Prevalence of obstructive sleep apnea, associated risk factors, and quality of life among Indian congestive heart failure patients: a cross-sectional survey

Cardiovascular diseases and sleep disorders in South Asians: A scoping review

BACKGROUND

South Asians comprise 20% of the world population. There is a high prevalence of cardiovascular diseases among South Asians, and sleep disorders may be a key risk factor.

OBJECTIVE

The review examined literature about cardiovascular and sleep disorders in South Asian countries and in the United States, United Kingdom, Canada, and the Netherlands.

METHODS

Methods from Arksey and O'Malley's framework and Peter et al. were used to synthesize findings from 23 research studies.

RESULTS

The studies addressed sleep disorders with hypertension, heart failure, diabetes, and obesity. Obstructive sleep apnea and short sleep duration were common and associated with cardiovascular morbidity and mortality at early ages in South Asians. Researchers analyzed polysomnography-derived sleep measures, vascular functions, polymorphisms, C-reactive protein levels, public knowledge about cardiovascular health, and sleep-related questionnaire scores. Most studies were conducted in major metropolitan areas; no data were available about people living in locations with limited health care resources. Among migrant South Asians, researchers did not explore the role of acculturation on sleep patterns and cardiovascular outcomes.

CONCLUSIONS

The review highlights important considerations for researchers who plan to investigate cardiovascular conditions in South Asian communities. There is a need for more knowledge about sleep-related risk factors, and researchers should also examine cultural, political, and socioeconomic factors that affect health care access. This knowledge will be imperative for designing effective and tailored disease prevention strategies for South Asian populations.

The mobile sleep medicine model in neurologic practice: Rationale and application

Background

Undiagnosed obstructive sleep apnea (OSA) is prevalent in neurological practice and significantly contributes to morbidity and mortality. OSA is prevalent in US adults and causes poor quality sleep and significant neurocognitive, cardiovascular, and cerebrovascular impairments. Timely treatment of OSA reduces cardio-cerebrovascular risks and improves quality of life. However, most of the US population has limited systematic access to sleep medicine care despite its clinical significance.

Focus

We discuss the importance of systematic screening, testing, and best-practice management of OSA and hypoventilation/hypoxemia syndromes (HHS) in patients with stroke, neurocognitive impairment, and neuromuscular conditions. This review aims to introduce and describe a novel integrated Mobile Sleep Medicine (iMSM) care model and provide the rationale for using an iMSM in general neurological practice to assist with systematic screening, testing and best-practice management of OSA, HHS, and potentially other sleep conditions.

Key points

The iMSM is an innovative, patient-centered, clinical outcome-based program that uses a Mobile Sleep Medicine Unit—a “sleep lab on wheels”—designed to improve access to OSA management and sleep care at all levels of health care system. The protocol for the iMSM care model includes three levels of operations to provide effective and efficient OSA screening, timely testing/treatment plans, and coordination of further sleep medicine care follow-up. The iMSM care model prioritizes effective, efficient, and patient-centered sleep medicine care; therefore, all parties and segments of care that receive and provide clinical sleep medicine services may benefit from adopting this innovative approach.

Quality of life of chronic heart failure patients: a systematic review and meta-analysis

Despite various individual studies on the quality of life (QOL) in patients with CHF, a comprehensive study has not yet been conducted; therefore, this study aims to assess the QOL of CHF patients. In the present systematic review and meta-analysis, PubMed, Scopus, and the Web of science databases were searched from January 1, 2000, to December 31, 2018, using QOL and heart failure as keywords. The searches, screenings, quality assessments, and data extractions were conducted separately by two researchers. A total of 70 studies including 25,180 participants entered the final stage. The mean QOL score was 44.1 (95% confidence interval (CI) 40.6, 47.5; I² = 99.3%) using a specific random effects method in 40 studies carried out on 12,520 patients. Moreover, according to the geographical region, heart failure patients in the Americas had higher scores. In 14 studies, in which a general SF-36 survey was implemented, the average physical component score (PCS) and mental component score (MCS) were 33.3 (95% CI 31.9, 34.7; I² = 88.0%) and 50.6 (95% CI 43.8, 57.4; I² = 99.3%), respectively. The general and specific tools used in this study indicated moderate and poor QOL, respectively. Therefore, it is necessary to carry out periodic QOL measurements using appropriate tools as part of the general care of CHF patients.

