine University Hospital Clementino Fraga Filho Universidade Federal do Rio de Janeiro Rio de Janeiro Brasil
| | - Arthur F. Cortez
- Department of Internal Medicine School of Medicine University Hospital Clementino Fraga Filho Universidade Federal do Rio de Janeiro Rio de Janeiro Brasil
| | - Elizabeth S. Muxfeldt
- Department of Internal Medicine School of Medicine University Hospital Clementino Fraga Filho Universidade Federal do Rio de Janeiro Rio de Janeiro Brasil
| | - Gil F. Salles
- Department of Internal Medicine School of Medicine University Hospital Clementino Fraga Filho Universidade Federal do Rio de Janeiro Rio de Janeiro Brasil
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11
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Theorell-Haglöw J, Hoyos CM, Phillips CL, Yee BJ, Melehan KL, Liu PY, Cistulli PA, Grunstein RR. Associations Between Obstructive Sleep Apnea and Measures of Arterial Stiffness. J Clin Sleep Med 2019; 15:201-206. [PMID: 30736873 DOI: 10.5664/jcsm.7616] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 09/25/2018] [Indexed: 12/12/2022]
Abstract
STUDY OBJECTIVES The aim of this study was to determine whether severity measures of obstructive sleep apnea (OSA) are associated with arterial stiffness and central blood pressure (two important cardiovascular risk factors) in a large group of patients with OSA. METHODS Baseline data from six studies on OSA in which arterial stiffness and central aortic blood pressure measures were determined using applanation tonometry were pooled. Associations between measures of arterial stiffness (heart rate corrected augmentation index [AI75]), central aortic blood pressure (central systolic pressure [CSP] and heart rate corrected central augmentation pressure [CAP75]) and measures of OSA severity were explored using stepwise regression modelling. RESULTS Data from 362 participants (M:F ratio 13:1) with mean (standard deviation) age 49.2 (11.0) years, body mass index 31.9 (5.3) kg/m2, apnea-hypopnea index (AHI) 35.7 (20.7) events/h were included in the analyses. The AHI, oxygen desaturation index (ODI3%), and sleep time with SpO2 < 90% (T90) were all associated with arterial stiffness (AI75), (AHI: adj. β = .069; P = .01; ODI3%: adj. β = .072; P = .01; T90: adj. β = .18; P < .0001) and CAP75 (AHI: adj. β = .030; P = .01; ODI3%: adj. β = .027; P = .02; T90: adj. β = .080; P < .0001). AHI was also associated with CSP (AHI: adj. β = .11; P = .002). CONCLUSIONS OSA severity was significantly associated with augmentation index and CAP75 although the relationships were not strong.
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Affiliation(s)
- Jenny Theorell-Haglöw
- Centre for Sleep and Chronobiology (CIRUS), Woolcock Institute of Medical Research, University of Sydney, New South Wales, Australia.,Uppsala University, Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala, Sweden
| | - Camilla M Hoyos
- Centre for Sleep and Chronobiology (CIRUS), Woolcock Institute of Medical Research, University of Sydney, New South Wales, Australia.,School of Psychology, University of Sydney, New South Wales, Australia
| | - Craig L Phillips
- Centre for Sleep and Chronobiology (CIRUS), Woolcock Institute of Medical Research, University of Sydney, New South Wales, Australia.,Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, New South Wales, Australia
| | - Brendon J Yee
- Centre for Sleep and Chronobiology (CIRUS), Woolcock Institute of Medical Research, University of Sydney, New South Wales, Australia.,Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Kerri L Melehan
- Centre for Sleep and Chronobiology (CIRUS), Woolcock Institute of Medical Research, University of Sydney, New South Wales, Australia.,Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Peter Y Liu
- Division of Endocrinology, Department of Medicine, David Geffen School of Medicine at UCLA, Harbor-UCLA Medical Center and Los Angeles Biomedical Research Institute, Los Angeles, California
| | - Peter A Cistulli
- Centre for Sleep and Chronobiology (CIRUS), Woolcock Institute of Medical Research, University of Sydney, New South Wales, Australia.,Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, New South Wales, Australia.,Sleep Research Group, Charles Perkins Centre, University of Sydney, New South Wales, Australia
| | - Ronald R Grunstein
- Centre for Sleep and Chronobiology (CIRUS), Woolcock Institute of Medical Research, University of Sydney, New South Wales, Australia.,Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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12
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Igami K, Maruyama K, Tomooka K, Ikeda A, Tabara Y, Kohara K, Saito I, Tanigawa T. Relationship between sleep-disordered breathing and central systolic blood pressure in a community-based population: the Toon Health Study. Hypertens Res 2019; 42:1074-1082. [DOI: 10.1038/s41440-019-0219-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 12/30/2018] [Accepted: 01/08/2019] [Indexed: 12/11/2022]
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13
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Is Maxillomandibular Advancement Associated With Comorbidity Reduction in Patients With Obstructive Sleep Apnea? J Oral Maxillofac Surg 2019; 77:1044-1049. [PMID: 30639150 DOI: 10.1016/j.joms.2018.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 11/20/2018] [Accepted: 12/05/2018] [Indexed: 11/22/2022]
Abstract
