The relationship between obstructive sleep apnoea and coronary heart disease

Validation of NoSAS score for the screening of obstructive sleep apnea

Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder (SBD) characterized by the repetitive collapse of the upper airway during sleep. The aim of the present study was to validate the Neck circumference, Obesity, Snoring, Age, Sex (NoSAS) score in a sample population and to compare its validity for OSA screening, with that of the Berlin questionnaire, STOP-BANG questionnaire and Epworth Sleepiness Scale (ESS). A retrospective analysis was conducted on individuals, aged 18 to 80 years, who reported symptoms indicating SBD and were examined with full-night polysomnography (PSG) at a sleep center. Demographics, anthropometric parameters, comorbidities, ESS, STOP-BANG questionnaire, Berlin questionnaire and PSG data were obtained from the recorded data of the patients. The NoSAS score was determined using the recorded data. A total of 347 participants were enrolled in the study. The NoSAS scores identified individuals with OSA, with an area under the curve (AUC) of 0.774. The NoSAS score performed significantly better than the Berlin questionnaire (AUC 0.617) and the ESS (AUC 0.642), and similarly to STOP-BANG (AUC 0.777) for OSA screening. Using a NoSAS score >7 to predict OSA, the sensitivity and specificity were 85.6 and 50%, respectively; using the STOP-BANG questionnaire, for a score >2, the values were 98.32 and 22% respectively; using the Berlin questionnaire for >1 positive categories, the values were 93.6 and 20%, and using the ESS, for a score >10, the values were 30.3% and 72%, respectively. On the whole, the present study demonstrates that the NoSAS score is a simple, efficient and easy method for screening OSA in the clinical setting. The NoSAS score performs significantly more efficiently than the Berlin questionnaire and ESS, and similarly to STOP-BANG questionnaire for OSA screening.

Information-Based Similarity of Ordinal Pattern Sequences as a Novel Descriptor in Obstructive Sleep Apnea Screening Based on Wearable Photoplethysmography Bracelets

Obstructive sleep apnea (OSA) is a common respiratory disorder associated with autonomic nervous system (ANS) dysfunction, resulting in abnormal heart rate variability (HRV). Capable of acquiring heart rate (HR) information with more convenience, wearable photoplethysmography (PPG) bracelets are proven to be a potential surrogate for electrocardiogram (ECG)-based devices. Meanwhile, bracelet-type PPG has been heavily marketed and widely accepted. This study aims to investigate the algorithm that can identify OSA with wearable devices. The information-based similarity of ordinal pattern sequences (OP_IBS), which is a modified version of the information-based similarity (IBS), has been proposed as a novel index to detect OSA based on wearable PPG signals. A total of 92 PPG recordings (29 normal subjects, 39 mild-moderate OSA subjects and 24 severe OSA subjects) were included in this study. OP_IBS along with classical indices were calculated. For severe OSA detection, the accuracy of OP_IBS was 85.9%, much higher than that of the low-frequency power to high-frequency power ratio (70.7%). The combination of OP_IBS, IBS, CV and LF/HF can achieve 91.3% accuracy, 91.0% sensitivity and 91.5% specificity. The performance of OP_IBS is significantly improved compared with our previous study based on the same database with the IBS method. In the Physionet database, OP_IBS also performed exceptionally well with an accuracy of 91.7%. This research shows that the OP_IBS method can access the HR dynamics of OSA subjects and help diagnose OSA in clinical environments.

Associations of Chronic Diabetes Complications and Cardiovascular Risk with the Risk of Obstructive Sleep Apnea in Patients with Type 2 Diabetes

