Excessive Daytime Sleepiness Independently Predicts Increased Cardiovascular Risk After Myocardial Infarction

Excessive daytime sleepiness is associated with increased residual cardiovascular risks among coronary artery disease patients with obstructive sleep apnea

OBJECTIVE

Excessive daytime sleepiness (EDS) frequently accompanies obstructive sleep apnea (OSA) and may increase cardiovascular risks. The majority of coronary artery disease (CAD) patients receive understandard treatments, it is not clear whether EDS is associated with increased residual cardiovascular risks in CAD patients with OSA.

METHOD

This study is a prospective cohort study that included 1215 consecutive CAD patients underwent overnight sleep study with a 3.7 year follow-up. Sleepiness was is determined by the Epworth Sleepiness Scale questionnaire. The primary endpoint was major adverse cardiovascular and cerebrovascular events (MACCE), including cardiovascular death, myocardial infarction, stroke, and heart failure. Kaplan-Meier model and Cox proportional hazards models were used to explore the relationship between residual cardiovascular risks and EDS.

RESULT

1027 cases were eventually enrolled, and a total of 129 patients experienced cardiovascular and cerebrovascular events. Participants with EDS had a higher risk of MACCE compared to those without EDS (17.02% vs. 9.58%, P = 0.005). The presence of EDS is associated with higher incidence of MACCE compared to non-EDS patients (HR 2.833; 95%CI:1.394-5.762; P < 0.001). EDS was significantly associated with increased incidence of MACCE in OSA patients (HR 1.765; 95%CI:1.276-2.543; P = 0.193), while there was no significant association between EDS and cardiovascular risks in non-OSA patients (HR 1.233; 95%CI: 0.893-2.755; P = 0.127).

CONCLUSIONS

The existence of EDS may lead to increased cardiovascular risks, EDS is associated with increased cardiovascular risks in CAD patients, especially in patients with OSA.

[Diabetes and obstructive sleep apnoea: A case-control study]

INTRODUCTION

Obstructive sleep apnoea (OSA) and diabetes mellitus (DM) are very prevalent diseases frequently associated. Their coexistence is independently associated with an increased prevalence of cardiovascular comorbidities. As this association is underdiagnosed, it is necessary to optimise clinical suspicion by studying independent predictors of DM or prediabetes (preDM) in patients with OSA.

METHOD

A simple randomised case-control study, matched for sex, body mass index (BMI) and age, aimed to study the association of OSA with DM and preDM and to identify independent predictors for both diseases in people with OSA.

RESULTS

We included 208 cases with OSA and 208 controls without OSA. In the former, 18.8% had DM compared to only 10.1% in the latter (P=.00). Prevalence of preDM was 41.8% vs. 10.6%, respectively (P=.00). One hundred and twenty-four cases (59.6%) reported excessive daytime sleepiness (EDS) (Epworth scale, 10.5±3.1) vs. 24.5% of the control group (Epworth scale, 6.6±2.9). Apnoea-hypopnoea index (AHI) and O2 desaturation indices (IDO, CT90 and CT80) were significantly higher in the case group. The risk of MD was related to age, nocturnal hypoxaemia and EDS. The risk of pre-MD was related to BMI and AHI.

CONCLUSIONS

OSA is associated with DM and preDM. Age, nocturnal hypoxaemia and EDS are predictors of DM. BMI and AHI are predictors of pre-MD.

Incident Coronary Calcium Score in Patients With OSA With and Without Excessive Sleepiness: Brazilian Longitudinal Study of Adult Health

BACKGROUND

Uncertainty exists about the impact of OSA and its phenotypes on cardiovascular disease.

RESEARCH QUESTION

Are OSA and clinical features such as daytime sleepiness associated with incident subclinical coronary atherosclerosis?