PURPOSE This study investigated whether patients with documented obstructive sleep apnea (OSA) who have a decrease in apnea-hypopnea index (AHI) score and self-reported symptoms after maxillomandibular advancement (MMA) with genial tubercle advancement (GTA) also have a change in their medical comorbidity profile a minimum of 2 years postoperatively. Changes in the quantity of medical diagnoses, quantity of prescription medications, and average weight and body mass index (BMI) were assessed. PATIENTS AND METHODS This is a retrospective cohort study of patients with a diagnosis of OSA (AHI score >5 on polysomnogram [PSG]) treated at the Massachusetts General Hospital (Boston, MA) with MMA and GTA from 2001 through 2015. Patients were identified through the oral and maxillofacial surgery patient data registry. Inclusion criteria were the availability of complete clinical records and requisite follow-up time. The primary predictor variable was operative status (preoperative or postoperative). The primary outcome variables were comorbidities reported to be associated with OSA and identified in the authors' previous study (J Oral Maxillofac Surg 76:1999.e1, 2018). Two-tailed paired t tests were used for continuous variables and χ2 or Fisher exact tests were used for categorical variables. RESULTS Forty-six patients (39 men, 7 women) met the inclusion criteria. Average weight (206.7 ± 42.4 lb preoperatively; 213.8 ± 41.7 lb postoperatively; P = .014) and average BMI (30.0 ± 5.7 kg/m2 preoperatively; 30.9 ± 5.3 kg/m2 postoperatively; P = .041) significantly increased in patients postoperatively. No meaningful changes in the number of medical diagnoses or number of prescription medications were noted. Stratification of patients by BMI showed significant increases in weight (188.6 ± 21.5 lb preoperatively; 200.1 ± 27.9 lb postoperatively; P = .0085) and BMI (27.1 ± 1.44 kg/m2 preoperatively; 28.9 ± 3.52 kg/m2 postoperatively; P = .013) only in "overweight" patients. No other parameters were found to be relevant. CONCLUSIONS Subjective improvement in OSA symptoms was reported by all patients and objective PSG improvement was reported for 71% of those evaluated. However, no relevant changes in comorbidity profile were found, suggesting that the medical conditions commonly observed with OSA are likely of multifocal etiology.
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14
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Phillips CL, Drager LF. Is obstructive sleep apnoea an innocent bystander in the pathophysiology of arterial stiffening? Thorax 2018; 73:1099-1100. [PMID: 30194093 DOI: 10.1136/thoraxjnl-2018-212332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2018] [Indexed: 11/04/2022]
Affiliation(s)
- Craig L Phillips
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia.,Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Luciano F Drager
- Hypertension Unit, Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil.,Hypertension Unit, Renal Division, University of Sao Paulo Medical School, Sao Paulo, Brazil
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15
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Abstract
PURPOSE OF REVIEW Central blood pressure is a novel predictor of cardiovascular risk that can be measured in the clinical setting using currently available technology. This paper will review current available methods of central blood pressure monitoring as well as its impact in cardiac and renal disease. RECENT FINDINGS Both aortic and carotid systolic blood pressure are independently associated with cardiovascular mortality and serious cardiac events. Furthermore, studies show that systolic aortic blood pressure has been shown to be superior predictor of cardiovascular as compared to brachial blood pressure. Inhibitors of the renin angiotensin axis may have a beneficial effect on central blood pressure; however, long term studies evaluating the impact of lowering central blood pressure on clinical outcomes are lacking. Central blood pressure is a good predictor of cardiovascular risk. As more studies emerge demonstrating the value of central blood pressure as a therapeutic target, it is possible that targeting central blood pressure may become an important part of the armamentarium to lower cardiovascular risk.
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16
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Pengo MF, Bonafini S, Fava C, Steier J. Cardiorespiratory interaction with continuous positive airway pressure. J Thorac Dis 2018; 10:S57-S70. [PMID: 29445529 PMCID: PMC5803058 DOI: 10.21037/jtd.2018.01.39] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 01/09/2018] [Indexed: 12/27/2022]
Abstract
The treatment of choice for obstructive sleep apnoea (OSA) is continuous positive airway pressure therapy (CPAP). Since its introduction in clinical practice, CPAP has been used in various clinical conditions with variable and heterogeneous outcomes. In addition to the well-known effects on the upper airway CPAP impacts on intrathoracic pressures, haemodynamics and blood pressure (BP) control. However, short- and long-term effects of CPAP therapy depend on multiple variables which include symptoms, underlying condition, pressure used, treatment acceptance, compliance and usage. CPAP can alter long-term cardiovascular risk in patients with cardiorespiratory conditions. Furthermore, the effect of CPAP on the awake patient differs from the effect on the patients while asleep, and this might contribute to discomfort and removal of the use interface. The purpose of this review is to highlight the physiological impact of CPAP on the cardiorespiratory system, including short-term benefits and long-term outcomes.