Diagnostic accuracy and suitability of instruments that screen for obstructive sleep apnoea, insomnia and sleep quality in cardiac patients: a meta-analysis

BACKGROUND

A number of clinical guidelines recommend that all cardiac rehabilitation patients should be screened for potential sleep disorders with a validated screening instrument. There is currently no consensus on what specific tools should be used.

OBJECTIVE

To identify tools that are practical to use in the clinical environment and have high diagnostic accuracy.

METHODS

We systematically searched online databases to identify patient reported outcome instruments that have been used in published research studies to assess the likelihood of obstructive sleep apnoea (OSA) in cardiac patients. In studies that provided diagnostic data, these data were extracted and verified via an evidence-based diagnostic calculator. Where sufficient numbers of studies were available, a meta-analysis was conducted to determine pooled estimates of specificity, sensitivity and diagnostic odds ratios. Selected papers were qualitatively assessed using the Standards for Reporting Diagnostic accuracy studies (STARD).

RESULTS

Of the 21 instruments identified, six detected likelihood of OSA, two assessed daytime sleepiness, five assessed insomnia and eight examined sleep quality. A meta-analysis of 14 studies that assessed diagnostic accuracy of moderate OSA, revealed moderate sensitivity for the Berlin Questionnaire, Sens = 0.49 (95% CI 0.45-0.52) and good sensitivity for the Stop-BANG, Sens = 0.93 (95% CI 0.87-0.96) but poor specificity at standard cut-off criteria.

CONCLUSION

There are promising practical tools available to screen patients with OSA and other sleep disorders in cardiac rehabilitation settings, but specificity could be improved. Additional assessment of sleep quality may enhance prognostic ability with both OSA and insomnia screening.

Heart Failure With Preserved Ejection Fraction in the Young

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF), traditionally considered a disease of the elderly, may also affect younger patients. However, little is known about HFpEF in the young.

METHODS

We prospectively enrolled 1203 patients with HFpEF (left ventricular ejection fraction ≥50%) from 11 Asian regions. We grouped HFpEF patients into very young (<55 years of age; n=157), young (55-64 years of age; n=284), older (65-74 years of age; n=355), and elderly (≥75 years of age; n=407) and compared clinical and echocardiographic characteristics, quality of life, and outcomes across age groups and between very young individuals with HFpEF and age- and sex-matched control subjects without heart failure.

RESULTS

Thirty-seven percent of our HFpEF population was <65 years of age. Younger age was associated with male preponderance and a higher prevalence of obesity (body mass index ≥30 kg/m²; 36% in very young HFpEF versus 16% in elderly) together with less renal impairment, atrial fibrillation, and hypertension (all P<0.001). Left ventricular filling pressures and prevalence of left ventricular hypertrophy were similar in very young and elderly HFpEF. Quality of life was better and death and heart failure hospitalization at 1 year occurred less frequently ( P<0.001) in the very young (7%) compared with elderly (21%) HFpEF. Compared with control subjects, very young HFpEF had a 3-fold higher death rate and twice the prevalence of hypertrophy.

CONCLUSIONS

Young and very young patients with HFpEF display similar adverse cardiac remodeling compared with their older counterparts and very poor outcomes compared with control subjects without heart failure. Obesity may be a major driver of HFpEF in a high proportion of HFpEF in the young and very young.

Microvascular Disease in Patients With Diabetes With Heart Failure and Reduced Ejection Versus Preserved Ejection Fraction

OBJECTIVE

Microvascular complications are common among patients with diabetes mellitus (DM). The presence of heart failure (HF) is presumed to be due to macrovascular disease (typically HF with reduced ejection fraction [HFrEF] following myocardial infarction). We hypothesized that HF with preserved ejection fraction (HFpEF) in patients with DM may be a manifestation of microvascular disease compared with HFrEF. The objective of this study was to examine the prevalence and association with clinical outcome of microvascular complications in patients with HF and DM.

