Association of incident obstructive sleep apnoea with outcomes in a large cohort of US veterans

Sleep Apnea Among Gulf War Veterans: An Examination of VA Utilization Rates, Treatment Initiation, and Health Outcomes

OBJECTIVES

Obstructive sleep apnea (OSA) among veterans is frequently underdiagnosed and undertreated. The present study sought to: 1) characterize the prevalence and rate of treatment of OSA among VA users and non-users and 2) examine the associations between diagnosed or probable OSA and key physical and mental health outcomes.

METHODS

Gulf-War I-era Veterans were recruited as part of a national survey assessing mental and physical health concerns, healthcare needs, and healthcare utilization. OSA diagnoses were self-reported while sleep apnea risk was assessed via the STOP-Bang. Veterans also completed questionnaires assessing overall health, pain, depression, PTSD, and psychosocial functioning.

RESULTS

1,153 veterans were included in the present analyses (Mean age = 58.81; 21.84% female). Compared to non-VA healthcare users, veterans receiving care at the VA were more likely to have been diagnosed with OSA (p < .001) and report receiving treatment for OSA (p = .005). Compared to veterans at low risk for OSA, veterans at elevated risk reported higher levels of pain (p = .001), depression (p = .02), and poorer psychosocial functioning (p < .001).

CONCLUSIONS

OSA diagnoses appear to be more common among VA healthcare users. Findings suggest that OSA remains underdiagnosed and associated with important physical and mental health consequences. Additional screening for OSA, especially among non-VA clinics, is warranted.

Obstructive Sleep Apnea and Stroke: Determining the Mechanisms Behind their Association and Treatment Options

Sleep-disordered breathing (SDB) can be a sequela of stroke caused by vascular injury to vital respiratory centers, cerebral edema, and increased intracranial pressure of space-occupying lesions. Likewise, obstructive sleep apnea (OSA) contributes to increased stroke risk through local mechanisms such as impaired ischemic cerebrovascular response and systemic effects such as promoting atherosclerosis, hypercoagulability, cardiac arrhythmias, vascular-endothelial dysfunction, and metabolic syndrome. The impact of OSA on stroke outcomes has been established, yet it receives less attention in national guidelines on stroke management than hyperglycemia and blood pressure dysregulation. Furthermore, whether untreated OSA worsens stroke outcomes is not well-described in the literature. This scoping review provides an updated investigation of the correlation between OSA and stroke, including inter-relational pathophysiology. This review also highlights the importance of OSA treatment and its role in stroke outcomes. Knowledge of pathophysiology, the inter-relationship between these common disorders, and the impact of OSA therapy on outcomes affect the clinical management of patients with acute ischemic stroke. In addition, understanding the relationship between stroke outcomes and pre-existing OSA will allow clinicians to predict outcomes while treating acute stroke.

Obstructive sleep apnea and cardiovascular risk

Patients with obstructive sleep apnea (OSA) experience repetitive episodes of upper airway obstruction due to recurrent collapse during sleep. This leads to intermittent hypoxia episodes, which, through complex pathophysiological mechanisms, trigger sympathetic overactivation, endothelial dysfunction, hypercoagulation, and metabolic dysregulation. Consequently, other cardiovascular risk factors such as hypertension, metabolic syndrome, and diabetes are induced. Furthermore, this enhances target organ damage, affecting the heart, arteries, and kidneys, leading to an increased risk of cardiovascular morbidity and mortality. Among the various treatments for OSA, Continuous Positive Airway Pressure (CPAP) has been extensively studied. To date, this treatment has shown mild benefits in reducing blood pressure, particularly noticeable in patients with resistant hypertension. Furthermore, CPAP treatment appears to reduce cardiovascular events, both in primary and secondary prevention, though this benefit is limited to individuals with good compliance (CPAP use ≥4h/night). Future research perspectives in OSA seem to focus on identifying patients in whom the condition significantly influences cardiovascular risk, thus determining those who would benefit the most from treatment in the reduction of cardiovascular risk.

Association of obstructive sleep apnea and diurnal variation of cystatin C

PURPOSE

Obstructive sleep apnea is a known risk factor for the progression of chronic kidney disease. To find early signs of the progression in subjects with obstructive sleep apnea., we assessed the diurnal variation of kidney biomarkers.

METHODS

A prospective observational study was conducted at Kangwon National University Hospital, Chuncheon, South Korea. All participants underwent in-laboratory polysomnography and phlebotomy in the evening before the polysomnography and in the morning after the polysomnography. Kidney biomarkers, including serum creatinine, blood urea nitrogen, and serum cystatin C, were measured. Delta kidney biomarkers were calculated by subtracting the evening level of the biomarkers from the morning level.

RESULTS

Twenty-six of 50 participants had severe obstructive sleep apnea. Delta cystatin C was significantly correlated with apnea-hypopnea index, oxygen desaturation index, and total arousal index with coefficients of -0.314, -0.323, and -0.289, respectively. In participants without severe obstructive sleep apnea, the morning cystatin C level (0.84 ± 0.11 mg/L) was significantly higher than the evening cystatin C level (0.81 ± 0.11 mg/L) (P = 0.005). With severe obstructive sleep apnea, the cystatin C levels were not different between the morning (0.85 ± 0.11 mg/L) and the evening (0.85 ± 0.10 mg/L).

CONCLUSIONS

Cystatin C level was increased in the morning in participants without severe obstructive sleep apnea, but not in participants with severe obstructive sleep apnea.

BASET scoring: A novel simple biometric score for screening and grading obstructive sleep apnea

Background

Polysomnography (PSG) is the gold-standard diagnostic tool for Obstructive Sleep Apnea (OSA). However, the availability of PSG is limited, and OSA is widely underdiagnosed; more than 80% of most developed nations undiagnosed. There is no diagnostic validated simple tool with clear cutoff point for predicting and roll out patient with OSA in primary care clinics significantly alters clinical outcomes.

Objectives

Our study aimed to assess the validity of BASET scoring as a new potential tool for screening and grading the severity of OSA patients.

Methods

After institution review board approval and formal patient consent, 144 subjects for suspected OSA and their relatives were enrolled. All subjects were subjected to a full night PSG study after history taking, sleep questionnaires, and physical examination, including BASET score components: B= Body Mass Index (BMI), A= Abdominal circumference (AC), S = Snoring, E= Epworth Sleepiness Scale, and T= Tongue teeth imprint. ROC analysis that used to assess the optimal cutoff point of the BASET score and to compare its accuracy for predicting OSA with Berlin and STOP-Bang scores.

Results

This study included 63 OSAS patients, 33 (52.38%) males and 30 (47.62%) females, and 81 controls; 22 (27.16%) males and 50 (72.84%) females. The Cronbach's alpha for the 5 BASET score components was 0.846, indicating the internal consistency reliability of the scale. Moreover, BASET score has a moderately strong positive significant correlation (r = 0.778, p<0.001) with AHI. By ROC analysis, the accuracy of the three measures was generally high, with BASET score predicting OSA most accurately (AUC=0.984, 95%CI: 0.956-0.999), followed by STOP-Bang (AUC=0.939, 95%CI: (0.887-0.972) and Berlin (AUC=0.901, 95%CI: 0.841-0.945). The AUC of BASET score was significantly higher compared to the Berlin score (difference= 0.0825, 95%CI: 0.039-0.125) and STOP-Bang score (difference= 0.0447, 95%CI: 0.011-0.078). On the other hand, there was no difference between the AUC of Berlin and STOP-Bang scores (difference=0.0378, 95%CI: 0.006 - 0.081 4). BASET score was significantly (p<0.001) associated with OSA grades.

Conclusion

BASET score is a convenient, reliable, and valid tool for diagnosing OSA. BASET score is more accurate for predicting OSA than Berlin and STOP-Bang scores, while there is no difference between Berlin and STOP-Bang scores. BASET score indicates OSA grades.

Registration of clinical trials by number

NCT05511974.

Name of the registry

ClinicalTrials.gov URL: https://clinicaltrials.gov/.