Background: Type 2 diabetes mellitus (T2DM) is associated with increased mortality and morbidity, including cardiovascular diseases and obstructive sleep apnea (OSA). The aim of this study was to assess the associations between cardiovascular risk, chronic diabetes complications and the risk of OSA in adult patients with T2DM. Methods: The study included 529 patients with T2DM in whom moderate-to-severe OSA risk was assessed using the STOP-Bang questionnaire, dividing the subjects into two groups: group 1: STOP-Bang score <5, and group 2: STOP-Bang score ≥5, respectively. In all the subjects, cardiovascular risk was assessed using the UKPDS risk engine. Statistical analysis was performed using SPSS 26.0, the results being statistically significant if p value was <0.05. Results: 59% of the subjects scored ≥5 on the STOP-Bang questionnaire. We recorded statistically significant differences between the two groups regarding diabetes duration, HbA1c, HOMA-IR, albuminuria, as well as cardiovascular risk at 10 years for both coronary heart disease (CHD) and stroke (p < 0.05). Furthermore, through logistic regression, adjusting for confounding factors, we demonstrated that the STOP-Bang score ≥ 5 is a risk factor for 10-year fatal and nonfatal CHD risk. Conclusions: It is extremely important to screen and diagnose OSA in patients with T2DM, in order to improve the primary and secondary prevention of cardiovascular events in these patients.

To Analyze the Influencing Factors of Senile Coronary Heart Disease Patients Complicated with Frailty Syndrome

To analyze the influencing factors of senile coronary heart disease patients complicated with frailty syndrome. A total of 80 elderly patients with coronary heart disease admitted to our hospital from March 2020 to March 2021 were selected as the research subjects. The Fried Frailty Symptom Scale was used to evaluate whether the 80 patients were complicated with frailty syndrome. According to the evaluation results, the patients were divided into a nonfrailty syndrome group (52 cases in total) and frailty syndrome group (28 cases in total). Clinical data of two groups of patients were collected, and multivariate logistic regression was used to analyze the influencing factors of senile coronary heart disease patients complicated with frailty syndrome. Among 80 patients, the incidence of frailty syndrome was 35.00% (28/80), including 18 cases in early frailty and 10 cases in frailty stage. Univariate analysis showed that age, body mass (BMI), diabetes mellitus, congestive heart failure, chronic renal insufficiency, chronic obstructive pulmonary disease (COPD), tumor, high uric acid hematic disease, arrhythmia, interleukin-6 (IL-6), c-reactive protein (CRP), fibrinogen (FIB), brain natriuretic peptide (BNP), uric acid (UA), serum creatinine (Scr), serum protein (ALB), white blood cell count (WBC), and neutrophil count were the possible risk factors for senile coronary heart disease complicated with frailty syndrome (P < 0.05). Multivariate logistic regression analysis showed that combined COPD, combined tumor, IL-6, BNP, UA, SCR, ALB, and neutrophil count were independent risk factors for senile CHD complicated with frailty syndrome (P < 0.05). Combined with COPD, combined with tumor, IL-6, BNP, UA, SCR, ALB, and neutron cell count are the influencing factors for senile coronary heart disease patients complicated with frailty syndrome. These factors can be used as the basis for the diagnosis of frailty syndrome and guide the clinical development of targeted diagnosis and treatment plan.

Cardiovascular Complications of Sleep Disorders: A Better Night's Sleep for a Healthier Heart / From Bench to Bedside

Sleep is essential to and an integral part of life and when lacking or disrupted, a multitude of mental and physical pathologies ensue, including cardiovascular (CV) disease, which increases health care costs. Several prospective studies and meta-analyses show that insomnia, short (<7h) or long (>9h) sleep and other sleep disorders are associated with an increased risk of hypertension, metabolic syndrome, myocardial infarction, heart failure, arrhythmias, CV disease risk and/or mortality. The mechanisms by which insomnia and other sleep disorders lead to increased CV risk may encompass inflammatory, immunological, neuro-autonomic, endocrinological, genetic and microbiome perturbations. Guidelines are emerging that recommend a target of >7 h of sleep for all adults >18 years for optimal CV health. Treatment of sleep disorders includes cognitive-behavioral therapy considered the mainstay of non-pharmacologic management of chronic insomnia, and drug treatment with benzodiazepine receptor agonists binding to gamma aminobutyric acid type A (benzodiazepine and non-benzodiazepine agents) and some antidepressants. However, observational studies and meta-analyses indicate an increased mortality risk of anxiolytics and hypnotics, although bias may be involved due to confounding and high heterogeneity in these studies. Nevertheless, it seems that the risk incurred by the non-benzodiazepine hypnotic agents (Z drugs) may be relatively less than the risk of anxiolytics, with evidence indicating that at least one of these agents, zolpidem, may even confer a lower risk of mortality in adjusted models. All these issues are herein reviewed.