RESEARCH DESIGN AND METHODS

We investigated the prevalence, association with clinical outcome, and cardiac structure and function of microvascular (neuropathy, nephropathy, and retinopathy) complications of DM in 2,800 prospectively enrolled participants with HF and DM (561 with HFpEF) from the Asian Sudden Cardiac Death In Heart Failure (ASIAN-HF) registry.

RESULTS

A total of 601 (21.5%) participants with DM had microvascular complications. Participants with DM and any (one or more) microvascular complications were more likely to have HFpEF (odds ratio 1.70 [95% CI 1.15-2.50]; P = 0.008). Furthermore, the likelihood of having HFpEF increased with an increasing number of microvascular complications (P _trend < 0.001). Microvascular complications were associated with more left ventricular (LV) hypertrophy and a greater reduction in quality of life in HFpEF than HFrEF (P _interaction < 0.001 for all). Compared with participants with DM and without microvascular complications, the adjusted hazard ratio for the composite outcome of all-cause death or HF hospitalization was 1.35 (95% CI 1.04-1.76) for participants with DM and microvascular complications regardless of HF type (P _interaction = 0.112).

CONCLUSIONS

Diabetic microvascular disease is more common, and related to greater LV remodeling, more impairment of quality in life, and similar adverse outcomes, in participants with HFpEF compared with HFrEF. HFpEF may be a clinical manifestation of microvascular disease in DM.

Multimorbidity in patients with heart failure from 11 Asian regions: A prospective cohort study using the ASIAN-HF registry

BACKGROUND

Comorbidities are common in patients with heart failure (HF) and complicate treatment and outcomes. We identified patterns of multimorbidity in Asian patients with HF and their association with patients' quality of life (QoL) and health outcomes.

METHODS AND FINDINGS

We used data on 6,480 patients with chronic HF (1,204 with preserved ejection fraction) enrolled between 1 October 2012 and 6 October 2016 in the Asian Sudden Cardiac Death in Heart Failure (ASIAN-HF) registry. The ASIAN-HF registry is a prospective cohort study, with patients prospectively enrolled from in- and outpatient clinics from 11 Asian regions (Hong Kong, Taiwan, China, Japan, Korea, India, Malaysia, Thailand, Singapore, Indonesia, and Philippines). Latent class analysis was used to identify patterns of multimorbidity. The primary outcome was defined as a composite of all-cause mortality or HF hospitalization within 1 year. To assess differences in QoL, we used the Kansas City Cardiomyopathy Questionnaire. We identified 5 distinct multimorbidity groups: elderly/atrial fibrillation (AF) (N = 1,048; oldest, more AF), metabolic (N = 1,129; obesity, diabetes, hypertension), young (N = 1,759; youngest, low comorbidity rates, non-ischemic etiology), ischemic (N = 1,261; ischemic etiology), and lean diabetic (N = 1,283; diabetic, hypertensive, low prevalence of obesity, high prevalence of chronic kidney disease). Patients in the lean diabetic group had the worst QoL, more severe signs and symptoms of HF, and the highest rate of the primary combined outcome within 1 year (29% versus 11% in the young group) (p for all <0.001). Adjusting for confounders (demographics, New York Heart Association class, and medication) the lean diabetic (hazard ratio [HR] 1.79, 95% CI 1.46-2.22), elderly/AF (HR 1.57, 95% CI 1.26-1.96), ischemic (HR 1.51, 95% CI 1.22-1.88), and metabolic (HR 1.28, 95% CI 1.02-1.60) groups had higher rates of the primary combined outcome compared to the young group. Potential limitations include site selection and participation bias.

CONCLUSIONS

Among Asian patients with HF, comorbidities naturally clustered in 5 distinct patterns, each differentially impacting patients' QoL and health outcomes. These data underscore the importance of studying multimorbidity in HF and the need for more comprehensive approaches in phenotyping patients with HF and multimorbidity.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01633398.