Veterans' Experiences of Support in Managing Comorbid Sleep Apnea and Type 2 Diabetes

BACKGROUND

Obstructive sleep apnea (OSA) is highly prevalent in patients with Type 2 diabetes, more so in veterans compared with nonveterans. Positive airway pressure is the recommended first-line treatment for OSA. However, adherence to both positive airway pressure and diabetes management regimens can be challenging for older adults. Support from family or friends may improve glucose control or sleep-apnea-related symptoms, yet the evidence is limited when both conditions coexist.

OBJECTIVES

This study aimed to describe veterans' experiences of support from family and friends with managing comorbid sleep apnea and Type 2 diabetes.

METHODS

We conducted a postal survey of older veterans with OSA and Type 2 diabetes from one healthcare system. Questions include demographic and health-related information, information about sleep apnea and diabetes treatment and education received, related support from family or a friend, perceived benefits of regular positive airway pressure device use on improving sleep health, and perceived benefits of education for family or a friend on sleep apnea and diabetes. Descriptive and bivariate analyses were performed.

RESULTS

Of 145 respondents (mean age = 72 years), 43% reported receiving help for Type 2 diabetes from family or a friend. Almost two thirds of the respondents were currently using a positive airway pressure device, of whom 27% received support with device use from family or friends. About one third of veterans perceived family and friends receiving education on treating sleep apnea and diabetes to be very or extremely helpful. Such perceived benefit was higher among those who were married or identified as non-White. Veterans using a positive airway pressure device had lower hemoglobin A1c levels than nonusers.

DISCUSSION

Veterans perceived that additional education for the individuals providing support would be beneficial. Future studies could address interventions to increase sleep apnea and Type 2 diabetes knowledge among families and friends of veterans with these comorbid conditions. In addition, patients' adherence to positive airway pressure may be enhanced by support from family and friends.

The relationship between obstructive sleep apnea and risk of renal impairment in patients with hypertension, a longitudinal study

OBJECTIVE

Association of obstructive sleep apnea (OSA) with renal damage is undetermined, especially in the population with hypertension, a high-risk group for chronic kidney disease. Therefore, we aimed to explore whether OSA is an independent risk factor for renal impairment in patients with hypertension, by considering the effects of gender, age, obesity and OSA severity.

METHODS

The longitudinal observational study included patients with hypertension and suspected OSA without renal damage at baseline who visited Hypertension Center between January 2011 and December 2018, and followed up till renal outcomes, death, loss to follow-up, or May 31, 2022, using annual health check-ups, hospital readmission or out-patient visits. Main renal outcome was chronic kidney disease (CKD), defined as estimated glomerular filtration rate <60 ml/min per 1.73 m2 and/or positive proteinuria. Cox proportional hazard models were used to evaluate the association, and repeated after propensity score matching. Sensitivity analysis were performed by excluding those with primary aldosteronism.

RESULTS

7961 patients with hypertension were included with 5022 ones with OSA, and 82% were followed up. During median follow-up of 3.42 years, 1486 patients developed CKD. Per 1000 person-year incidence of CKD was 56.72 in OSA group. In Cox regression analysis, OSA and severe OSA group respectively showed 1.21 (95% CI: 1.08-1.35) and 1.27 (95% CI: 1.09-1.47) fold risk for CKD in total, compared with non-OSA group. Overall results remained consistent in propensity score matching and sensitivity analysis.

CONCLUSION

OSA is independently associated with higher risk of chronic kidney disease in hypertension.

Adherence to Positive Airway Pressure Therapy in a Cohort of Colombian Patients with Obstructive Sleep Apnea Syndrome

Objective  To describe the adherence to the use of positive air pressure (PAP) devices in a cohort of patients with sleep apnea syndrome in Colombia. Material and Methods  Descriptive cross-sectional study of adult patients treated between January 2018 and December 2019 in the sleep clinic of a private insurer in Colombia. Results  The analysis included 12,538 patients (51.3% women) with a mean age of 61.3 years; 10,220 patients (81.5%) use CPAP and 1,550 (12.4%) BIPAP. Only 37% are adherent (> 70% of use for 4 hours or more), adherence rates were highest in the >65 years age groups. 2,305 patients (18.5%) were hospitalized, on average 3.2 times; 515 of these (21.3%) had one or more cardiovascular comorbidities. Conclusion  Adherence rates in this sample are lower than those reported elsewhere. They are similar in males and females and tend to improve with age.

Race and Socioeconomic Status: Interlinked Drivers of Sleep Health Disparities

The effect of race and socioeconomic status on sleep disorders has significant effects on the availability of healthcare and health outcomes. This paper examines how race and SES contribute to sleep health disparities, emphasizing the importance of understanding their impact on sleep disorders and treatment particularly in minority populations and veterans.

A QTc risk score in patients with obstructive sleep apnea

INTRODUCTION

Patients with obstructive sleep apnea (OSA) are at risk for QTc prolongation, a known risk factor for increased mortality. The pro-QTc score can help identify individuals at increased risk for mortality associated with increased QTc however, it has not been evaluated in patients with OSA. The goal of this study was to evaluate the pro-QTc score in patients with OSA.

METHODS

Medical records of patients undergoing a sleep study at our sleep center from February 2012 to August 2020 were analyzed. Presence or absence of OSA was determined by polysomnography. The pro-QTc score was calculated with 1 point assigned for each of the following: female sex, QT-prolonging diagnoses and conditions, QT-prolonging electrolyte abnormalities, and medications with known risk for QT-prolongation. Mortality was determined from the electronic medical record of an integrated healthcare system.

RESULTS

There were 2246 patients (age 58 ± 15 years, 54% male, 82 dead) with OSA and 421 patients (age 54 ± 18 years, 43% male, 18 dead) without OSA. Of those with OSA, 1628 (72.5%) had at least one risk factor for QTc prolongation. A higher pro-QTc score was associated with greater mortality in patients with OSA (HR 1.48 per pro-QTc score, p < 0.001, 95% CI 1.3-1.7) but not in patients without OSA (HR 1.25 per pro-QTc score, p = 0.30, 95% CI 0.82-1.9), after adjusting for age, body mass index (BMI), and smoking status.

CONCLUSION

In patients with OSA, a higher pro-QTc score was associated with greater mortality.

Association of insomnia and short sleep duration, alone or with comorbid obstructive sleep apnea, and the risk of chronic kidney disease

STUDY OBJECTIVES

Obstructive sleep apnea (OSA), sleep fragmentation, and short sleep duration (SD) have been associated with chronic kidney disease (CKD). However, these potential mechanisms for CKD have not been compared in the same cohort. This study investigated the independent and combined impact of OSA and insomnia with short sleep duration on the risk of CKD progression in a sleep clinic population.

METHODS

In a cross-sectional study design, adults with suspected OSA completed an overnight sleep study and a questionnaire that included the Insomnia Severity Index (ISI) and Pittsburgh Sleep Quality Index (PSQI). They also provided blood and urine samples for measurement of the glomerular filtration rate and urine albumin:creatinine ratio, from which the risk of CKD progression was determined.

RESULTS

Participants (n = 732, 41% female, 55 ± 13 years) were categorized into four groups: no/mild OSA without insomnia (NM-OSA, n = 203), insomnia with SD without OSA (Insomnia-SD, n = 104), moderate-to-severe OSA without insomnia (MS-OSA, n = 242), and comorbid insomnia and OSA with SD (COMISA-SD, n = 183). After stratification, 12.8% of NM-OSA, 15.4% of Insomnia-SD, 28.9% of MS-OSA, and 31.7% of the COMISA-SD participants had an increased risk of CKD progression. Compared to NM-OSA, the odds ratio (OR) for an increased risk of CKD progression was not increased in Insomnia-SD (OR 0.95, confidence interval [CI]: 0.45-1.99) and was increased to the same degree in MS-OSA (OR 2.79, CI: 1.60-4.85) and COMISA-SD (OR 3.04, CI: 1.69-5.47). However, the ORs were similar between the MS-OSA and COMISA-SD groups across all statistical models (p ≥ .883).

CONCLUSIONS

In a sleep clinic population, insomnia with short sleep duration does not increase the risk of CKD progression; nor does it further increase the risk of CKD progression associated with moderate-to-severe OSA.

Markers of ventricular repolarization and overall mortality in sleep disordered breathing

INTRODUCTION

Variability and prolongation of ventricular repolarization - measured by changes in QT interval and QT variability are independently associated with ventricular arrhythmias, sudden death, and mortality but such studies did not examine the role of sleep-disordered breathing. We aimed to determine whether sleep-disordered breathing moderated the association between measures of ventricular repolarization and overall mortality.