Association of C1q/TNF-Related Protein-9 (CTRP9) Level with Obstructive Sleep Apnea in Patients with Coronary Artery Disease

Background

Obstructive sleep apnea (OSA) is closely related to the incidence and progression of coronary artery disease (CAD), and the mechanisms linking OSA and CAD are multifactorial. C1q/TNF-related protein-9 (CTRP9) is a novel adipokine that protects the heart against ischemic injury and ameliorates cardiac remodeling. We aimed to ascertain the clinical relevance of CTRP9 with OSA prevalence in patients with CAD.

Methods

From August 2016 to March 2019, consecutive eligible patients with CAD (n = 154; angina pectoris, n = 88; acute myocardial infarction [AMI], n = 66) underwent cardiorespiratory polygraphy. OSA was defined as an apnea-hypopnea index (AHI) ≥15 events·h^-1. Plasma CTRP9 concentrations were measured by ELISA method.

Results

Moderate/severe OSA was present in 89 patients (57.8%). CTRP9 levels were significantly decreased in the moderate/severe OSA group than in the no/mild OSA group (4.7 [4.1-5.2] ng/mL vs. 4.9 [4.4-6.0] ng/mL, P = 0.003). The difference between groups was only observed in patients with AMI (3.0 [2.3-4.9] vs. 4.5 [3.2-7.9], P = 0.009). Correlation analysis showed that CTRP9 levels were negatively correlated with AHI (r = -0.238, P = 0.003) and oxygen desaturation index (r = -0.234, P = 0.004) and positively correlated with left ventricular ejection fraction (r = 0.251, P = 0.004) in all subjects. Multivariate analysis showed that male gender (OR 3.099, 95% CI 1.029-9.330, P = 0.044), BMI (OR 1.148, 95% CI 1.040-1.268, P = 0.006), and CTRP9 levels (OR 0.726, 95% CI 0.592-0.890, P = 0.002) were independently associated with the prevalence of moderate/severe OSA.

Conclusions

Plasma CTRP9 levels were independently related to the prevalence of moderate/severe OSA in patients with CAD, suggesting that CTRP9 might play a role in the pathogenesis of CAD exacerbated by OSA.

The novel indicators of moderate to severe sleep apnea: fibrinogen to albumin ratio vs. CRP to albumin ratio

PURPOSE

This study aimed at investigating the association of severity of obstructive sleep apnea with the markers of inflammation as fibrinogen to albumin ratio and C-reactive protein to albumin ratio.

METHODS

We included 126 patients admitted to sleep disorders outpatient clinic. We constituted four groups by reference to the apnea-hypopnea index (mild-moderate-severe sleep apnea and control group). We investigated the difference of white blood cell, fibrinogen to albumin ratio, C-reactive protein to albumin ratio, neutrophil to lymphocyte ratio, platelet to lymphocyte ratio, and hemoglobin among the groups.

RESULTS

Neutrophil to lymphocyte ratio, platelet to lymphocyte ratio, and hemoglobin did not significantly differ among four groups (p = 0.39, p = 0.06, and p = 0.31, respectively). A significant difference of fibrinogen to albumin ratio and C-reactive protein to albumin ratio was evident among four groups (p < 0.001). Fibrinogen to albumin ratio and C-reactive protein to albumin ratio did not significantly differ between the mild sleep apnea and control groups (p = 0.65, and p = 0.85, respectively), but were significantly greater in moderate sleep apnea group compared with the control group (p < 0.001 and p = 0.001, respectively). Also, fibrinogen to albumin ratio and C-reactive protein to albumin ratio were significantly greater in the severe sleep apnea group compared with the control group (p < 0.001). Fibrinogen to albumin ratio and C-reactive protein to albumin ratio did not significantly differ between the severe sleep apnea and moderate sleep apnea groups (p = 0.49, and p = 0.58, respectively).

CONCLUSION

Higher fibrinogen to albumin ratio and C-reactive protein to albumin ratio may be predictive of inflammation in patients with moderate-to-severe sleep apnea.