Multinational and multiethnic variations in health-related quality of life in patients with chronic heart failure

BACKGROUND

Assessing health-related quality of life (HRQoL) in patients with heart failure (HF) is an important goal of clinical care and HF research. We sought to investigate ethnic differences in perceived HRQoL and its association with mortality among patients with HF and left ventricular ejection fraction ≤35%, controlling for demographic characteristics and HF severity.

METHODS AND RESULTS

We compared 5697 chronic HF patients of Indian (26%), white (23%), Chinese (17%), Japanese/Koreans (12%), black (12%), and Malay (10%) ethnicities from the HF-ACTION and ASIAN-HF multinational studies using the Kansas City Cardiomyopathy Questionnaire (KCCQ; range 0-100; higher scores reflect better health status). KCCQ scores were lowest in Malay (58±22) and Chinese (60±23), intermediate in black (64±21) and Indian (65±23), and highest in white (67±20) and Japanese or Korean patients (67±22) after adjusting for age, sex, educational status, HF severity, and risk factors. Self-efficacy, which measures confidence in the ability to manage symptoms, was lower in all Asian ethnicities (especially Japanese/Koreans [60±26], Malay [66±23], and Chinese [64±28]) compared to black (80±21) and white (82±19) patients, even after multivariable adjustment (P<.001). In all ethnicities, KCCQ strongly predicted 1-year mortality (HR 0.45, 95% CI 0.30-0.67 for highest vs lowest quintile of KCCQ; P for interaction by ethnicity .101).

CONCLUSIONS

Overall, HRQoL is inversely and independently related to mortality in chronic HF but is not modified by ethnicity. Nevertheless, ethnic differences exist independent of HF severity and comorbidities. These data may have important implications for future global clinical HF trials that use patient-reported outcomes as endpoints.

Clinical effectiveness and cost-effectiveness results from the randomised controlled Trial of Oral Mandibular Advancement Devices for Obstructive sleep apnoea-hypopnoea (TOMADO) and long-term economic analysis of oral devices and continuous positive airway pressure

BACKGROUND

Obstructive sleep apnoea-hypopnoea (OSAH) causes excessive daytime sleepiness (EDS), impairs quality of life (QoL) and increases cardiovascular disease and road traffic accident risks. Continuous positive airway pressure (CPAP) treatment is clinically effective but undermined by intolerance, and its cost-effectiveness is borderline in milder cases. Mandibular advancement devices (MADs) are another option, but evidence is lacking regarding their clinical effectiveness and cost-effectiveness in milder disease.

OBJECTIVES

(1) Conduct a randomised controlled trial (RCT) examining the clinical effectiveness and cost-effectiveness of MADs against no treatment in mild to moderate OSAH. (2) Update systematic reviews and an existing health economic decision model with data from the Trial of Oral Mandibular Advancement Devices for Obstructive sleep apnoea-hypopnoea (TOMADO) and newly published results to better inform long-term clinical effectiveness and cost-effectiveness of MADs and CPAP in mild to moderate OSAH.

TOMADO

A crossover RCT comparing clinical effectiveness and cost-effectiveness of three MADs: self-moulded [SleepPro 1™ (SP1); Meditas Ltd, Winchester, UK]; semibespoke [SleepPro 2™ (SP2); Meditas Ltd, Winchester, UK]; and fully bespoke [bespoke MAD (bMAD); NHS Oral-Maxillofacial Laboratory, Addenbrooke's Hospital, Cambridge, UK] against no treatment, in 90 adults with mild to moderate OSAH. All devices improved primary outcome [apnoea-hypopnoea index (AHI)] compared with no treatment: relative risk 0.74 [95% confidence interval (CI) 0.62 to 0.89] for SP1; relative risk 0.67 (95% CI 0.59 to 0.76) for SP2; and relative risk 0.64 (95% CI 0.55 to 0.76) for bMAD (p < 0.001). Differences between MADs were not significant. Sleepiness [as measured by the Epworth Sleepiness Scale (ESS)] was scored 1.51 [95% CI 0.73 to 2.29 (SP1)] to 2.37 [95% CI 1.53 to 3.22 (bMAD)] lower than no treatment (p < 0.001), with SP2 and bMAD significantly better than SP1. All MADs improved disease-specific QoL. Compliance was lower for SP1, which was unpopular at trial exit. At 4 weeks, all devices were cost-effective at £20,000/quality-adjusted life-year (QALY), with SP2 the best value below £39,800/QALY.