METHODS

Eight hundred participants were randomly selected from each of the following four groups in the Sleep Heart Health Study: mild, moderate, severe or no sleep disordered breathing (n = 200 each). Overnight electrocardiograms were analyzed for QTc duration and QT variability (standard deviation of QT intervals, normalized QT interval variance and the short-term interval beat-to-beat QT variability). Cox proportional hazards penalized regression modeling was used to identify predictors of mortality.

RESULTS

Eight hundred of 5600 participants were randomly selected. The participants (68 ± 10 years; 56.8% male) were followed for an average of 8.2 years during which time 222 (28.4%) died. QTc, SDQT, and QTVN were associated with the presence of SDB (p = 0.002, p = 0.014, and p = 0.024, respectively). After adjusting for covariates, the presence of sleep-disordered breathing did not moderate the association between QTc length, QT variability and mortality (p > 0.05).

CONCLUSION

Sleep-disordered breathing was associated with some measures of ventricular repolarization. However, sleep-disordered breathing was not an effect modifier for the relationship between QTc and QT variability and mortality.

Barriers to positive airway pressure adherence among veterans with sleep apnea: a mixed methods study

Rates of adherence to positive airway pressure (PAP) for sleep apnea are suboptimal. Though previous studies have identified individual factors associated with PAP nonadherence, few projects have investigated a wide range of possible barriers directly from the patient perspective. We examined the range of factors that patients identify as barriers to optimal use of PAP as well as the solutions most commonly offered by providers. We employed a mixed methods design including semistructured interviews and medical record review at a US Department of Veterans Affairs Medical Center. Thirty patients identified as nonadherent to PAP participated. Patients were asked to report on current sleep problems, reasons for nonadherence, and solutions proposed by providers. Chart review was used to identify untreated apnea severity, Epworth Sleepiness Scale score, therapy hours, and residual apnea severity. Patients described physical and psychological barriers to adherent use at approximately equal rates: Mask leaks and dry throat/nose were common physical barriers, and anxiety/claustrophobia and worsening insomnia were common psychological barriers. Untreated apnea severity, residual apnea severity, and daytime sleepiness were not associated with therapy hours. Solutions offered by providers most frequently addressed physical barriers, and solutions to psychological barriers were rarely proposed. The most common solution offered by providers was trying different masks. We recommend individualized assessment of each patient's barriers to use as well as increased involvement of behavioral health providers in sleep medicine clinics.

Sleep-disordered breathing was associated with lower health-related quality of life and cognitive function in a cross-sectional study of older adults

Background and objective

The clinical significance of sleep‐disordered breathing (SDB) in older age is uncertain. This study determined the prevalence and associations of SDB with mood, daytime sleepiness, quality of life (QOL) and cognition in a relatively healthy older Australian cohort.

Methods

A cross‐sectional analysis was conducted from the Study of Neurocognitive Outcomes, Radiological and retinal Effects of Aspirin in Sleep Apnoea. Participants completed an unattended limited channel sleep study to measure the oxygen desaturation index (ODI) to define mild (ODI 5–15) and moderate/severe (ODI ≥ 15) SDB, the Centre for Epidemiological Studies Scale, the Epworth Sleepiness Scale, the 12‐item Short‐Form for QOL and neuropsychological tests.

Results

Of the 1399 participants (mean age 74.0 years), 36% (273 of 753) of men and 25% (164 of 646) of women had moderate/severe SDB. SDB was associated with lower physical health‐related QOL (mild SDB: beta coefficient [β] −2.5, 95% CI −3.6 to −1.3, p < 0.001; moderate/severe SDB: β −1.8, 95% CI −3.0 to −0.6, p = 0.005) and with lower global composite cognition (mild SDB: β −0.1, 95% CI −0.2 to 0.0, p = 0.022; moderate/severe SDB: β −0.1, 95% CI −0.2 to 0.0, p = 0.032) compared to no SDB. SDB was not associated with daytime sleepiness nor depression.

Conclusion

SDB was associated with lower physical health‐related quality of life and cognitive function. Given the high prevalence of SDB in older age, assessing QOL and cognition may better delineate subgroups requiring further management, and provide useful treatment target measures for this age group.

The clinical implications for sleep‐disordered breathing (SDB) in older age remain uncertain. This study of healthy community‐dwelling older Australians reports significant associations between SDB and a lower physical health‐related quality of life, in contrast to other studies of SDB in older age, and between SDB and lower cognitive function.

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Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Effect of nocturnal hypoxemia on glycemic control among diabetic Saudi patients presenting with obstructive sleep apnea

BACKGROUND

Obstructive sleep apnea (OSA) is a prevalent disease that is associated with an increased incidence of type II diabetes mellitus (DM) if left untreated. We aimed to determine the association between glycosylated hemoglobin (HbA1c) levels and both nocturnal hypoxemia and apnea-hypopnea index (AHI) among a Saudi patients with OSA.

METHODS

A cross-sectional study that enrolled 103 adult patients diagnosed with DM and confirmed to have OSA by full night attended polysomnography between 2018 and 2021. Those who presented with acute illness, chronic obstructive pulmonary disease (COPD)/restrictive lung diseases causing sleep-related hypoxemia, or no available HbA1c level within 6 months before polysomnography were excluded from the study. Univariate and multivariate linear regression analyses between HbA1c levels and parameters of interest were tested.

RESULTS

Sixty-seven (65%) of the studied population had uncontrolled DM (HbA1c ≥7%). In univariate regression analysis, there was a significant positive association between HbA1c, and sleep time spent with an oxygen saturation below 90% (T90), female gender, and body mass index (BMI) (p<0.05) but not AHI, or associated comorbidities (p>0.05). In the multivariate analysis, HbA1c was positively associated with increasing T90 (p<0.05), and ODI (p<0.05), but not with AHI (p>0.05).

CONCLUSION

Nocturnal hypoxemia could be an important factor affecting glycemic control in patients with OSA suffering from DM irrespective of the severity of both diseases.

Risk of chronic kidney disease in patients with obstructive sleep apnea

STUDY OBJECTIVES

Chronic kidney disease (CKD) is a global health concern and a major risk factor for cardiovascular morbidity and mortality. Obstructive sleep apnea (OSA) may exacerbate this risk by contributing to the development of CKD. This study investigated the prevalence and patient awareness of the risk of CKD progression in individuals with OSA.

METHODS

Adults referred to five Canadian academic sleep centers for suspected OSA completed a questionnaire, a home sleep apnea test or in-lab polysomnography and provided blood and urine samples for measurement of estimated glomerular filtration rate (eGFR) and the albumin:creatinine ratio (ACR), respectively. The risk of CKD progression was estimated from a heat map incorporating both eGFR and ACR.

RESULTS

1295 adults (42% female, 54±13y) were categorized based on the oxygen desaturation index (4% desaturation): <15 (no/mild OSA, n=552), 15-30 (moderate OSA, n=322), and >30 (severe OSA, n=421). After stratification, 13.6% of the no/mild OSA group, 28.9% of the moderate OSA group, and 30.9% of the severe OSA group had a moderate-to-very high risk of CKD progression (p<0.001), which was defined as an eGFR < 60 mL/min/1.73m2, an ACR ≥3 mg/mmol, or both. Compared to those with no/mild OSA, the odds ratio for moderate-to-very high risk of CKD progression was 2.63 (95% CI: 1.79-3.85) for moderate OSA and 2.96 (2.04-4.30) for severe OSA after adjustment for CKD risk factors. Among patients at increased risk of CKD progression, 73% were unaware they had abnormal kidney function.

CONCLUSION

Patients with moderate and severe OSA have an increased risk of CKD progression independent of other CKD risk factors; most patients are unaware of this increased risk.

Sleep-disordered breathing-related symptoms and risk of stroke: cohort study and Mendelian randomization analysis

BACKGROUND

Sleep-disordered breathing (SDB) may contribute to development of stroke. However, findings are inconclusive. We investigated whether SDB-related symptoms are associated with incidence of stroke and its types in a general community sample of adult men and women as well as to perform Mendelian randomization (MR) analysis.