Untreated Obstructive Sleep Apnea Is Associated With Myocardial Injury Independent of Blood Pressure Control in Hypertension

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) and hypertension are independent risk factors of cardiovascular morbidities. This study aims to investigate the relationship between OSA, blood pressure (BP) control, and myocardial injury in patients with difficult-to-control hypertension.

METHODS

Patients with hypertension who required three or more medications were prospectively recruited at a tertiary referral center. In-laboratory polysomnography, followed by blood tests for fasting glucose, glycated hemoglobin, lipids, high-sensitivity troponin I (hsTnI), B-type natriuretic peptide (BNP), C-reactive protein, and advanced oxidation protein products were performed. After polysomnography, 24-hour ambulatory BP monitoring was arranged.

RESULTS

A total of 98 participants were analyzed, with mean age 51 ± 9 years and body mass index 30 ± 5 kg/m². Previously undiagnosed severe OSA (apneahypopnea index [AHI] ≥ 30 events/h) was present in 51 patients (52%). hsTnI was negatively correlated with nocturnal dip in systolic BP (r = -.205, P = .048). After controlling for confounders, including BP control, AHI and oxygen desaturation index (ODI) were positively correlated with hsTnI (r = .282, P = .009 and r = .279, P = .010, respectively) and C-reactive protein (r = .302, P = .005 and r = .285, P = .008, respectively), but not with BNP or advanced oxidation protein products. Age, ODI, and loss of nocturnal systolic BP dip were significant determinants of hsTnI level (β = .225, P = .022; β = .293, P = .003; and β = -.215, P = .029; R² = .151). Age, female sex, 24-hour mean diastolic BP, and metabolic syndrome, but not indices of apnea severity, were predictors of BNP level.

CONCLUSIONS

Unrecognized severe OSA was common in patients with difficult-to-control hypertension, and OSA severity was associated with myocardial injury, independent of BP control with medications.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov, Title: A Cross-sectional Study of the Occurrence and Effect of Obstructive Sleep Apnea in Subjects With Resistant Hypertension, Identifier: NCT00843583, URL: https://clinicaltrials.gov/ct2/show/NCT00843583.

The role of vitamin D in obstructive sleep apnoea syndrome

Obstructive sleep apnoea syndrome (OSAS) is a common disorder of multifactorial pathogenesis and is associated with obesity, diabetes and cardiovascular disease. Vitamin D is a fat-soluble vitamin with an important function in calcium absorption and homeostasis, which is also implicated in several nonskeletal conditions. The prevalence of vitamin D deficiency is increasing worldwide and is associated with similar metabolic disturbances to OSAS. Moreover, recent data suggest that in OSAS patients serum levels of vitamin D are lower compared with non-apnoeic subjects. However, the mechanisms linking vitamin D deficiency and OSAS are not completely understood and several hypotheses have been advanced. To date, a limited number of studies have assessed the association between lower serum concentrations of vitamin D and OSAS, and have reported inconsistent results. Similarly, contradictory results have been produced by studies which evaluated the effect of continuous positive airway pressure treatment on serum vitamin D levels. The aim of this review is to summarise current knowledge on the association between OSAS and vitamin D levels.

Due to multiple confounding factors, vitamin D deficiency is common among sleep apnoea patients; thus, screening should be performed when clinically indicatedhttp://ow.ly/L3ow30krmol

Cardiovascular Risk Assessment in a Cohort of Newly Diagnosed Patients with Obstructive Sleep Apnea Syndrome

Objectives

Obstructive sleep apnea syndrome (OSAS) is associated with increased cardiovascular morbidity and mortality. The aim of this study was to assess whether the 10-year risk for cardiovascular disease in newly diagnosed patients with OSAS is increased.

Materials and Methods

Recently diagnosed, with polysomnography, consecutive OSAS patients were included. The Systematic Coronary Risk Evaluation (SCORE) and the Framingham Risk Score (FRS) were used to estimate the 10-year risk for cardiovascular disease.