META-ANALYSIS

A MEDLINE, EMBASE and Science Citation Index search updating two existing systematic reviews (one from November 2006 and the other from June 2008) to August 2013 identified 77 RCTs in adult OSAH patients comparing MAD with conservative management (CM), MADs with CPAP or CPAP with CM. MADs and CPAP significantly improved AHI [MAD -9.3/hour (p < 0.001); CPAP -25.4/hour (p < 0.001)]. Effect difference between CPAP and MADs was 7.0/hour (p < 0.001), favouring CPAP. No trials compared CPAP with MADs in mild OSAH. MAD and CPAP reduced the ESS score similarly [MAD 1.6 (p < 0.001); CPAP 1.6 (p < 0.001)].

LONG-TERM COST-EFFECTIVENESS

An existing model assessed lifetime cost-utility of MAD and CPAP in mild to moderate OSAH, using the revised meta-analysis to update input values. The TOMADO provided utility estimates, mapping ESS score to European Quality of Life-5 Dimensions three-level version for device cost-utility. Using SP2 as the standard device, MADs produced higher mean costs and mean QALYs than CM [incremental cost-effectiveness ratio (ICER) £6687/QALY]. From a willingness to pay (WTP) of £15,367/QALY, CPAP is cost-effective, although the likelihood of MADs (p = 0.48) and CPAP (p = 0.49) being cost-effective is very similar. Both were better than CM, but there was much uncertainty in the choice between CPAP and MAD (at a WTP £20,000/QALY, the probability of being the most cost-effective was 47% for MAD and 52% for CPAP). When SP2 lifespan increased to 18 months, the ICER for CPAP compared with MAD became £44,066. The ICER for SP1 compared with CM was £1552, and for bMAD compared with CM the ICER was £13,836. The ICER for CPAP compared with SP1 was £89,182, but CPAP produced lower mean costs and higher mean QALYs than bMAD. Differential compliance rates for CPAP reduces cost-effectiveness so MADs become less costly and more clinically effective with CPAP compliance 90% of SP2.

CONCLUSIONS

Mandibular advancement devices are clinically effective and cost-effective in mild to moderate OSAH. A semi-bespoke MAD is the appropriate first choice in most patients in the short term. Future work should explore whether or not adjustable MADs give additional clinical and cost benefits. Further data on longer-term cardiovascular risk and its risk factors would reduce uncertainty in the health economic model and improve precision of effectiveness estimates.

TRIAL REGISTRATION

This trial is registered as ISRCTN02309506.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 67. See the NIHR Journals Library website for further project information.

Adverse respiratory events after general anesthesia in patients at high risk of obstructive sleep apnea syndrome

INTRODUCTION

Patients with STOP-BANG score >3 have a high risk of Obstructive sleep apnea. The aim of this study was to evaluate early postoperative respiratory complications in adults with STOP-BANG score >3 after general anesthesia.

METHODS

This is a prospective double cohort study matching 59 pairs of adult patients with STOP-BANG score >3 (high risk of obstructive sleep apnea) and patients with STOP-BANG score <3 (low risk of obstructive sleep apnea), similar with respect to gender, age and type of surgery, admitted after elective surgery in the Post-Anaesthesia Care Unit in May 2011. Primary outcome was the development of adverse respiratory events. Demographics data, perioperative variables, and postoperative length of stay in the Post-Anesthesia Care Unit and in hospital were recorded. The Mann-Whitney test, the chi-square test and the Fisher exact test were used for comparisons.