METHODS

We used data from a cohort of 41,742 Swedish adults (56-94 years of age) who completed questionnaires regarding snoring, cessation of breathing, lifestyle and health characteristics. Participants were followed up for incident stroke and death over 8 years through linkage to the Swedish Registers. Hazard ratios, adjusted for potential confounders, were estimated by Cox proportional hazards regression. MR analyses were performed using single-nucleotide polymorphisms associated with sleep apnea at the genome-wide significance level and summary-level data for stroke and its subtypes from consortia and a meta-analysis of Genome-Wide Association Studies.

RESULTS

In the cohort study, symptoms of disturbing snoring and/or cessation of breathing were associated with increased risk of total stroke (hazard ratio 1.12, 95% confidence interval 1.02-1.24) and intracerebral hemorrhage (hazard ratio 1.59, 95% confidence interval 1.23-2.05) but not with ischemic stroke or subarachnoid hemorrhage. MR analyses showed no association of genetic liability to sleep apnea with the risk of overall stroke or any specific types of stroke or ischemic stroke subtypes.

CONCLUSIONS

SDB-related symptoms were associated with increased risk of total stroke, specifically intracerebral hemorrhage, in the observational analyses but not in the MR analyses. There was limited evidence of an association of SDB with ischemic stroke and subarachnoid hemorrhage.

Is kidney a new organ target in patients with obstructive sleep apnea? Research priorities in a rapidly evolving field

The bidirectional relationship between sleep disordered breathing and chronic kidney disease (CKD) has recently gained a lot of interest. Several lines of evidence suggest the high prevalence of coexistent obstructive sleep apnea (OSA) in patients with CKD and end-stage renal disease (ESRD). In addition, OSA seems to result in loss of kidney function in some patients, especially in those with cardio-metabolic comorbidities. Treatment of CKD/ESRD and OSA can alter the natural history of each other; still better phenotyping with selection of appropriate treatment approaches is urgently needed. The aim of this narrative review is to provide an update of recent studies on epidemiological associations, pathophysiological interactions, and management of patients with OSA and CKD or ESRD.

Age-Specific Associations Between Habitual Snoring and Cardiovascular Diseases in China: A 10-Year Cohort Study

BACKGROUND

Limited convincing evidence is available of the relationship between habitual snoring and cardiovascular diseases (CVDs).

RESEARCH QUESTION

Is habitual snoring associated with total CVD and CVD subtypes in different age groups of Chinese adults?

STUDY DESIGN AND METHODS

The China Kadoorie Biobank study enrolled more than 0.5 million adults aged 30 to 79 years from 10 regions in China. Snoring status and other baseline characteristics were collected from 2004 to 2008, using an interviewer-administered laptop-based questionnaire. The current analysis included 489,583 participants without stroke or coronary heart disease at baseline. Cox proportional hazards models were used to calculate the adjusted hazard ratios (HRs) and 95% CIs of cardiovascular diseases (CVDs) for habitual snoring vs nonhabitual snoring.

RESULTS

During a median follow-up of 9.6 years, 130,935 participants developed CVDs. Associations between habitual snoring and CVDs varied with age. Among participants aged younger than 50 years at baseline, habitual snoring was associated with an increased risk of total CVD (HR, 1.11; 95% CI, 1.07-1.14) after adjustment for known CVD risk factors, including systolic BP. The corresponding HRs (95% CIs) for ischemic heart disease, ischemic stroke, and hemorrhagic stroke were 1.18 (1.12-1.24), 1.12 (1.05-1.19), and 1.05 (0.92-1.19), respectively. However, such associations in adults aged 50 to 64 years were much weaker, and no statistically significant association was observed among individuals aged ≥65 years. Age-specific risk estimates were generally similar across sex and obesity subgroups.

INTERPRETATION

Habitual snoring was associated with increased risks of total CVD, ischemic heart disease, ischemic stroke, but not hemorrhagic stroke in Chinese, and these associations were mainly limited to those aged <50 years. Clinicians in China are encouraged to identify snoring, particularly in younger adults.

Efficacy of metformin monotherapy in US veterans with type 2 diabetes and preexisting chronic kidney disease stage 3

AIM

To evaluate the glycaemic efficacy of metformin in people with type 2 diabetes (T2D) and stage 3 chronic kidney disease (CKD3).

PARTICIPANTS AND METHODS

This was a retrospective study including 145980 US veterans with T2D and an estimated glomerular filtration rate (eGFR) ≥30 mL/min/1.73 m² who initiated metformin monotherapy between November 1999 and July 2017. Propensity-score-matched cohorts were generated based on baseline variables associated with CKD3 (eGFR 30-59 mL/min/1.73 m² ) to evaluate the independent association between CKD3 and metformin discontinuation, the addition of a second hypoglycaemic agent, and changes in glycated haemoglobin (HbA1c) from baseline in those with and without CKD3. Associations were examined using the Kaplan-Meier method and multivariable regression models, adjusted for baseline and 12-month average metformin dose.

RESULTS

The mean age of the entire cohort was 60.7 years, and 95% of the cohort were men, 21% were African American and 9% had CKD3. In the adjusted analyses, patients with CKD3 had a higher risk of metformin discontinuation or addition of a second hypoglycaemic agent, as compared with patients without CKD (hazard ratio [HR] 1.22, 95% confidence interval [CI] 1.19-1.26, and HR 1.26, 95% CI 1.13-1.40, respectively). Among metformin monotherapy users, there were no differences in the average HbA1c reduction from baseline to 12 or 24 months between patients with and without CKD3.

CONCLUSIONS

Individuals with CKD3 and T2D were at increased risk of metformin monotherapy failure. However, the HbA1c-lowering efficacy of metformin was similar in patients with and without CKD3, highlighting that metformin is a valuable treatment option for newly treated individuals with T2D and CKD3.

Sleep apnea in women veterans: results of a national survey of VA health care users

STUDY OBJECTIVES

The goals of this study were to estimate rates of undiagnosed, diagnosed, and treated sleep apnea in women veterans and to identify factors associated with diagnosis and treatment of sleep apnea in this population.

METHODS

A large nationwide postal survey was sent to a random sample of 4,000 women veterans who had received health care at a Veterans Health Administration (VA) facility in the previous 6 months. A total of 1,498 surveys were completed. Survey items used for the current analyses included: demographics; sleep apnea risk, diagnostic status, and treatment; symptoms of other sleep disorders (eg, insomnia); mental health symptoms; and comorbidities.

RESULTS

Among responders, 13% of women reported a prior sleep apnea diagnosis. Among women who reported a diagnosis of sleep apnea, 65% reported using positive airway pressure therapy. A sleep apnea diagnosis was associated with older age, higher BMI, non-Hispanic African American/Black racial/ethnic identity, being unemployed, other sleep disorder symptoms (eg, insomnia), depression and post-traumatic stress disorder symptoms, and multimorbidity. Among women without a sleep apnea diagnosis, 43% scored as "high risk" on the STOP (snoring, tiredness, observed apneas, blood pressure) questionnaire. High risk scores were associated with older age, higher BMI, African American/Black identity, other sleep disorder symptoms (eg, insomnia), mental health symptoms, and multimorbidity. Only BMI differed between women using vs not using positive airway pressure therapy.

CONCLUSIONS

Women veterans with diagnosed sleep apnea were commonly treated with positive airway pressure therapy, which is standard first-line treatment; however, many undiagnosed women were at high risk. Efforts to increase screening, diagnosis, and treatment of sleep apnea in women with comorbid mental and physical health conditions are needed.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.

RESULTS

Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Effect of CPAP Therapy on Kidney Function in Patients With Chronic Kidney Disease: A Pilot Randomized Controlled Trial

BACKGROUND

OSA is common in chronic kidney disease (CKD) and may accelerate a decline in kidney function. It is not clear whether treatment of OSA with CPAP improves kidney function.

RESEARCH QUESTION

Does treatment with CPAP improve kidney function in patients with CKD and coexisting OSA?

STUDY DESIGN AND METHODS

A randomized, controlled, nonblinded, parallel clinical trial was performed of patients with stages 3 and 4 CKD and coexisting OSA comparing the effect of CPAP vs usual care on the estimated glomerular filtration rate (eGFR) and the urine albumin to creatinine ratio (ACR) over 12 months.