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Affiliation(s)
- Martino F. Pengo
- King’s College London, Faculty of Life Sciences and Medicine, London, UK
- Guy’s and St Thomas’ NHS Foundation Trust, Lane Fox Respiratory Unit/Sleep Disorders Centre, London, UK
| | - Sara Bonafini
- Department of Medicine, General Medicine and Hypertension Unit, University of Verona, Italy
| | - Cristiano Fava
- Department of Medicine, General Medicine and Hypertension Unit, University of Verona, Italy
| | - Joerg Steier
- King’s College London, Faculty of Life Sciences and Medicine, London, UK
- Guy’s and St Thomas’ NHS Foundation Trust, Lane Fox Respiratory Unit/Sleep Disorders Centre, London, UK
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17
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Jain S, Gurubhagavatula I, Townsend R, Kuna ST, Teff K, Wadden TA, Chittams J, Hanlon AL, Maislin G, Saif H, Broderick P, Ahmad Z, Pack AI, Chirinos JA. Effect of CPAP, Weight Loss, or CPAP Plus Weight Loss on Central Hemodynamics and Arterial Stiffness. Hypertension 2017; 70:1283-1290. [PMID: 29038203 PMCID: PMC5726418 DOI: 10.1161/hypertensionaha.117.09392] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 04/03/2017] [Accepted: 08/14/2017] [Indexed: 01/02/2023]
Abstract
Obesity and obstructive sleep apnea tend to coexist. Little is known about the effects of obstructive sleep apnea, obesity, or their treatment on central aortic pressures and large artery stiffness. We randomized 139 adults with obesity (body mass index >30 kg/m2) and moderate-to-severe obstructive sleep apnea to (1) continuous positive airway pressure (CPAP) therapy (n=45), (2) weight loss (WL) therapy (n=48), or (3) combined CPAP and WL (n=46) for 24 weeks. We assessed the effect of these interventions on central pressures and carotid-femoral pulse wave velocity (a measure of large artery stiffness), measured with arterial tonometry. Central systolic pressure was reduced significantly only in the combination arm (-7.4 mm Hg; 95% confidence interval, -12.5 to -2.4 mm Hg; P=0.004), without significant reductions detected in either the WL-only (-2.3 mm Hg; 95% confidence interval, -7.5 to 3.0; P=0.39) or the CPAP-only (-3.1 mm Hg; 95% confidence interval, -8.3 to 2.0; P=0.23) arms. However, none of these interventions significantly changed central pulse pressure, pulse pressure amplification, or the central augmentation index. The change in mean arterial pressure (P=0.008) and heart rate (P=0.027) induced by the interventions was significant predictors of the change in carotid-femoral pulse wave velocity. However, after adjustment for mean arterial pressure and heart rate, no significant changes in carotid-femoral pulse wave velocity were observed in any group. In obese subjects with obstructive sleep apnea, combination therapy with WL and CPAP is effective in reducing central systolic pressure. However, this effect is largely mediated by changes in mean, rather than central pulse pressure. WL and CPAP, alone or in combination, did not reduce large artery stiffness in this population. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00371293.
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Affiliation(s)
- Snigdha Jain
- From the Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX (S.J.); Divisions of Sleep Medicine (I.G., G.M., S.T.K, A.I.P.), Nephrology (R.T) and Cardiovascular Medicine (J.A.C., Z.A.), Department of Medicine and Center for Weight and Eating Disorders, Department of Psychiatry (T.A.W), University of Pennsylvania Perelman School of Medicine, Philadelphia; Hospital of University of Pennsylvania, Philadelphia (R.T., S.T.K., T.A.W., A.I.P., J.A.C.); Corporal Michael Crescenz VA Medical Center, Philadelphia, PA (I.G.); Division of Diabetes, National Institutes of Health, Bethesda, MD (K.T.); Departments of Biostatistics Consulting Unit (J.C.) and Family and Community Health, (A.L.H.), School of Nursing, University of Pennsylvania, Philadelphia; Department of Cardiology, Lehigh Valley Health Network, Allentown, PA (H.S.); and Johns Hopkins University Technology and Innovation Center, Johns Hopkins University, Baltimore, MD (P.B.)
| | - Indira Gurubhagavatula
- From the Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX (S.J.); Divisions of Sleep Medicine (I.G., G.M., S.T.K, A.I.P.), Nephrology (R.T) and Cardiovascular Medicine (J.A.C., Z.A.), Department of Medicine and Center for Weight and Eating Disorders, Department of Psychiatry (T.A.W), University of Pennsylvania Perelman School of Medicine, Philadelphia; Hospital of University of Pennsylvania, Philadelphia (R.T., S.T.K., T.A.W., A.I.P., J.A.C.); Corporal Michael Crescenz VA Medical Center, Philadelphia, PA (I.G.); Division of Diabetes, National Institutes of Health, Bethesda, MD (K.T.); Departments of Biostatistics Consulting Unit (J.C.) and Family and Community Health, (A.L.H.), School of Nursing, University of Pennsylvania, Philadelphia; Department of Cardiology, Lehigh Valley Health Network, Allentown, PA (H.S.); and Johns Hopkins University Technology and Innovation Center, Johns Hopkins University, Baltimore, MD (P.B.)
| | - Raymond Townsend
- From the Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX (S.J.); Divisions of Sleep Medicine (I.G., G.M., S.T.K, A.I.P.), Nephrology (R.T) and Cardiovascular Medicine (J.A.C., Z.A.), Department of Medicine and Center for Weight and Eating Disorders, Department of Psychiatry (T.A.W), University of Pennsylvania Perelman School of Medicine, Philadelphia; Hospital of University of Pennsylvania, Philadelphia (R.T., S.T.K., T.A.W., A.I.P., J.A.C.); Corporal Michael Crescenz VA Medical Center, Philadelphia, PA (I.G.); Division of Diabetes, National Institutes of Health, Bethesda, MD (K.T.); Departments of Biostatistics Consulting Unit (J.C.) and Family and Community Health, (A.L.H.), School of Nursing, University of Pennsylvania, Philadelphia; Department of Cardiology, Lehigh Valley Health Network, Allentown, PA (H.S.); and Johns Hopkins University Technology and Innovation Center, Johns Hopkins University, Baltimore, MD (P.B.)