STUDY DESIGN AND METHODS

In this prospective community-based cohort study, we administered a sleepiness questionnaire, actigraphy, and home sleep studies at baseline. Coronary artery calcium (CAC; 64-slice multidetector CT scan imaging) was measured at two different time points throughout the study (baseline, between 2010 and 2014, and follow-up, between 2016 and 2018). Incidence of subclinical atherosclerosis was defined as baseline CAC of 0 followed by CAC of > 0 at a 5-year follow-up visit. The association of incident CAC outcome was assessed using logistic regression. Stratified analyses based on excessive daytime sleepiness (EDS) were performed.

RESULTS

We analyzed 1,956 participants with available CAC scores at baseline (mean age, 49 ± 8 years; 57.9% female; 32.4% with OSA). In covariate-adjusted analyses (n = 1,247; mean follow-up, 5.1 ± 0.9 years), we found a significant association between OSA and incidence of subclinical atherosclerosis (OR, 1.26; 95% CI, 1.06-1.48), with stronger effects among those reporting EDS (OR, 1.66; 95% CI, 1.30-2.12; P = .028 for interaction). Interestingly, EDS per se was not associated with any CAC outcome. An exploratory analysis of the square root of CAC progression (baseline CAC > 0 followed by a numerical increase in scores at follow-up; n = 319) showed a positive association for both OSA (β = 1.084; 95% CI, 0.032-2.136; P = .043) and OSA with EDS (β = 1.651; 95% CI, 0.208-3.094; P = .025).

INTERPRETATION

OSA, particularly with EDS, predicts the incidence and progression of CAC. These results support biological plausibility for the increased cardiovascular risk observed among patients with OSA with excessive sleepiness.

Excessive daytime sleepiness, morning tiredness, and prognostic biomarkers in patients with chronic coronary syndrome

BACKGROUND

Sleep-related breathing disorders (SRBD) are related to cardiovascular outcomes in patients with chronic coronary syndrome (CCS). Whether SRBD-related symptoms are associated with prognostic biomarkers in patients with CCS is not established.

METHODS

Associations between frequency (never/rarely, sometimes, often, always) of self-reported SRBD-related symptoms (excessive daytime sleepiness [EDS]; morning tiredness [MT]; loud snoring; multiple awakenings/night; gasping, choking, or apnea when asleep) and levels of biomarkers related to cardiovascular prognosis (high-sensitivity C-reactive protein [hs-CRP], interleukin 6 [IL-6], high-sensitivity cardiac troponin T [hs-cTnT], N-terminal pro B-type natriuretic peptide [NT-proBNP], cystatin C, growth differentiation factor 15 [GDF-15] and lipoprotein-associated phospholipase A2 activity) were assessed at baseline in 15,640 patients with CCS on optimal secondary preventive therapy in the STABILITY trial. Cross-sectional associations were assessed by adjusted linear regression models testing for trends with the never/rarely category serving as reference.

RESULTS

EDS was associated (geometric mean ratio, 95% confidence interval) with increased levels of IL-6 (often 1.07 [1.03-1.10], always 1.15 [1.10-1.21]), GDF-15 (often 1.03 [1.01-1.06], always 1.07 [1.03-1.11]), NT-proBNP (always 1.22 [1.12-1.33]), and hs-cTnT (always 1.07 [1.01-1.12]). MT was associated with increased levels of IL-6 (often 1.05 [1.01-1.09], always 1.09 [1.04-1.15]), and GDF-15 (always 1.06 [1.03-1.10]). All symptoms were to some degree associated with higher levels of hs-CRP and loud snoring was also associated with decreased levels of NT-proBNP and hs-cTnT.

CONCLUSIONS

In patients with CCS, stepwise increased frequency of SRBD-related symptoms, such as EDS and MT, were associated with gradually higher levels of IL-6 and GDF-15, each reflecting distinct pathophysiological pathways.