RESULTS

Fifty-seven patients were enrolled and 30 were randomized to CPAP. They had moderately severe CKD (eGFR, 38.4 ± 1.5 mL/min/1.73 m²) and significant OSA and nocturnal hypoxemia (oxygen desaturation index: 23.9 events/h; interquartile range [IQR], 20.3 events/h; mean peripheral capillary oxygen saturation: 89.5%; IQR, 1.7%); 60% had baseline albuminuria (ACR, > 3 mg/mmol). No significant difference was found between CPAP and usual care in the change in eGFR and ACR over 12 months. Although some improvement in eGFR occurred with CPAP therapy in patients with a lower risk of CKD progression, this did not reach statistical significance.

INTERPRETATION

Although CPAP did not provide additional renal benefits over usual care in all CKD patients, some evidence suggested that CPAP slowed the decline in eGFR in CKD patients with a lower risk of CKD progression. These preliminary data support the need for larger clinical trials exploring the effects of CPAP on kidney function.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT02420184; URL: www.clinicaltrials.gov.

The impact of obstructive sleep apnoea severity on cardiac structure and injury

BACKGROUND

Obstructive sleep apnoea (OSA) is an important factor in the development and progression of heart failure (HF). The prevalence of OSA is higher in patients with HF than in the general population. We sought to test the hypothesis that OSA severity was predictive of ventricular function and cardiac injury [as assessed by high-sensitivity cardiac troponin I(hs-cTnI)].

METHODS

A total of 60 patients were recruited after evaluation for sleep disturbances using the Jenkins Sleep Questionnaire (JSQ) and Epworth Sleepiness Scale (ESS). Subsequently, they underwent polysomnography thus confirming the diagnosis of OSA and were equally divided into three groups according to OSA severity grade. Following polysomnography, the next morning patients underwent venous blood sampling and echocardiography.

RESULTS

We observed a statistically significant association (P = 0.009) between diastolic dysfunction grades and severity grades of OSA. All the three diastolic dysfunction variables E/A ratio, deceleration time and E/e' ratio had a significant association(P < 0.05) with severity grades of OSA. There was a marginally significant positive correlation (ρ = 0.3244, p = 0.04) between AHI events per hour and mitral E/e' ratio. There was a statistically significant association(P < 0.001) between hs-cTnI value among different severity grades of OSA.

CONCLUSIONS

Here in our study, we found OSA a potential risk factor for development of myocardial injury and diastolic dysfunction. Severe grades of OSA are associated with higher grades of diastolic dysfunction and circulating levels of hs-cTnI. These data are consistent with the notion of a vicious cycle of frequent apnoea's or hypoxemia and recurrent myocardial injury, which could increase the risk of heart failure especially diastolic dysfunction in OSA.

Bidirectional association between chronic kidney disease and sleep apnea: a systematic review and meta-analysis

BACKGROUND

Previous data have suggested a link between chronic kidney disease (CKD) and sleep apnea (SA). However, the prevalence and risk association of both disease entities are not uniformly described.

METHODS

Ovid MEDLINE, EMBASE, and the Cochrane Library were searched for eligible publications that included patients aged ≥ 18 years diagnosed with CKD or SA. Included studies were divided into two cohorts: (1) a cohort of CKD or end-stage kidney disease (ESKD) patients reporting the prevalence of SA or odds ratio (OR) for SA (CKD cohort) and (2) a cohort of SA patients reporting the prevalence of CKD/ESKD or OR for CKD/ESKD (SA cohort).

RESULTS

CKD cohort: Of 16 studies (n = 340,587), the pooled estimated prevalence of SA among CKD/ESKD patients was 47.5% (95% CI 28.8-66.9). The pooled adjusted OR for SA among CKD/ESKD patients was 1.961 (95% CI 1.702-2.260). Male sex, history of diabetes, and lower BMI were associated with increased prevalence of SA. SA cohort: Of 12 studies (n = 3,103,074), the pooled prevalence of CKD/ESKD among patients with SA was 8.2% (95% CI 4.7-13.7), whereas the pooled adjusted OR for CKD/ESKD among patients with SA was 2.088 (95% CI 1.777-2.452). Increasing age, higher BMI, male sex, white race, and history of diabetes were associated with higher prevalence of CKD/ESKD.

CONCLUSION

There was a bidirectional association between CKD/ESKD and SA. Interventions aiming to prevent the progression of either CKD or SA are important.

Comparing VA and Community-Based Care: Trends in Sleep Studies Following the Veterans Choice Act

BACKGROUND

To address concerns about access to care, the Veterans Access, Choice, and Accountability Act of 2014 was enacted to make care available in the community when Veterans Health Administration (VA) care was unavailable or not timely. This paper examined VA referrals for diagnostic sleep studies from federal fiscal year (FY) 2015-2018.

DESIGN

Sleep studies completed between FY2015 and 2018 for Veterans tested within VA facilities (VAF) or referred to VA community care (VACC) providers were identified using VA administrative data files. Sleep studies were divided into laboratory and home studies.

KEY RESULTS

The number of sleep studies conducted increased over time; the proportion of home studies increased in VAF (32 to 47%). Veterans were more likely to be referred for a sleep study to VACC if they lived in a rural or highly rural area (ORs = 1.47 and 1.55, respectively), and had public or public and private insurance (ORs = 2.01 and 1.35), and were less likely to be referred to VACC if they were age 65+ (OR = 0.72) and were in the highest utilization risk based on Nosos score (OR = 0.78). Regression analysis of sleep study type revealed that lab studies were much more likely for VACC referrals (OR = 3.16), for persons living in rural areas (OR = 1.21), with higher comorbidity scores (OR = 1.28) and for ages 44-54, 55 to 64, and 65+ (ORs = 1.12, 1.28, 1.45, respectively) compared to younger Veterans. Veterans with some or full VA copayments (ORs = 0.91 and 0.86, respectively), and overweight Veterans (OR = 0.94) were less likely to have lab studies.

CONCLUSIONS

The number of sleep studies performed on Veterans increased from 2015 to 2018. Access to sleep studies improved through a combination of providing care through the Veteran Choice Program, predominantly used by rural Veterans, and increased use of home sleep studies by VA.

Effects of chronic intermittent hypoxia caused by obstructive sleep apnea on lipopolysaccharide-induced acute lung injury

AIM OF THE STUDY

Obstructive sleep apnea (OSA) is a common disease associated with significant morbidity and mortality. Sleep quality is an important issue; some patients with acute lung injury (ALI) have underlying OSA. However, the potential influences of OSA on ALI have not been reported until now. In this study, we evaluated the impact of preceding intermittent hypoxia (IH), a typical characteristic of OSA, on lipopolysaccharide (LPS)-induced ALI in a mouse model.

METHODS

C57BL/6J mice were randomly divided into four groups: room air-control (RA-CTL), intermittent hypoxia-control (IH-CTL), room air-lipopolysaccharide (RA-LPS), and intermittent hypoxia-lipopolysaccharide (IH-LPS) groups. The mice were exposed to RA or IH (20 cycles/h, FiO₂ nadir 7 ± 0.5%, 8 h/day) for 30 days. The LPS groups received intratracheal LPS on day 28.

RESULTS

The IH-LPS group tended to exhibit more severe inflammation, fibrosis, and oxidative stress compared to the other groups, including the RA-LPS group. Total cell, neutrophil, and eosinophil counts in bronchoalveolar lavage fluid increased significantly in the IH-LPS group compared to the RA-LPS group. Compared to the RA-LPS group, the hydroxyproline level increased significantly in the IH-LPS group. In addition, the IH-LPS group exhibited significantly more terminal deoxynucleotidyl transferase dUTP nick end labeled-positive cells compared to the RA-LPS group.

CONCLUSIONS

We found that prior IH may negatively impact LPS-induced ALI in a mouse model. This result suggests that ALI in patients with OSA may be more of a concern. Further research into the mechanisms underlying the effects of IH on ALI is needed.

Sleep Apnea and the Kidney

Purpose of Review

There are some uncertainties about the interactions between obstructive sleep apnea (OSA) and chronic kidney disease (CKD). We critically reviewed recent studies on this topic with a focus on experimental and clinical evidence of bidirectional influences between OSA and CKD, as well as the effects of treatment of either disease.