| | - Samuel T Kuna
- From the Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX (S.J.); Divisions of Sleep Medicine (I.G., G.M., S.T.K, A.I.P.), Nephrology (R.T) and Cardiovascular Medicine (J.A.C., Z.A.), Department of Medicine and Center for Weight and Eating Disorders, Department of Psychiatry (T.A.W), University of Pennsylvania Perelman School of Medicine, Philadelphia; Hospital of University of Pennsylvania, Philadelphia (R.T., S.T.K., T.A.W., A.I.P., J.A.C.); Corporal Michael Crescenz VA Medical Center, Philadelphia, PA (I.G.); Division of Diabetes, National Institutes of Health, Bethesda, MD (K.T.); Departments of Biostatistics Consulting Unit (J.C.) and Family and Community Health, (A.L.H.), School of Nursing, University of Pennsylvania, Philadelphia; Department of Cardiology, Lehigh Valley Health Network, Allentown, PA (H.S.); and Johns Hopkins University Technology and Innovation Center, Johns Hopkins University, Baltimore, MD (P.B.)
| | - Karen Teff
- From the Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX (S.J.); Divisions of Sleep Medicine (I.G., G.M., S.T.K, A.I.P.), Nephrology (R.T) and Cardiovascular Medicine (J.A.C., Z.A.), Department of Medicine and Center for Weight and Eating Disorders, Department of Psychiatry (T.A.W), University of Pennsylvania Perelman School of Medicine, Philadelphia; Hospital of University of Pennsylvania, Philadelphia (R.T., S.T.K., T.A.W., A.I.P., J.A.C.); Corporal Michael Crescenz VA Medical Center, Philadelphia, PA (I.G.); Division of Diabetes, National Institutes of Health, Bethesda, MD (K.T.); Departments of Biostatistics Consulting Unit (J.C.) and Family and Community Health, (A.L.H.), School of Nursing, University of Pennsylvania, Philadelphia; Department of Cardiology, Lehigh Valley Health Network, Allentown, PA (H.S.); and Johns Hopkins University Technology and Innovation Center, Johns Hopkins University, Baltimore, MD (P.B.)
| | - Thomas A Wadden
- From the Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX (S.J.); Divisions of Sleep Medicine (I.G., G.M., S.T.K, A.I.P.), Nephrology (R.T) and Cardiovascular Medicine (J.A.C., Z.A.), Department of Medicine and Center for Weight and Eating Disorders, Department of Psychiatry (T.A.W), University of Pennsylvania Perelman School of Medicine, Philadelphia; Hospital of University of Pennsylvania, Philadelphia (R.T., S.T.K., T.A.W., A.I.P., J.A.C.); Corporal Michael Crescenz VA Medical Center, Philadelphia, PA (I.G.); Division of Diabetes, National Institutes of Health, Bethesda, MD (K.T.); Departments of Biostatistics Consulting Unit (J.C.) and Family and Community Health, (A.L.H.), School of Nursing, University of Pennsylvania, Philadelphia; Department of Cardiology, Lehigh Valley Health Network, Allentown, PA (H.S.); and Johns Hopkins University Technology and Innovation Center, Johns Hopkins University, Baltimore, MD (P.B.)
| | - Jesse Chittams
- From the Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX (S.J.); Divisions of Sleep Medicine (I.G., G.M., S.T.K, A.I.P.), Nephrology (R.T) and Cardiovascular Medicine (J.A.C., Z.A.), Department of Medicine and Center for Weight and Eating Disorders, Department of Psychiatry (T.A.W), University of Pennsylvania Perelman School of Medicine, Philadelphia; Hospital of University of Pennsylvania, Philadelphia (R.T., S.T.K., T.A.W., A.I.P., J.A.C.); Corporal Michael Crescenz VA Medical Center, Philadelphia, PA (I.G.); Division of Diabetes, National Institutes of Health, Bethesda, MD (K.T.); Departments of Biostatistics Consulting Unit (J.C.) and Family and Community Health, (A.L.H.), School of Nursing, University of Pennsylvania, Philadelphia; Department of Cardiology, Lehigh Valley Health Network, Allentown, PA (H.S.); and Johns Hopkins University Technology and Innovation Center, Johns Hopkins University, Baltimore, MD (P.B.)
| | - Alexandra L Hanlon
- From the Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX (S.J.); Divisions of Sleep Medicine (I.G., G.M., S.T.K, A.I.P.), Nephrology (R.T) and Cardiovascular Medicine (J.A.C., Z.A.), Department of Medicine and Center for Weight and Eating Disorders, Department of Psychiatry (T.A.W), University of Pennsylvania Perelman School of Medicine, Philadelphia; Hospital of University of Pennsylvania, Philadelphia (R.T., S.T.K., T.A.W., A.I.P., J.A.C.); Corporal Michael Crescenz VA Medical Center, Philadelphia, PA (I.G.); Division of Diabetes, National Institutes of Health, Bethesda, MD (K.T.); Departments of Biostatistics Consulting Unit (J.C.) and Family and Community Health, (A.L.H.), School of Nursing, University of Pennsylvania, Philadelphia; Department of Cardiology, Lehigh Valley Health Network, Allentown, PA (H.S.); and Johns Hopkins University Technology and Innovation Center, Johns Hopkins University, Baltimore, MD (P.B.)