Results

Totally, 393 individuals (73.3% males), scheduled to undergo a polysomnographic study with symptoms indicative of OSAS, were enrolled. According to apnea-hypopnea index (AHI), subjects were divided in four groups: mild OSAS (AHI 5–14.9/h) was diagnosed in 91 patients (23.2%), moderate OSAS (AHI 15–29.9/h) in 58 patients (14.8%), severe OSAS (AHI > 30/h) in 167 patients (42.5%), while 77 individuals (19.6%) had an AHI < 5/h and served as controls. Increased severity of OSAS was associated with increased SCORE (p < 0.001) and FRS values (p < 0.001). More specifically, a significant correlation was observed both between AHI and SCORE (r=0.251,  p < 0.001) and AHI and FRS values (r=0.291,  p < 0.001). Furthermore, a negative correlation was observed between FRS values and sleep efficiency (r=−0.224,  p=0.006).

Conclusions

The 10-year risk for cardiovascular morbidity and mortality seems to increase with severity of OSAS. Physicians should bear this finding in mind, in order to seek for and consecutively eliminate risk factors for cardiovascular disease and to prevent future cardiovascular events in OSAS patients.

Insulin Sensitivity and Insulin Resistance in Non-Diabetic Middle-Aged Patients with Obstructive Sleep Apnoea Syndrome

Background:

Obstructive sleep apnoea syndrome (OSAS) has been linked with abnormal glucose metabolism, insulin resistance (IR) and development of diabetes mellitus.

Methods:

Non-diabetic patients (n=69) with OSAS, diagnosed by polysomnography, were prospectively recruited. To evaluate IR among OSAS patients, the Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) and Insulin sensitivity by Quantitative Insulin sensitivity Check Index (QUICKI) were used.

Results:

HOMA-IR was positively associated with body-mass index (BMI) (ρ=0.364, p=0.002), time with oxyhaemoglobin saturation <90% (ρ=0.291, p=0.015), arousal index (ρ=0.268, p=0.027), Epworth sleepiness scale (ESS) score (ρ=0.293, p=0.019) and negatively with average oxyhaemoglobin saturation (ρ=-0.398, p=0.001) and minimum oxyhaemoglobin saturation (ρ=-0.327, p=0.006). QUICKI was positively associated with forced vital capacity (r=0.301, p=0.014), average oxyhaemoglobin saturation (r=0.443, p<0.001), minimum oxyhaemoglobin saturation (ρ=0.318, p=0.008), and negatively associated with sleep stage transitions (r=-0.266, p=0.032), oxygen desaturation index (r=-0.404, p=0.005), time with oxyhaemoglobin saturation <90% (r=-0.311, p=0.019), arousal index (r=-0.344, p=0.004) and ESS score (r=-0.299, p=0.016). After adjustment for age and BMI, HOMA-IR was associated with sleep stage transitions, time with oxyhaemoglobin saturation <90%, average oxyhaemoglobin saturation, minimum oxyhaemoglobin saturation and arousal index. QUICKI was associated with oxygen desaturation index, sleep stage transitions, ESS score, minimum oxyhaemoglobin saturation and arousal index.

Conclusions:

An independent association between OSAS and IR in patients without pre-existing diabetes mellitus was observed. Recurrent hypoxia and sleep fragmentation in OSAS are associated with IR in these patients.

Coronary artery disease presenting with left upper quadrant pain in a patient with chronic cervical tetraplegia

INTRODUCTION

This single-subject case report aims to describe and discuss a case of a patient with established C5 tetraplegia with acute coronary syndrome presenting with left upper quadrant pain and tenderness.

CASE PRESENTATION

A 65-year-old male with chronic C5 American Spinal Injury Association Impairment Scale (AIS) A tetraplegia presented to the emergency department with severe left upper quadrant pain radiating across the chest to the right upper limb with associated dyspnoea and diaphoresis. Prior to his emergency department admission, he had experienced progressive worsening of left upper quadrant pain and tenderness over several months. He was a non-smoker and swam regularly. He underwent coronary angiography and was found to have significant coronary artery disease. Drug-eluting stents were placed to critical coronary artery lesions followed by an uneventful hospital course with complete symptom resolution and discharge home.

DISCUSSION

Patients with tetraplegia are known to have higher rates of cardiovascular disease compared to ambulatory patients. Their cardiovascular risk profile may include atypical risk factors, for example, sleep disordered breathing, relative immobility and autonomic dysfunction. A high index of suspicion for cardiac pathology is warranted in those with cervical tetraplegia with persistent 'atypical' symptoms, including within the abdomen (especially when no specific abdominal organ dysfunction is evident). Sleep apnoea and significantly impaired mobility are potential cardiac risk factors in this patient group and should alert the emergency physician to cardiac disease (as in this case) irrespective of their complex past medical history and symptomatology.