Recent Findings

Experimental intermittent hypoxia endangers the kidneys, possibly through activation of inflammatory pathways and increased blood pressure. In humans, severe OSA can independently decrease kidney function. Treatment of OSA by CPAP tends to blunt kidney function decline over time, although its effect may vary. OSA may increase cardiovascular complications and mortality in patients with end-stage renal disease (ESRD), while it seems of little harm after renal transplantation. Excessive fluid removal may explain some of the improvements in OSA severity in ESRD and after transplantation.

Summary

Severe OSA and CKD do interact negatively, mainly through hypoxia and fluid retention. The moderate mutually interactive benefits that treatment of each disease exerts on the other one warrant further studies to improve patient management.

Obstructive Sleep Apnea, Other Sleep Characteristics, and Risk of CKD in the Atherosclerosis Risk in Communities Sleep Heart Health Study

BACKGROUND

Obstructive sleep apnea may be associated with development of CKD through hypoxia, inflammation, and oxidative stress. Individuals with this sleep disorder are also at increased risk for established CKD risk factors, including obesity, hypertension, and type 2 diabetes.

METHODS

We examined the association between obstructive sleep apnea, other sleep characteristics, and risk of incident CKD (stage 3 or higher) in 1525 participants (mean age, 62.5 years; 52.4% women) in the Atherosclerosis Risk in Communities (ARIC) study who completed in-home polysomnography assessments. We used the apnea-hypopnea index (events per hour) to define obstructive sleep apnea severity (normal, <5.0; mild, 5.0-14.9; moderate, 15.0-29.9; and severe, ≥30.0) and defined incident CKD (stage 3 or higher) as eGFR<60 ml/min per 1.73 m² and ≥25% decline from baseline, CKD-related hospitalization or death, or ESKD. Cox proportional hazards regression was used to estimate obstructive sleep apnea severity with risk of incident CKD, adjusting for demographics, lifestyle behaviors, and cardiometabolic conditions.

RESULTS

During 19 years (median) of follow-up, 461 CKD events occurred. After adjustment for demographics and lifestyle behaviors, severe obstructive sleep apnea associated with increased risk of CKD (hazard ratio [HR], 1.51; 95% confidence interval [95% CI], 1.08 to 2.10), which was attenuated after adjustment for body mass index (HR, 1.07; 95% CI, 0.75 to 1.52). No other sleep characteristics associated with incident CKD.

CONCLUSIONS

We found a link between obstructive sleep apnea and an elevated risk of stage 3 CKD or higher, but this association was no longer significant after adjusting for obesity, a risk factor for both conditions. Given the high prevalence of obstructive sleep apnea and CKD among adults, further investigation is warranted.

US Trends in Prevalence of Sleep Problems and Associations with Chronic Kidney Disease and Mortality

BACKGROUND

To better understand the relation between sleep problems and CKD, we examined temporal trends in the prevalence of self-reported sleep problems in adults in the United States and their associations with CKD and all-cause mortality.

METHODS

Using data from 27,365 adult participants in five biannual National Health and Examination Surveys (2005-2006 through 2013-2014), we studied five self-reported sleep problems-trouble sleeping, sleep disorder, nocturia (urinating ≥2 times/night), inadequate sleep (<7 hours/night), and excessive sleep (>9 hours/night)-plus a composite index. We conducted three types of analysis: temporal trends in the prevalence of each sleep measure by CKD status, using model-based standardization; cross-sectional analysis of associations between four CKD measures and each sleep measure, using logistic regression; and survival analysis of the association between each sleep measure and mortality, using Cox regression.

RESULTS

The prevalence of trouble sleeping and sleep disorder increased over the five surveys by 4% and 3%, respectively, whereas the other sleep problems remained relatively stable. All sleep problems, except inadequate sleep, were more common during the study period among adults with CKD than without CKD (40% versus 21% for nocturia; 5% versus 2% for excessive sleep; 30% versus 25% for trouble sleeping; 12% versus 8% for sleep disorder). Both eGFR <30 ml/min per 1.73 m² and albuminuria were positively associated with nocturia and excessive sleep. Excessive sleep and nocturia were also associated with higher mortality (adjusted hazard ratio for >9 versus 7-9 hours/night=1.7; 95% CI, 1.3 to 2.1; and for nocturia=1.2; 95% CI, 1.1 to 1.4).

CONCLUSIONS

The high prevalence of sleep problems among persons with CKD and their associations with mortality suggest their potential importance to clinical practice. Future work could examine the health effects of identifying and treating sleep problems in patients with CKD.

SAS Care 1: sleep-disordered breathing in acute stroke an transient ischaemic attack - prevalence, evolution and association with functional outcome at 3 months, a prospective observational polysomnography study

Sleep-disordered breathing (SDB) is frequent in patients with acute stroke. Little is known, however about the evolution of SDB after stroke. Most of our knowledge stems from smaller cohort studies applying limited cardiopulmonary sleep recordings or from cross-sectional data collected in different populations.

This study aims to determine prevalence, type and intra-individual evolution of SDB based on full-night polysomnography (PSG) in acute stroke and 3 months thereafter. Furthermore, we aimed to identify predictors of SDB in the acute and chronic phase and to evaluate associations between SDB and functional outcome at 3 months (M3).

A total of 166 patients with acute cerebrovascular events were evaluated by full PSG at baseline and 105 again at M3. The baseline prevalence of SDB (apnoea–hypopnoea index (AHI)>5·h⁻¹) was 80.5% and 25.4% of the patients had severe SDB (AHI>30·h⁻¹). Obstructive sleep apnoea was more prevalent than central sleep apnoea (83.8% versus 13%). Mean±SD AHI was 21.4±17.6·h⁻¹and decreased significantly at M3 (18±16.4·h⁻¹; p=0.018). At M3, 91% of all patients with baseline SDB still had an AHI>5·h⁻¹ and in 68.1% the predominant type of SDB remained unchanged (78.9% in obstructive sleep apnoea and 44.4% in central sleep apnoea). The only predictors of SDB at baseline were higher age and body mass index and in the chronic phase additionally baseline AHI. Baseline AHI was associated with functional outcome (modified Rankin score >3) at M3.

The high prevalence of SDB in acute stroke, its persistence after 3 months, and the association with functional outcome supports the recommendation for a rapid SDB screening in stroke patients.

The high prevalence of SDB in acute stroke, its persistence after 3 months and its association with functional outcome support the recommendation for rapid SDB screening in stroke patientshttps://bit.ly/3bFWqV7

Association of Positive Airway Pressure Prescription With Mortality in Patients With Obesity and Severe Obstructive Sleep Apnea: The Sleep Heart Health Study

Importance

The association of positive airway pressure (PAP) with reduced mortality in patients with obstructive sleep apnea (OSA) remains uncertain.

Objective

To investigate the association between PAP prescription and mortality.

Design, Setting, and Participants

This multicenter, population-based cohort study evaluated data from the Sleep Heart Health Study (SHHS), a long-term observational cohort study that included participants between 1995 and 1998, with a mean follow-up of 11.1 years. Analyses were performed in September 2018. Within the SHHS, we compared patients with obesity and severe OSA with (n = 81) and without (n = 311) prescription of PAP therapy, after matching patients from each group by age, sex, and apnea-hypopnea index.

Exposures

Self-reported use of PAP.

Main Outcomes and Measures

All-cause mortality.

Results

Of 392 study participants, 316 (80.6%) were men, and mean (SD) age was 63.1 (11.0) years. Ninety-six deaths occurred; 12 among the prescribed-PAP group and 84 among the nonprescribed-PAP group, yielding crude incidence rates of 12.8 vs 24.7 deaths per 1000 person-years. In Cox multivariate analysis, the hazard ratio (HR) of all-cause mortality for prescribed PAP therapy was 0.38 (95% CI, 0.18-0.81). After propensity matching, the HR of all-cause mortality for prescribed PAP therapy was 0.58 (95% CI, 0.35-0.96). According to survival curves, the difference in mortality appears 6 to 7 years after initiation of PAP therapy.

Conclusions and Relevance

Positive airway pressure prescription is associated with reduced all-cause mortality, and this association appears several years after PAP initiation. If replicated, these findings may have strong clinical implications.