Long-term health outcomes for patients with obstructive sleep apnea: placing the Agency for Healthcare Research and Quality report in context-a multisociety commentary

This multisociety commentary critically examines the Agency for Healthcare Research and Quality (AHRQ) final report and systematic review on long-term health outcomes in obstructive sleep apnea. The AHRQ report was commissioned by the Centers for Medicare & Medicaid Services and particularly focused on the long-term patient-centered outcomes of continuous positive airway pressure, the variability of sleep-disordered breathing metrics, and the validity of these metrics as surrogate outcomes. This commentary raises concerns regarding the AHRQ report conclusions and their potential implications for policy decisions. A major concern expressed in this commentary is that the AHRQ report inadequately acknowledges the benefits of continuous positive airway pressure for several established, long-term clinically important outcomes including excessive sleepiness, motor vehicle accidents, and blood pressure. While acknowledging the limited evidence for the long-term benefits of continuous positive airway pressure treatment, especially cardiovascular outcomes, as summarized by the AHRQ report, this commentary reviews the limitations of recent randomized controlled trials and nonrandomized controlled studies and the challenges of conducting future randomized controlled trials. A research agenda to address these challenges is proposed including study designs that may include both high quality randomized controlled trials and nonrandomized controlled studies. This commentary concludes by highlighting implications for the safety and quality of life for the millions of people living with obstructive sleep apnea if the AHRQ report alone was used by payers to limit coverage for the treatment of obstructive sleep apnea while not considering the totality of available evidence.

CITATION

Patil SP, Billings ME, Bourjeily G, et al. Long-term health outcomes for patients with obstructive sleep apnea: placing the Agency for Healthcare Research and Quality report in context-a multisociety commentary. J Clin Sleep Med. 2024;20(1):135-149.

Causal Association Between Subtypes of Excessive Daytime Sleepiness and Risk of Cardiovascular Diseases

BACKGROUND

Excessive daytime sleepiness (EDS), experienced in 10% to 20% of the population, has been associated with cardiovascular disease and death. However, the condition is heterogeneous and is prevalent in individuals having short and long sleep duration. We sought to clarify the relationship between sleep duration subtypes of EDS with cardiovascular outcomes, accounting for these subtypes.

METHODS AND RESULTS

We defined 3 sleep duration subtypes of excessive daytime sleepiness: normal (6-9 hours), short (<6 hours), and long (>9 hours), and compared these with a nonsleepy, normal-sleep-duration reference group. We analyzed their associations with incident myocardial infarction (MI) and stroke using medical records of 355 901 UK Biobank participants and performed 2-sample Mendelian randomization for each outcome. Compared with healthy sleep, long-sleep EDS was associated with an 83% increased rate of MI (hazard ratio, 1.83 [95% CI, 1.21-2.77]) during 8.2-year median follow-up, adjusting for multiple health and sociodemographic factors. Mendelian randomization analysis provided supporting evidence of a causal role for a genetic long-sleep EDS subtype in MI (inverse-variance weighted β=1.995, P=0.001). In contrast, we did not find evidence that other subtypes of EDS were associated with incident MI or any associations with stroke (P>0.05).

CONCLUSIONS

Our study suggests the previous evidence linking EDS with increased cardiovascular disease risk may be primarily driven by the effect of its long-sleep subtype on higher risk of MI. Underlying mechanisms remain to be investigated but may involve sleep irregularity and circadian disruption, suggesting a need for novel interventions in this population.

Unmasking Heterogeneity of Sleep Apnea

Sleep apnea is heterogeneous in multiple dimensions. There are different physiological risk factors that may have clinical relevance. However, assessing them is challenging. An approach to ascertain them using a simple model of ventilatory control has been proposed. It is based, however, on untenable assumptions. There are limited validation data and reproducibility is not stellar. There are also different symptom subtypes. They have been found in multiple population-based and clinical cohorts worldwide. Symptomatic benefit from therapy is most marked in the excessively sleepy subtype. This group may also be the group at increased CV risk from obstructive sleep apnea.

Daytime sleepiness is associated with increased coronary plaque burden among patients with obstructive sleep apnea

PURPOSE

To investigate the cross-sectional associations of daytime sleepiness with coronary plaque volume and composition in patients with obstructive sleep apnea (OSA), and whether or not these associations are modified by age, gender, and obesity.