RESULTS

Subjects in both pairs of study subjects had a median age of 56 years, including 25% males, and 59% were submitted to intra-abdominal surgery. High risk of obstructive sleep apnea patients had a higher median body mass index (31 versus 24kg/m(2), p<0.001) and had more frequently co-morbidities, including hypertension (58% versus 24%, p<0.001), dyslipidemia (46% versus 17%, p<0.001) and insulin-treated diabetes mellitus (17% versus 2%, p=0.004). These patients were submitted more frequently to bariatric surgery (20% versus 2%, p=0.002). Patients with high risk of obstructive sleep apnea had more frequently adverse respiratory events (39% versus 10%, p<0.001), mild to moderate desaturation (15% versus 0%, p=0.001) and inability to breathe deeply (34% versus 9%, p=0.001).

CONCLUSION

After general anesthesia high risk of obstructive sleep apnea patients had an increased incidence of postoperative respiratory complications.

Supine fluid redistribution: should we consider this as an important risk factor for obstructive sleep apnea?

INTRODUCTION

Obstructive sleep apnea (OSA) is a common medical disorder affecting at least 2 % of women and 4 % of men living in Western societies. Obesity, older age, male gender, alcohol and sedative use, smoking, craniofacial parameters, and volume overload are some of the risk factors for this disorder.

DISCUSSION

OSA is a known risk factor complicating the course of arterial hypertension, heart failure, and chronic kidney disease. It is important to note that all of the aforementioned comorbid disorders are associated with volume overload. This explains why patients with OSA and comorbid disorders associated with fluid overload can benefit from treatment with diuretics and drugs modulating the renin-angiotensin-aldosterone system. Additionally, patients with heart failure and high sodium intake are at increased risk for OSA, further supporting the complex interrelationship.

CONCLUSIONS

Hemodialysis and renal transplantation can markedly improve the severity of OSA in patients with concomitant kidney disease. Finally, there is a potential of a vicious cycle between OSA and fluid overload disorders, whereby OSA can contribute to the pathogenesis of arterial hypertension, heart failure, and chronic kidney disease, which in turn will significantly contribute to the course OSA.

Non drowsy obstructive sleep apnea as a potential cause of resistant hypertension: a case report

BACKGROUND

Obstructive sleep apnea (OSA) and arterial hypertension (AH) are common and underrecognized medical disorders. OSA is a potential risk factor for the development of AH and/or may act as a factor complicating AH management. The symptoms of excessive daytime sleepiness (EDS) are considered essential for the initiation of continuous positive airway pressure (CPAP) therapy, which is a first line treatment of OSA. The medical literature and practice is controversial about the treatment of people with asymptomatic OSA. Thus, OSA patients without EDS may be left at increased cardiovascular risk.

CASE PRESENTATION

The report presents a case of 42 year old Asian woman with symptoms of heart failure and angina like chest pain upon admission. She didn't experience symptoms of EDS, and the Epworth Sleepiness Scale was seven points. Snoring was reported on direct questioning. The patient had prior medical history of three unsuccessful pregnancies complicated by gestational AH and preeclampsia with C-section during the last pregnancy. The admission blood pressure (BP) was 200/120 mm Hg. The patients treatment regimen consisted of five hypotensive medications including diuretic. However, a target BP wasn't achieved in about one and half month. The patient was offered to undergo a polysomnography (PSG) study, which she rejected. One month after discharge the PSG study was done, and this showed an apnea-hypopnea index (AHI) of 46 events per hour. CPAP therapy was initiated with a pressure of 11 H₂0 cm. After 2 months of compliant CPAP use, adherence to pharmacologic regimen and lifestyle modifications the patients BP decreased to 134/82 mm Hg.

CONCLUSIONS

OSA and AH are common and often underdiagnosed medical disorders independently imposing excessive cardiovascular risk on a diseased subject. When two conditions coexist the cardiovascular risk is likely much greater. This case highlights a possible clinical phenotype of OSA without EDS and its association with resistant AH. Most importantly a good hypotensive response to medical treatment in tandem with CPAP therapy was achieved in this patient. Thus, it is reasonable to include OSA in the differential list of resistant AH, even if EDS is not clinically obvious.