Long-Term Changes in Sleep Disordered Breathing in Renal Transplant Patients: Relevance of the BMI

Sleep disordered breathing (SDB), as defined by the Apnea Hypopnea Index (AHI), is a highly prevalent disturbance in end stage kidney disease. SDB improves early on after renal transplantation but long-term changes in AHI in these patients have not been studied. We studied the long-term changes in AHI in a series of 221 renal transplant patients (mean age: 47 ± 12 years; 70% males) over a median follow up of 35 months. Data analysis was made by the generalized estimating equations method (GEE). On longitudinal observation, the median AHI rose from 1.8 (Interquartile range: 0.6-5.0) to 2.9 (IQR: 1.0-6.6) and to 3.6 (IQR: 1.7-10.4) at the second and third visit, respectively (p = 0.009 by the GEE model and the proportion of patients with moderate to severe SDB rose from 8% to 20%. Longitudinal changes in minimum oxygen saturation (minSaO2) mirrored those in the AHI. In adjusted analyses, repeated measurements of BMI (p < 0.009) emerged as the strongest independent longitudinal correlate of AHI and MinSaO2. The AHI worsens over time in renal transplant patients and longitudinal changes of this biomarker are directly related to simultaneous changes in BMI. Overweight/obesity, a potentially modifiable risk factor, is an important factor underlying the risk of SDB in this population.

Obstructive sleep apnea syndrome and risk of renal impairment: a systematic review and meta-analysis with trial sequential analysis

BACKGROUND

Obstructive sleep apnea syndrome (OSAS) is associated with a variety of systemic diseases. Among patients with chronic kidney diseases (CKD), the prevalence of OSAS is high. OSAS can induce progression of CKD. However, whether or not OSAS can cause renal damage in healthy people is not clear. Thus, the purpose of this meta-analysis was to elucidate whether or not there was an association between OSAS and early renal damage.

METHODS

PubMed, Embase Database, Cochrane Library, Web of Science, China National Knowledge Infrastructure, China Biology Medicine Database, Chinese Scientific Journals Database, and Wanfang Database were searched systematically. The relative risk (RR), weighted mean difference (WMD), and 95% confidence intervals (CI) were used to evaluate the relationship between OSAS and early renal damage. Funnel plot and Egger's test were used to evaluate publication bias, and trial sequential analysis (TSA) was employed to verify the sufficiency of the research conclusions.

RESULTS

A total of 18 studies were analyzed comprising 4,567 participants. Compared with the healthy control group, levels of cystatin C (MD = 0.530, 95% CI 0.423, 0.637, P < 0.01) and proteinuria in patients with OSAS were significantly increased, while the levels of estimated glomerular filtration rate (eGFR) (MD = - 0.194, 95% CI - 0.268, - 0.121, P < 0.01) were significantly decreased. Furthermore, patients with OSAS also had an increased risk of CKD. Subgroup analysis showed that compared with patients without OSAS, the level of serum cystatin C in patients with OSAS was significantly increased independent of hypertension and diabetes, and the eGFR was significantly decreased in patients with moderate to severe OSAS and comorbid hypertension and/or diabetes.

CONCLUSION

In this meta-analysis, OSAS was associated with a higher risk of early renal damage. Patients with OSAS and comorbid hypertension and/or diabetes appear to suffer from severe renal damage.

EAN/ERS/ESO/ESRS statement on the impact of sleep disorders on risk and outcome of stroke

Sleep disorders are highly prevalent in the general population and may be linked in a bidirectional fashion to stroke, which is one of the leading causes of morbidity and mortality.Four major scientific societies established a task force of experts in neurology, stroke, respiratory medicine, sleep medicine and methodology, to critically evaluate the evidence regarding potential links and the impact of therapy. 13 research questions were evaluated in a systematic literature search using a stepwise hierarchical approach: first, systematic reviews and meta-analyses; second, primary studies post-dating the systematic reviews/meta-analyses. A total of 445 studies were evaluated and 88 included. Statements were generated regarding current evidence and clinical practice.Severe obstructive sleep apnoea (OSA) doubles the risk for incident stroke, especially in young to middle-aged patients. Continuous positive airway pressure (CPAP) may reduce stroke risk, especially in treatment-compliant patients. The prevalence of OSA is high in stroke patients and can be assessed by polygraphy. Severe OSA is a risk factor for recurrence of stroke and may be associated with stroke mortality, while CPAP may improve stroke outcome. It is not clear if insomnia increases stroke risk, while pharmacotherapy of insomnia may increase it. Periodic limb movements in sleep (PLMS), but not restless limb syndrome (RLS), may be associated with an increased risk of stroke. Preliminary data suggest a high frequency of post-stroke insomnia and RLS and their association with a less favourable stroke outcome, while treatment data are scarce.Overall, the evidence base is best for OSA relationship with stroke and supports active diagnosis and therapy. Research gaps remain especially regarding insomnia and RLS/PLMS relationships with stroke.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Changes in heart rate variability (HRV) in patients with severe and moderate obstructive sleep apnea before and after acute CPAP therapy during nocturnal polysomnography

INTRODUCTION

Obstructive sleep apnea is an important risk factor for cardiovascular disease. Noninvasive positive pressure ventilation is the standard treatment of this disease, and it can reduce mortality in patients. Dysfunction of the autonomic system is one of the reasons for an increased risk of cardiovascular disease in these patients. The purpose of the present study was to investigate the effect of positive airway pressure (PAP) therapy on heart rate variability (HRV) indices.

METHODS

The study population was comprised of 55 patients, who underwent nocturnal polysomnography for the diagnosis of obstructive sleep apnea and PAP titration on the same night. The levels of continuous positive airway pressure (CPAP) and bilevel positive airway pressure were adjusted to relieve obstructive sleep apnea, hypopnea, and desaturation. The patients' heart changes and cardiac characteristics were recorded before and after the start of routine CPAP therapy. Finally, the cases' sleep and polysomnography tests were analyzed and interpreted in collaboration with a sleep specialist and their cardiac changes with the aid of a cardiologist before and after treatment with CPAP.

RESULTS

The participants were 55 patients at a mean age of 57.04±12.9 years. There were 34 (61.8%) male and 21 (38.2%) female cases. PAP therapy on the same night resulted in a decreased standard deviation of the N-N interval index (p=0.036) and a low-frequency index (p=0.021), as well as increased high-frequency index (p<0.001) and low frequency / high frequency ratios (p=0.008).

CONCLUSION

Our findings indicate a relative improvement in the activity of the autonomic system in patients with obstructive sleep apnea after 1 night of PAP therapy. Overwhelming evidence suggests that improvement in the sympathetic balance can reduce the risk of cardiovascular disease in patients.

Effects of suboptimal adherence of CPAP therapy on symptoms of obstructive sleep apnoea: a randomised, double-blind, controlled trial

Introduction

Continuous positive airway pressure (CPAP) is currently the treatment of choice for sleepiness in patients with obstructive sleep apnoea (OSA); however, adherence is often thought to be suboptimal. We investigated the effects of suboptimal CPAP usage on objective and subjective sleepiness parameters in patients with OSA.

Material and methods

In this 2-week, parallel, double-blind, randomised controlled trial we enrolled moderate-to-severe OSA patients with excessive pre-treatment daytime sleepiness (Epworth sleepiness scale (ESS) score >10 points) who had suboptimal CPAP adherence over ≥12 months (mean nightly usage time 3–4 h). Patients were allocated through minimisation to either subtherapeutic CPAP (“sham CPAP”) or continuation of CPAP (“therapeutic CPAP”). A Bayesian analysis with historical priors calculated the posterior probability of superiority.

Results

Between May, 2016 and November, 2018, 57 patients (aged 60±8 years, 79% male, 93% Caucasian) were allocated in total, and 52 who completed the study (50% in each arm) were included in the final analysis. The unadjusted ESS score increase was 2.4 points (95% CI 0.6–4.2, p=0.01) in the sham-CPAP group when compared to continuing therapeutic CPAP. The probability of superiority of therapeutic CPAP over sham CPAP was 90.4% for ESS, 90.1% for systolic blood pressure and 80.3% for diastolic blood pressure.

Conclusions

Patients with moderate-to-severe OSA and daytime sleepiness are still getting a substantial benefit from suboptimal CPAP adherence, albeit not as much as they might get if they adhered more. Whether a similar statement can be made for even lower adherence levels remains to be established in future trials.