METHODS

Patients who were confirmed with OSA through respiratory polygraphy and also underwent coronary CTA at a tertiary hospital were consecutively enrolled. The interval between the sleep monitoring and coronary CTA scan was  < 3 months. Every patient completed the Epworth sleepiness scale (ESS) to assess daytime sleepiness, and an ESS score of ≥ 11 was recognized as excessive daytime sleepiness (EDS). Coronary plaque volume and composition were measured using semi-automatic software.

RESULTS

Of the 394 patients with OSA (median [IQR] age, 56.0 [49.0-64.0] years; median [IQR] body mass index, 27.9 [25.5-30.2] kg/m2; median [IQR] apnea-hypopnea index, 21.3 [11.7, 36.3] events/h), a total of 200 patients had EDS. In the overall participants, a significant dose-response relationship between ESS scores and low-attenuation plaque volume was found in the fully adjusted model (P = 0.019). Further analysis demonstrated that there was a significant interactive effect of ESS levels and obesity on coronary plaque volume (all P values for interaction analysis < 0.05). Specifically, ESS levels were associated with total plaque volume, volumes of noncalcified, low-attenuation, and calcified plaque (P = 0.008, 0.006, 0.005, and 0.043 respectively) in obese patients with OSA.

CONCLUSION

Daytime sleepiness is significantly correlated with increased coronary plaque burden among patients with OSA. Thus, clinicians should recognize that patients with OSA reporting high ESS scores, especially those with obesity, are more prone to experience adverse coronary events.

Cardiovascular capacity in adults with obstructive sleep apnoea

BACKGROUND: Obstructive sleep apnoea (OSA) patients have a decreased exercise capacity. Potential cardiovascular capacity in patients with OSA with different severity without known cardiovascular disease has not been described.OBJECTIVE: To evaluate impaired potential exercise cardiovascular capacity during cardiopulmonary exercise testing (CPET) in OSA patients and to compare cardiovascular performance reaction with different severity during graded exercise stages.DESIGN: All participants were accompanied without cardiovascular disease, especially hypertension and arrhythmia. Parameters of different stages were compared between subjects with and without OSA, and among OSA patients with varied severity.RESULTS: Despite having significantly higher peak exercise diastolic blood pressure (DBP) and ventilatory equivalent for CO2 (EQCO₂), patients with OSA had a lower peak oxygen uptake (VO₂), heart rate (HR), heart rate recovery (HRR) and respiratory reserve (BR) than normal subjects. Furthermore, significant correlations were found between VO₂, DBP, EQCO₂, HRR, BR and the apnoea-hypopnea index. In severe OSA, there was a greater difference in HR and HRR during the anaerobic threshold stages.CONCLUSIONS: OSA patients demonstrate reduced potential cardiovascular capacity, even without documented cardiovascular disease. Patients with severe OSA develop impaired exercise capacity at early stage during exercise. These data point to exaggerated haemodynamic response to graded exercise and delayed post-exercise cardiovascular response recovery in OSA patients. CPET can be a supplement for assessment of OSA severity.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Cardiovascular Outcomes in Adults with Coronary Artery Disease and Obstructive Sleep Apnea with versus without Excessive Daytime Sleepiness in the RICCADSA Cinical Trial