| | - Greg Maislin
- From the Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX (S.J.); Divisions of Sleep Medicine (I.G., G.M., S.T.K, A.I.P.), Nephrology (R.T) and Cardiovascular Medicine (J.A.C., Z.A.), Department of Medicine and Center for Weight and Eating Disorders, Department of Psychiatry (T.A.W), University of Pennsylvania Perelman School of Medicine, Philadelphia; Hospital of University of Pennsylvania, Philadelphia (R.T., S.T.K., T.A.W., A.I.P., J.A.C.); Corporal Michael Crescenz VA Medical Center, Philadelphia, PA (I.G.); Division of Diabetes, National Institutes of Health, Bethesda, MD (K.T.); Departments of Biostatistics Consulting Unit (J.C.) and Family and Community Health, (A.L.H.), School of Nursing, University of Pennsylvania, Philadelphia; Department of Cardiology, Lehigh Valley Health Network, Allentown, PA (H.S.); and Johns Hopkins University Technology and Innovation Center, Johns Hopkins University, Baltimore, MD (P.B.)
| | - Hassam Saif
- From the Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX (S.J.); Divisions of Sleep Medicine (I.G., G.M., S.T.K, A.I.P.), Nephrology (R.T) and Cardiovascular Medicine (J.A.C., Z.A.), Department of Medicine and Center for Weight and Eating Disorders, Department of Psychiatry (T.A.W), University of Pennsylvania Perelman School of Medicine, Philadelphia; Hospital of University of Pennsylvania, Philadelphia (R.T., S.T.K., T.A.W., A.I.P., J.A.C.); Corporal Michael Crescenz VA Medical Center, Philadelphia, PA (I.G.); Division of Diabetes, National Institutes of Health, Bethesda, MD (K.T.); Departments of Biostatistics Consulting Unit (J.C.) and Family and Community Health, (A.L.H.), School of Nursing, University of Pennsylvania, Philadelphia; Department of Cardiology, Lehigh Valley Health Network, Allentown, PA (H.S.); and Johns Hopkins University Technology and Innovation Center, Johns Hopkins University, Baltimore, MD (P.B.)
| | - Preston Broderick
- From the Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX (S.J.); Divisions of Sleep Medicine (I.G., G.M., S.T.K, A.I.P.), Nephrology (R.T) and Cardiovascular Medicine (J.A.C., Z.A.), Department of Medicine and Center for Weight and Eating Disorders, Department of Psychiatry (T.A.W), University of Pennsylvania Perelman School of Medicine, Philadelphia; Hospital of University of Pennsylvania, Philadelphia (R.T., S.T.K., T.A.W., A.I.P., J.A.C.); Corporal Michael Crescenz VA Medical Center, Philadelphia, PA (I.G.); Division of Diabetes, National Institutes of Health, Bethesda, MD (K.T.); Departments of Biostatistics Consulting Unit (J.C.) and Family and Community Health, (A.L.H.), School of Nursing, University of Pennsylvania, Philadelphia; Department of Cardiology, Lehigh Valley Health Network, Allentown, PA (H.S.); and Johns Hopkins University Technology and Innovation Center, Johns Hopkins University, Baltimore, MD (P.B.)
| | - Zeshan Ahmad
- From the Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX (S.J.); Divisions of Sleep Medicine (I.G., G.M., S.T.K, A.I.P.), Nephrology (R.T) and Cardiovascular Medicine (J.A.C., Z.A.), Department of Medicine and Center for Weight and Eating Disorders, Department of Psychiatry (T.A.W), University of Pennsylvania Perelman School of Medicine, Philadelphia; Hospital of University of Pennsylvania, Philadelphia (R.T., S.T.K., T.A.W., A.I.P., J.A.C.); Corporal Michael Crescenz VA Medical Center, Philadelphia, PA (I.G.); Division of Diabetes, National Institutes of Health, Bethesda, MD (K.T.); Departments of Biostatistics Consulting Unit (J.C.) and Family and Community Health, (A.L.H.), School of Nursing, University of Pennsylvania, Philadelphia; Department of Cardiology, Lehigh Valley Health Network, Allentown, PA (H.S.); and Johns Hopkins University Technology and Innovation Center, Johns Hopkins University, Baltimore, MD (P.B.)
| | - Allan I Pack
- From the Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX (S.J.); Divisions of Sleep Medicine (I.G., G.M., S.T.K, A.I.P.), Nephrology (R.T) and Cardiovascular Medicine (J.A.C., Z.A.), Department of Medicine and Center for Weight and Eating Disorders, Department of Psychiatry (T.A.W), University of Pennsylvania Perelman School of Medicine, Philadelphia; Hospital of University of Pennsylvania, Philadelphia (R.T., S.T.K., T.A.W., A.I.P., J.A.C.); Corporal Michael Crescenz VA Medical Center, Philadelphia, PA (I.G.); Division of Diabetes, National Institutes of Health, Bethesda, MD (K.T.); Departments of Biostatistics Consulting Unit (J.C.) and Family and Community Health, (A.L.H.), School of Nursing, University of Pennsylvania, Philadelphia; Department of Cardiology, Lehigh Valley Health Network, Allentown, PA (H.S.); and Johns Hopkins University Technology and Innovation Center, Johns Hopkins University, Baltimore, MD (P.B.)