Association of diagnosed obstructive sleep apnea with kidney transplant outcomes

Obstructive sleep apnea (OSA) is common but underdiagnosed among patients with kidney disease. This study examines whether the diagnosis of OSA in kidney transplant recipients (KTR) affected death, death-censored graft failure (DCGF), and acute rejection (AR). We analyzed the records of KTR who underwent transplant between 2000 and 2015. A total of 4014 kidney transplants were performed during the study period. Of these, 415 (10.3%) had a diagnosis of pretransplant OSA. Pretransplant OSA was associated with a higher risk of death in unadjusted analyses. After adjustment for potential confounders, pretransplant OSA was not associated with risk of death (HR = 1.04, 95% CI: 0.80-1.36). Similarly, pretransplant OSA was associated with a slightly higher incidence of DCGF or AR but neither associations were significant (HR: 1.23, 95% CI: 0.85-1.47 for DCGF; HR 1.10, 95% CI: 0.90-1.36 for AR). A total of 117 (3.3%) were diagnosed with de novo OSA after transplant. Similar to the pretransplant OSA, unadjusted HR for death was significantly higher in the de novo OSA group (HR: 1.48, 95% CI: 1.19-1.84); however, after adjustment, de novo OSA was not significantly associated with risk of death (HR: 1.15, 95% CI: 0.92-1.45). Similarly, DCGF and AR rates were not significantly associated with de novo OSA (HR: 1.10, 95% CI: 0.84-1.44 for DCGF; HR 1.10, 95% CI: 0.90-1.33 for AR). Our work did not detect significant associations between OSA and risk of death, graft failure, and rejection but the estimates might be underestimated due to underdiagnosis of OSA.

Sleep apnea and kidney transplant outcomes: findings from a 20-year (1997-2017) historical cohort study

OBJECTIVE/BACKGROUND

A historic cohort single-center study of kidney transplant recipients with graft loss examined the associations between sleep apnea and two transplant outcomes, death with a functioning graft (DWFG), and graft survival time.

PATIENT/METHODS

Adult patients who received transplants and experienced graft failure or DWFG from January 1, 1997 to January 1, 2017 constituted the cohort (n = 322). Data for the study were obtained by merging two secondary data sources: the Organ Procurement and Transplantation Network (OPTN) database and the transplant center's medical records. A Cox regression modeled the association of diagnosed sleep apnea, stratified by year-of transplant surgery, with graft survival time. Using backward elimination, this model was adjusted for recipient age, race/ethnicity, gender, functional status, donor age, and antigen mismatch.

RESULTS

No statistically significant differences were found for proportions of DWFG in those with, versus without, sleep apnea, informing our censoring approach. When examining graft survival time, the Cox regression model was stratified given a sleep apnea and year-of-transplant interaction (p < 0.01, adjusted model). For patients transplanted between 1997 and 2008, sleep apnea was statistically significantly associated with a decreased risk of graft failure or cardiovascular-related DWFG [adjusted Hazard Ratio (aHR) = 0.63, 95%CI, 0.42-0.94]. For patients transplanted between 2009 and 2017, sleep apnea statistically significantly increased the risk of graft failure or cardiovascular-related DWFG (aHR = 2.61, 95%CI, 1.13-6.00).

CONCLUSIONS

In a cohort of transplant recipients with graft loss, sleep apnea increased the risk of graft loss nearly three-fold among patients transplanted between 2009 and 2017. Similar DWFG proportions by sleep apnea presence indicate this risk is likely driven by renal failure, not mortality. Further research on whether treatment of sleep apnea can improve graft survival is warranted.

Snoring and incident chronic kidney disease: a community-based prospective cohort study

OBJECTIVES

Previous studies have shown that symptoms of sleep-disordered breathing are associated with metabolic derangements and vascular disease development. However, the relationship between snoring and renal function is not well investigated. The association between snoring and the development of incident chronic kidney disease (CKD) in subjects with normal renal function was evaluated.

DESIGN

Prospective cohort study.

SETTING

Ansung (rural community) and Ansan (urban community) cities.

PARTICIPANTS

Community-based cohort participants aged 40-69 years.

METHODS

A total of 9062 participants in the Ansung-Ansan cohort study were prospectively followed up from 2001 to 2014. The participants were classified into three groups: non-snorer, <1 day/week and ≥1 day/week. The main outcome was incident CKD, which was defined as an estimated glomerular filtration rate of <60 mL/min/1.73 m² during the follow-up period.

PRIMARY OUTCOME

Incident CKD.

RESULTS

The mean subject age was 52.0±8.9 years, and 4372 (48.2%) subjects were male. The non-snorer,<1 day/week and ≥1 day/week groups included 3493 (38.5%), 3749 (41.4%), and 1820 (20.1%) subjects, respectively. Metabolic syndrome was more prevalent in the snoring groups than in the non-snoring group. Snoring frequency showed a significant positive relationship with age, waist:hip ratio, fasting glucose, total cholesterol (Tchol) and low-density lipoprotein cholesterol. During a mean follow-up of 8.9 years, 764 (8.4%) subjects developed CKD. Cox proportional hazards model analysis revealed that the risk of CKD development was significantly higher in subjects who snored ≥1 day/week than in non-snorers, even after adjustments for confounding factors (HR 1.23, 95% CI 1.09 to 1.38, p<0.01).

CONCLUSION

Snoring may increase the risk of CKD development in subjects with normal renal function.

Drug-Induced Sleep Endoscopy: Technique, Indications, Tips and Pitfalls

Drug-induced sleep endoscopy (DISE) is a diagnostic tool to assess the upper airway of snorers and obstructive sleep apnea patients in conditions that mimic natural sleep. Although DISE appears simple and similar to awake endoscopy, there are many aspects that need to be standardized in order to obtain reliable and reproducible information. In this article, we will recommend how to reliably perform DISE, its indications, and how to obtain and interpret the information of the upper airway.

Chronic kidney disease in patients with obstructive sleep apnea. A narrative review

Prevalence of both chronic kidney disease (CKD) and obstructive sleep apnea (OSA) is continuously increasing. Moreover, the prevalence of OSA increases as kidney function declines and is higher among patients with end-stage renal disease (ESRD). In addition, OSA is recognized as a potential nontraditional risk factor for development and progression of CKD. Continuous positive airway pressure (CPAP) plays a pivotal role in the management of OSA, eliminating patients' symptoms and improving their quality of life. Recent studies suggested that CPAP treatment may have beneficial effects on kidney function among patients with OSA. This narrative review summarizes the existing knowledge on the association between CKD and OSA, with emphasis on the epidemiology, the pathophysiology of the development of CKD in OSA and vice versa, as well as the effect of CPAP on renal function.

Sleep Disorders and Stroke: Does Treatment of Obstructive Sleep Apnea Decrease Risk of Ischemic Stroke?

PURPOSE OF REVIEW

This review aims to support obstructive sleep apnea (OSA) as a risk factor for ischemic stroke, review treatment strategies for OSA, provide a comprehensive review of clinical data on OSA treatment and ischemic stroke risk, and to critically assess if treatment of OSA decreases the risk of ischemic stroke and if treatment improves outcomes and subsequent ischemic stroke risk in post-stroke patients.

RECENT FINDINGS

Several observational studies, randomized controlled trials (RCTs), and meta-analyses have examined the risk of ischemic stroke and cardiovascular events in patients with OSA and have also examined continuous positive airway pressure (CPAP) treatment in these patients. Observational studies have shown an increased risk of ischemic stroke in patients with untreated OSA when compared with patients treated with CPAP; however, results are not statistically significant. RCTs and meta-analyses have shown no significant ischemic stroke risk reduction in CPAP treated patients with OSA. Several studies have shown improved outcomes in post-stroke patients with OSA treated with CPAP; however, few data is available for subsequent ischemic stroke risk reduction. Further research is needed for surgical treatment of OSA and assessment of ischemic stroke risk. OSA is associated with increased risk of ischemic stroke, and OSA should be treated with the appropriate therapy. While the current data is promising, more studies are necessary to state whether treatment of OSA reduces ischemic stroke risk and subsequent ischemic stroke risk. A practical approach to the sleep disorder evaluation and treatment of patients with cerebrovascular disease is outlined.