Rationale: Recent randomized controlled trials did not show cardiovascular benefits of continuous positive airway pressure (CPAP) in adults with coronary artery disease (CAD) and obstructive sleep apnea (OSA) in intention-to-treat analyses. It has been argued that exclusion of patients with OSA with excessive daytime sleepiness (EDS), who may be most likely to benefit from CPAP treatment, may be a reason for the null results. Objectives: We addressed 1) the effect of concomitant EDS on adverse outcomes in patients with CAD and OSA; and 2) whether the cardiovascular benefit of CPAP adherence differs between individuals with versus without EDS. Methods: This was a secondary analysis of the RICCADSA (Randomized Intervention with CPAP in CAD and Obstructive Sleep Apnea) trial, conducted in Sweden between 2005 and 2013. Data were analyzed from 155 patients with CAD with OSA (apnea-hypopnea index ⩾ 15/h) and EDS (Epworth Sleepiness Scale score ⩾ 10), who were allocated to CPAP and 244 patients without EDS (ESS < 10), who were randomized to CPAP or no CPAP. Patients who were allocated to no CPAP or were nonadherent (CPAP usage < 4 h/night) were compared with adherent patients (CPAP usage ⩾ 4 h/night) at 1-year follow-up. Inverse probability of treatment weighting was applied to mimic randomization of EDS. The primary endpoint was the first event of repeat revascularization, myocardial infarction, stroke, or cardiovascular mortality. Results: The median follow-up was 52.2 months. The incidence of the primary endpoint did not differ significantly between the EDS versus no-EDS groups in the entire cohort. Within the adherent group, patients without EDS had a significantly decreased risk compared with patients with EDS (adjusted hazard ratio, 0.41; 95% confidence interval, 0.20-0.85; P = 0.02). Conclusions: Adverse cardiovascular outcomes did not differ by degrees of EDS for patients with CAD with OSA who were untreated or nonadherent to treatment. CPAP use, at least 4 h/night, was associated with reduced adverse outcomes in participants without EDS. Clinical trial registered with www.clinicaltrials.gov (NCT00519597).

Louis EK, Chahal AA, Schulte PJ, Mansukhani MP, Xie J, Lipford MC, Li N, Ramar K, Caples SM, Gay PC, Olson EJ, Silber MH, Li J, Somers VK. Sex-specific associations between daytime sleepiness, chronic diseases and mortality in obstructive sleep apnea

Objective

Excessive daytime sleepiness (EDS) is common in obstructive sleep apnea (OSA) and has been linked to adverse outcomes, albeit inconsistently. Furthermore, whether the prognostic impact of EDS differs as a function of sex is unclear. We aimed to assess the associations between EDS and chronic diseases and mortality in men and women with OSA.

Methods

Newly-diagnosed adult OSA patients who underwent sleep evaluation at Mayo Clinic between November 2009 and April 2017 and completed the Epworth Sleepiness Scale (ESS) for assessment of perceived sleepiness (N = 14,823) were included. Multivariable-adjusted regression models were used to investigate the relationships between sleepiness, with ESS modeled as a binary (ESS > 10) and as a continuous variable, and chronic diseases and all-cause mortality.

Results

In cross-sectional analysis, ESS > 10 was independently associated with lower risk of hypertension in male OSA patients (odds ratio [OR], 95% confidence interval [CI]: 0.76, 0.69-0.83) and with higher risk of diabetes mellitus in both OSA men (OR, 1.17, 95% CI 1.05-1.31) and women (OR 1.26, 95% CI 1.10-1.45). Sex-specific curvilinear relations between ESS score and depression and cancer were noted. After a median 6.2 (4.5-8.1) years of follow-up, the hazard ratio for all-cause death in OSA women with ESS > 10 compared to those with ESS ≤ 10 was 1.24 (95% CI 1.05-1.47), after adjusting for demographics, sleep characteristics and comorbidities at baseline. In men, sleepiness was not associated with mortality.

Conclusion

The implications of EDS for morbidity and mortality risk in OSA are sex-dependent, with hypersomnolence being independently associated with greater vulnerability to premature death only in female patients. Efforts to mitigate mortality risk and restore daytime vigilance in women with OSA should be prioritized.

Associations between sleep-related symptoms, obesity, cardiometabolic conditions, brain structural alterations and cognition in the UK biobank

OBJECTIVES

Sleep disturbances are increasingly recognized as adversely affecting brain health in aging. Our aim was to investigate interrelations between subjective sleep-related symptoms, obesity, cardiometabolic disorders, brain structure and cognitive decline in a population-based aging sample.