Cystatin C Levels in Middle-Aged Patients with Obstructive Sleep Apnea Syndrome

Background. Obstructive sleep apnea syndrome (OSAS) is associated with systemic inflammation and increased risk of cardiovascular and chronic kidney disease. Cystatin C (Cyst C) is a novel biomarker of both latent renal damage and cardiovascular disease. Aim of the study was to measure serum levels of Cyst C, as well as IL-8 and CRP, in otherwise healthy OSAS patients. Methods. 84 individuals examined with polysomnography for OSAS symptoms without known comorbidities were prospectively recruited. Results. According to apnea hypopnea index (AHI) subjects were divided in two groups: OSAS group (AHI > 5/hour, n = 64) and controls (AHI < 5/hour, n = 20), which were age- and BMI-matched. Cyst C levels were higher in OSAS patients versus controls (1176.13 ± 351.33 versus 938.60 ± 245.83 ng/mL, resp.; p = 0.017) while serum IL-8 and CRP levels did not differ significantly. Positive correlation was found between Cyst C levels and respiratory disturbance index (RDI) (r = 0.240, p = 0.039) and percentage of time with oxygen saturation <90% (r = 0.290, p = 0.02) and negative correlation was found between Cyst C levels and average oxygen saturation during sleep (r = -0.291, p = 0.012). After adjustment for age and BMI, RDI was the only independent predictor of Cyst C levels (β = 0.256, p = 0.039). Conclusion. Cyst C serum levels are increased in OSAS patients without comorbidities, suggesting an increased renal and cardiovascular disease risk.

Non-alcoholic fatty liver disease and dyslipidemia: An update

Non-alcoholic fatty liver (NAFLD) is the most common liver disease worldwide, progressing from simple steatosis to necroinflammation and fibrosis (leading to non-alcoholic steatohepatitis, NASH), and in some cases to cirrhosis and hepatocellular carcinoma. Inflammation, oxidative stress and insulin resistance are involved in NAFLD development and progression. NAFLD has been associated with several cardiovascular (CV) risk factors including obesity, dyslipidemia, hyperglycemia, hypertension and smoking. NAFLD is also characterized by atherogenic dyslipidemia, postprandial lipemia and high-density lipoprotein (HDL) dysfunction. Most importantly, NAFLD patients have an increased risk for both liver and CV disease (CVD) morbidity and mortality. In this narrative review, the associations between NAFLD, dyslipidemia and vascular disease in NAFLD patients are discussed. NAFLD treatment is also reviewed with a focus on lipid-lowering drugs. Finally, future perspectives in terms of both NAFLD diagnostic biomarkers and therapeutic targets are considered.

Relationship Between the Apolipoprotein E Genotype and LDL Particle Size in Patients With Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is associated with dyslipidemia and increased cardiovascular risk. We assessed the effects of apolipoprotein E ( APOE) genotype on low-density lipoprotein (LDL) and high-density lipoprotein (HDL) particle size and lipid subclasses (separated by gradient gel electrophoresis) in patients with OSA. Stable patients (n = 181) prospectively recruited underwent full polysomnography. Both LDL particle size and LDL I proportion were reduced from ∊3∊3 homozygotes to ∊2 carriers and to ∊4 carriers (analysis of variance: P = .024; P = .040, respectively); carriers of the ∊4 allele of the APOE genotype had significantly lower LDL particle size and LDL I proportion compared to ∊3∊3 homozygotes ( P < .05 for both comparisons). Insulin resistance increased from patients with no OSA to those with mild–moderate and to those with severe OSA ( P < .001). In multivariate analysis, LDL size was independently predicted by APOE genotype, male gender, and the presence of metabolic syndrome (MetS; P = .001, P = .020, P = .027, respectively). The HDL particle size was not affected by APOE genotype. Our data demonstrate that both the ∊4 APOE genotype and MetS are independently related to smaller LDL size in patients with OSA.