| | - Julio A Chirinos
- From the Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX (S.J.); Divisions of Sleep Medicine (I.G., G.M., S.T.K, A.I.P.), Nephrology (R.T) and Cardiovascular Medicine (J.A.C., Z.A.), Department of Medicine and Center for Weight and Eating Disorders, Department of Psychiatry (T.A.W), University of Pennsylvania Perelman School of Medicine, Philadelphia; Hospital of University of Pennsylvania, Philadelphia (R.T., S.T.K., T.A.W., A.I.P., J.A.C.); Corporal Michael Crescenz VA Medical Center, Philadelphia, PA (I.G.); Division of Diabetes, National Institutes of Health, Bethesda, MD (K.T.); Departments of Biostatistics Consulting Unit (J.C.) and Family and Community Health, (A.L.H.), School of Nursing, University of Pennsylvania, Philadelphia; Department of Cardiology, Lehigh Valley Health Network, Allentown, PA (H.S.); and Johns Hopkins University Technology and Innovation Center, Johns Hopkins University, Baltimore, MD (P.B.).
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18
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Shao L, Heizhati M, Yao X, Wang Y, Abulikemu S, Zhang D, Zhou L, Hong J, Li N. Influences of obstructive sleep apnea on blood pressure variability might not be limited only nocturnally in middle-aged hypertensive males. Sleep Breath 2017; 22:377-384. [PMID: 29150775 DOI: 10.1007/s11325-017-1571-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 08/11/2017] [Accepted: 09/11/2017] [Indexed: 01/26/2023]
Abstract
PURPOSE In this cross-sectional study, we analyzed the potential association between sleep measures and blood pressure variability. METHODS Ninety-three middle-aged hypertensive males, who underwent polysomnography and 24-h ambulatory blood pressure monitoring, were enrolled. Blood pressure variability was assessed by blood pressure standard deviation. Obstructive sleep apnea (apnea hypopnea index ≥ 15) was diagnosed in 52 (55.91%) patients. Mean body mass index and age were 27.77 ± 3.11 kg/m2 and 44.05 ± 8.07 years, respectively. RESULTS Hypertensive males with obstructive sleep apnea showed significantly higher 24-h, diurnal, and nocturnal diastolic blood pressure variability, compared to those without obstructive sleep apnea. While total cohort was further divided into two groups using the median of oxygen desaturation index, another indicator for severity of OSA, significant differences were also observed in 24-h, diurnal, and nocturnal diastolic blood pressure variability between two groups with higher and lower oxygen desaturation index. While subjects were also divided into two groups via the mean of sleep stage 1, hypertensive males with sleep stage 1 ≥ 8.1% showed significantly higher diurnal diastolic blood pressure variability than those with sleep stage 1 < 8.1%. Apnea hypopnea index was independently associated with 24-h and nocturnal diastolic blood pressure variability; oxygen desaturation index of 3% with 24-h diastolic, diurnal, and nocturnal diastolic blood pressure; and sleep stage 1 was with 24-h and with diurnal diastolic blood pressure variability in all study subjects. CONCLUSION Effects of obstructive sleep apnea on blood pressure variability may not be limited nocturnally.
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Affiliation(s)
- Liang Shao
- The Center of Hypertension of the People's Hospital of Xinjiang Uygur Autonomous Region China, The Center of Diagnosis, Treatment and Research of Hypertension in Xinjiang China, No. 91 Tianchi Road, Tianshan District, Urumqi, Xinjiang, 830001, China
| | - Mulalibieke Heizhati
- The Center of Hypertension of the People's Hospital of Xinjiang Uygur Autonomous Region China, The Center of Diagnosis, Treatment and Research of Hypertension in Xinjiang China, No. 91 Tianchi Road, Tianshan District, Urumqi, Xinjiang, 830001, China
| | - Xiaoguang Yao
- The Center of Hypertension of the People's Hospital of Xinjiang Uygur Autonomous Region China, The Center of Diagnosis, Treatment and Research of Hypertension in Xinjiang China, No. 91 Tianchi Road, Tianshan District, Urumqi, Xinjiang, 830001, China
| | - Yingchun Wang
- The Center of Hypertension of the People's Hospital of Xinjiang Uygur Autonomous Region China, The Center of Diagnosis, Treatment and Research of Hypertension in Xinjiang China, No. 91 Tianchi Road, Tianshan District, Urumqi, Xinjiang, 830001, China
| | - Suofeiya Abulikemu
- The Center of Hypertension of the People's Hospital of Xinjiang Uygur Autonomous Region China, The Center of Diagnosis, Treatment and Research of Hypertension in Xinjiang China, No. 91 Tianchi Road, Tianshan District, Urumqi, Xinjiang, 830001, China
| | - Delian Zhang
- The Center of Hypertension of the People's Hospital of Xinjiang Uygur Autonomous Region China, The Center of Diagnosis, Treatment and Research of Hypertension in Xinjiang China, No. 91 Tianchi Road, Tianshan District, Urumqi, Xinjiang, 830001, China
| | - Ling Zhou
- The Center of Hypertension of the People's Hospital of Xinjiang Uygur Autonomous Region China, The Center of Diagnosis, Treatment and Research of Hypertension in Xinjiang China, No. 91 Tianchi Road, Tianshan District, Urumqi, Xinjiang, 830001, China
| | - Jing Hong
- The Center of Hypertension of the People's Hospital of Xinjiang Uygur Autonomous Region China, The Center of Diagnosis, Treatment and Research of Hypertension in Xinjiang China, No. 91 Tianchi Road, Tianshan District, Urumqi, Xinjiang, 830001, China
| | - Nanfang Li
- The Center of Hypertension of the People's Hospital of Xinjiang Uygur Autonomous Region China, The Center of Diagnosis, Treatment and Research of Hypertension in Xinjiang China, No. 91 Tianchi Road, Tianshan District, Urumqi, Xinjiang, 830001, China.