METHODS

Data were extracted from the UK Biobank for anthropometric and demographic information, self-reported sleep behaviours, cardiometabolic measures, structural brain magnetic resonance imaging and cognitive test scores. "Sleep-related symptoms" (SRS) were measured using four questionnaire items: loud snoring, daytime sleepiness, likelihood to nap and difficulty getting up in the morning. Associations were tested using a structural equation model (SEM), adjusted for confounders. Further, multiple regression analysis was used to test for direct relationships between SRS and specific cognitive domains.

RESULTS

Among 36,468 participants with an average age of 63.6 (SD 7.5) years and 46.7% male, we found that SRS were associated with obesity and several pre-existing cardiometabolic disturbances. In turn, cardiometabolic disorders were associated with increased white matter hyperintensities and cortical thinning, which were related to cognitive dysfunction. SRS were also directly related to several structural brain changes and to cognitive dysfunction. Regression analyses showed that SRS were directly associated with slower reaction times, and lower scores in fluid intelligence, working memory and executive function.

CONCLUSIONS

Self-reported sleep-related symptoms were associated with cognitive dysfunction directly and through pre-existing cardiometabolic disorders and brain structural alterations. These findings provide evidence that symptoms of sleep disturbances, here defined primarily by hypersomnolence and snoring, are important risk factors or markers for cognitive dysfunction in an aging population.

Differences in the prevalence of cardiovascular and metabolic diseases coinciding with clinical subtypes of obstructive sleep apnea

BACKGROUND

It is unclear about the cardiovascular and metabolic diseases (CMD) among Chinese patients with different clinical subtypes of obstructive sleep apnea (OSA).

HYPOTHESIS

The prevalence of CMD varies among OSA patients of different clinical subtypes.

METHODS

A total of 1483 Chinese patients with OSA were assessed to evaluate the existence of clinical subtypes of OSA using latent class analysis. We compared the differences in demographic characteristics and prevalence of CMD using ANOVA and χ² tests. Associations between clinical subtypes and disease prevalence were assessed using adjusted logistic regression.

RESULTS

We identified prevalent CMD in Chinese patients with the four subtypes of OSA: excessively sleepy (ES), moderately sleepy with disturbed sleep (ModSwDS), moderately sleepy (ModS), and minimally symptomatic (MinS). The ES subtype had a higher body mass index, average Epworth Sleepiness Scale score, Apnea-hypopnea index, and oxyhemoglobin saturation below 90% compared with the other subtypes (p < .05). The MinS subtype had the lowest mean ESS score (p < .05). We found a significant difference in the prevalence of CMD among the four subtypes, with the highest proportion of cases of CMD in the ES subtype. In adjusted models, significant associations with CMD were also found. ES, ModSwDS, ModS, and MinS subtypes are very high-risk, high-risk, medium-risk, and low-risk in prevalent CMD.

CONCLUSIONS

This study identified four clinical subtypes of OSA in Chinese patients. Each clinical subtype corresponds with a different level of prevalence of CMD; this finding is helpful for the more precise treatment of patients with different clinical manifestations.

Impact of Obstructive Sleep Apnea Syndrome on Ventricular Remodeling after Acute Myocardial Infarction: A Proof-of-Concept Study

Background: Obstructive sleep apnea syndrome (OSA) is common in patients with acute myocardial infarction (AMI). Whether OSA impacts on the ventricular remodeling post-AMI remains unclear. We compared cardiac ventricular remodeling in patients assessed by cardiac magnetic resonance (CMR) imaging at baseline and six months after AMI based on the presence and severity of OSA. Methods: This prospective study included 47 patients with moderate to severe AMI. They all underwent CMR at inclusion and at six months after an AMI, and a polysomnography was performed three weeks after AMI. Left and right ventricular remodeling parameters were compared between patients based on the AHI, AHI in REM and NREM sleep, oxygen desaturation index, and daytime sleepiness. Results: Of the 47 patients, 49% had moderate or severe OSA with an AHI ≥ 15/h. No differences were observed between these patients and those with an AHI < 15/h for left ventricular end-diastolic and end-systolic volumes at six months. No association was found for left and right ventricular remodeling parameters at six months or for the difference between baseline and six months with polysomnographic parameters of OSA severity, nor with daytime sleepiness. Conclusions: Although with a limited sample size, our proof-of-concept study does not report an association between OSA and ventricular remodeling in patients with AMI. These results highlight the complexity of the relationships between OSA and post-AMI morbi-mortality.