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19
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Yu J, Zhou Z, McEvoy RD, Anderson CS, Rodgers A, Perkovic V, Neal B. Association of Positive Airway Pressure With Cardiovascular Events and Death in Adults With Sleep Apnea: A Systematic Review and Meta-analysis. JAMA 2017; 318:156-166. [PMID: 28697252 PMCID: PMC5541330 DOI: 10.1001/jama.2017.7967] [Citation(s) in RCA: 245] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE Sleep apnea (obstructive and central) is associated with adverse cardiovascular risk factors and increased risks of cardiovascular disease. Positive airway pressure (PAP) provides symptomatic relief, whether delivered continuously (CPAP) or as adaptive servo-ventilation (ASV), but the associations with cardiovascular outcomes and death are unclear. OBJECTIVE To assess the association of PAP vs control with cardiovascular events and death in patients with sleep apnea. DATA SOURCES AND STUDY SELECTION MEDLINE, EMBASE, and the Cochrane Library were systematically searched from inception date to March 2017 for randomized clinical trials that included reporting of major adverse cardiovascular events or deaths. DATA EXTRACTION AND SYNTHESIS Two authors independently extracted data using standardized forms. Summary relative risks (RRs), risk differences (RDs) and 95% CIs were obtained using random-effects meta-analysis. MAIN OUTCOMES AND MEASURES The main outcomes were a composite of acute coronary syndrome (ACS) events, stroke, or vascular death (major adverse cardiovascular events); cause-specific vascular events; and death. RESULTS The analyses included data from 10 trials (9 CPAP; 1 ASV) of patients with sleep apnea (N = 7266; mean age, 60.9 [range, 51.5 to 71.1] years; 5847 [80.5%] men; mean [SD] body mass index, 30.0 [5.2]. Among 356 major adverse cardiovascular events and 613 deaths recorded, there was no significant association of PAP with major adverse cardiovascular events (RR, 0.77 [95% CI, 0.53 to 1.13]; P = .19 and RD, -0.01 [95% CI, -0.03 to 0.01]; P = .23), cardiovascular death (RR, 1.15 [95% CI, 0.88 to 1.50]; P = .30 and RD -0.00 [95% CI, -0.02 to 0.02]; P = .87), or all-cause death (RR, 1.13 [95% CI, 0.99 to 1.29]; P = .08 and RD, 0.00 [95% CI, -0.01 to 0.01]; P = .51). The same was true for ACS, stroke, and heart failure. There was no evidence of different associations for CPAP vs ASV (all P value homogeneity >.24), and meta-regressions identified no associations of PAP with outcomes for different levels of apnea severity, follow-up duration, or adherence to PAP (all P values > .13). CONCLUSIONS AND RELEVANCE The use of PAP, compared with no treatment or sham, was not associated with reduced risks of cardiovascular outcomes or death for patients with sleep apnea. Although there are other benefits of treatment with PAP for sleep apnea, these findings do not support treatment with PAP with a goal of prevention of these outcomes.
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Affiliation(s)
- Jie Yu
- Department of Cardiology, Peking University Third Hospital, Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health, Key Laboratory of Molecular Cardiovascular Sciences, Ministry of Education, Beijing, People’s Republic of China
- The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, New South Wales, Australia
| | - Zien Zhou
- The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, New South Wales, Australia
- Department of Radiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - R. Doug McEvoy
- Adelaide Institute for Sleep Health, Flinders University, Adelaide, South Australia, Australia
| | - Craig S. Anderson
- The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, New South Wales, Australia
- The George Institute China, Peking University Health Science Center, Beijing, People’s Republic of China
- Neurology Department, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, New South Wales, Australia
| | - Anthony Rodgers
- The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, New South Wales, Australia
| | - Vlado Perkovic
- The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, New South Wales, Australia
| | - Bruce Neal
- The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, New South Wales, Australia
- The Charles Perkins Centre, University of Sydney, Sydney, New South Wales, Australia
- Division of Epidemiology and Biostatistics, Imperial College London, London, United Kingdom
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20
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Abstract
Emerging evidence has assigned an important role to sleep as a modulator of metabolic homeostasis. The impact of variations in sleep duration, sleep-disordered breathing, and chronotype to cardiometabolic function encompasses a wide array of perturbations spanning from obesity, insulin resistance, type 2 diabetes, the metabolic syndrome, and cardiovascular disease risk and mortality in both adults and children. Here, we critically and extensively review the published literature on such important issues and provide a comprehensive overview of the most salient pathophysiologic pathways underlying the links between sleep, sleep disorders, and cardiometabolic functioning.
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Affiliation(s)
- Dorit Koren
- Section of Adult and Pediatric Endocrinology, Diabetes, and Metabolism, Department of Medicine
- Section of Pediatric Sleep Medicine
| | - Magdalena Dumin
- Section of Adult and Pediatric Endocrinology, Diabetes, and Metabolism, Department of Medicine
| | - David Gozal
- Section of Pediatric Sleep Medicine
- Section of Pulmonology, Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division, The University of Chicago, Chicago, IL, USA
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21
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Paz Y Mar HL, Hazen SL, Tracy RP, Strohl KP, Auckley D, Bena J, Wang L, Walia HK, Patel SR, Mehra R. Effect of Continuous Positive Airway Pressure on Cardiovascular Biomarkers: The Sleep Apnea Stress Randomized Controlled Trial. Chest 2016; 150:80-90. [PMID: 26997243 DOI: 10.1016/j.chest.2016.03.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 02/26/2016] [Accepted: 03/01/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Although existing research highlights the relationship of OSA and cardiovascular disease, the effect of OSA treatment on cardiovascular biomarkers remains unclear. We evaluated the effect of OSA treatment on oxidative stress/inflammation measures. METHODS We conducted a parallel, randomized controlled trial in moderate to severe OSA (apnea-hypopnea index ≥ 15) patients to examine effects of 2-month CPAP vs sham-CPAP on the primary outcome of oxidative stress/inflammation (F2-isoprostanes: ng/mg) and myeloperoxidase: pmol/L) and secondary oxidative stress measures. Exploratory secondary analyses included vascular and systemic inflammation markers. Linear models adjusted for baseline values examined effect of CPAP on biomarker change (least squares means, 95% CI) including secondary stratified analyses examining CPAP adherence and degree of hypoxia. RESULTS Of 153 participants, 76 were randomized to CPAP and 77 to sham-CPAP. In an intent-to-treat analyses, no significant change was observed in the sham and CPAP groups respectively: F2-isoprostanes (-0.02 [-0.12 to 0.10] vs -0.08 [-0.18 to 0.03]) or myeloperoxidase (-3.33 [-17.02 to 10.37] vs -5.15 [-18.65 to 8.35]), nor other oxidative markers; findings that persisted in analyses stratified by adherence and hypoxia. Exploratory analyses revealed percentage reduction of soluble IL-6 receptor (ng/mL) levels (-0.04 [-0.08 to -0.01] vs 0.02 [-0.02 to 0.06], P = .019) and augmentation index (%) (-6.49 [-9.32 to -3.65] vs 0.44 [-2.22 to 3.10], P < .001) with CPAP compared with sham, respectively. CONCLUSIONS In moderate to severe OSA, 2-month CPAP vs sham did not reduce oxidative stress despite consideration of a broad range of measures, positive airway pressure adherence, and hypoxia burden. These findings suggest that nonoxidative stress pathways primarily modulate OSA-related cardiovascular consequences. TRIAL REGISTRATION ClinicalTrials.govNCT00607893.
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Affiliation(s)
- Hugo L Paz Y Mar
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Stanley L Hazen
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Russell P Tracy
- Departments of Biochemistry and Pathology, University of Vermont, Burlington, VT
| | - Kingman P Strohl
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH
| | - Dennis Auckley
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, MetroHealth Medical Center, Cleveland, OH
| | - James Bena
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Lu Wang
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Harneet K Walia
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Sanjay R Patel
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Reena Mehra
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, OH; Department of Molecular Cardiology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH.
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22
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Effect of CPAP therapy on cardiovascular events and mortality in patients with obstructive sleep apnea: a meta-analysis. Sleep Breath 2016; 20:965-74. [PMID: 26873722 DOI: 10.1007/s11325-016-1319-y] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 01/18/2016] [Accepted: 02/01/2016] [Indexed: 01/12/2023]
Abstract
PURPOSE Continuous positive airway pressure (CPAP) therapy may decrease the risk of mortality and cardiovascular events in patients with obstructive sleep apnea. However, these benefits are not completely clear. METHODS We undertook a meta-analysis of randomized clinical trials identified in systematic searches of MEDLINE, EMBASE, and the Cochrane Database. RESULTS Eighteen studies (4146 patients) were included. Overall, CPAP therapy did not significantly decrease the risk of cardiovascular events compared with the control group (odds ratio (OR), 0.84; 95 % confidence intervals (CI), 0.62-1.13; p = 0.25; I (2) = 0 %). CPAP was associated with a nonsignificant trend of lower rate of death and stroke (for death: OR, 0.85; 95 % CI, 0.35-2.06; p = 0.72; I (2) = 0.0 %; for stroke: OR, 0.56; 95 % CI, 0.18-1.73; p = 0.32; I (2) = 12.0 %), a significantly lower Epworth sleepiness score (ESS) (mean difference (MD), -1.78; 95 % CI, -2.31 to -1.24; p < 0.00001; I (2) = 76 %), and a significantly lower 24 h systolic and diastolic blood pressure (BP) (for 24 h systolic BP: MD, -2.03 mmHg; 95 % CI, -3.64 to -0.42; p = 0.01; I (2) = 0 %; for diastolic BP: MD, -1.79 mmHg; 95 % CI, -2.89 to -0.68; p = 0.001; I (2) = 0 %). Daytime systolic BP and body mass index were comparable between the CPAP and control groups. Subgroup analysis did not show any significant difference between short- and mediate-to-long-term follow-up groups with regard to cardiovascular events, death, and stroke. CONCLUSIONS CPAP therapy was associated with a trend of decreased risk of cardiovascular events. Furthermore, ESS and BP were significantly lower in the CPAP group. Larger randomized studies are needed to confirm these findings.
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