Symptom subtypes and risk of incident cardiovascular and cerebrovascular disease in a clinic-based obstructive sleep apnea cohort

STUDY OBJECTIVES

Patients with obstructive sleep apnea (OSA) are at increased risk of cardiovascular and cerebrovascular disease, but predicting those at greatest risk is challenging. Using latent class analysis, patients with OSA can be placed into discrete symptom subtypes. The aim of this study was to determine whether symptom subtypes are associated with future cerebrovascular disease in patients with OSA in a clinic-based cohort.

METHODS

Patients with suspected OSA referred for a polysomnogram at an academic sleep center completed a comprehensive symptom survey. Patients with OSA (apnea-hypopnea index ≥ 5 events/h) were then placed into symptom subtypes based on responses to survey questions using latent class analysis. Cardiovascular events (stroke, myocardial infarction, unstable angina, bypass grafting, percutaneous coronary intervention, cardiac resynchronization therapy, defibrillation) occurring within 8 years of polysomnogram were identified by linkage to provincial health databases.

RESULTS

1,607 patients were studied, of whom 1,292 had OSA. One hundred forty first events occurred within 8 years of polysomnogram. Patients in the excessively sleepy with disturbed sleep subtype had a significantly increased rate of events compared to the minimally symptomatic subtype (hazard ratio = 2.25, 95% confidence interval: 1.02-4.94; P = .04). Two symptoms (restless legs and dozing off or sleeping while talking to someone) were significantly associated with future risk of cerebrovascular disease (hazard ratio = 1.68, 1.12-2.49 and 4.23, 1.61-11.16, respectively).

CONCLUSIONS

Patients with OSA in the clinic who are in the excessively sleepy with disturbed sleep subtype are significantly more likely to have a future cardiovascular event. This underscores the importance of understanding clinical heterogeneity and incorporating symptom subtype definitions into routine clinical care.

CITATION

Allen AJH, Jen R, Mazzotti DR, et al. Symptom subtypes and risk of incident cardiovascular and cerebrovascular disease in a clinic-based obstructive sleep apnea cohort. J Clin Sleep Med. 2022;18(9):2093-2102.

Brazilian Thoracic Association Consensus on Sleep-disordered Breathing

Sleep is essential for the proper functioning of all individuals. Sleep-disordered breathing can occur at any age and is a common reason for medical visits. The objective of this consensus is to update knowledge about the main causes of sleep-disordered breathing in adult and pediatric populations, with an emphasis on obstructive sleep apnea. Obstructive sleep apnea is an extremely prevalent but often underdiagnosed disease. It is often accompanied by comorbidities, notably cardiovascular, metabolic, and neurocognitive disorders, which have a significant impact on quality of life and mortality rates. Therefore, to create this consensus, the Sleep-Disordered Breathing Department of the Brazilian Thoracic Association brought together 14 experts with recognized, proven experience in sleep-disordered breathing.

Implications of sympathetic activation for objective versus self-reported daytime sleepiness in obstructive sleep apnea

STUDY OBJECTIVES

Objective excessive daytime sleepiness (EDS) is associated with systemic inflammation and a higher risk of cardiometabolic morbidity in obstructive sleep apnea (OSA). We hypothesized that OSA with objective EDS is associated with higher levels of sympathetic nerve activity (SNA) when compared with self-reported EDS. We, therefore, examined the associations between objective and self-reported EDS with SNA in patients with OSA.

METHODS

We studied 147 consecutive male patients with OSA from the institutional sleep clinic. Objective EDS and self-reported EDS were defined based on Multiple Sleep Latency Test (MSLT) latency ≤ 8 minutes and Epworth Sleepiness Scale (ESS) > 10, respectively. Twenty-four-hour urinary norepinephrine was used for assessing SNA. Blood pressure (BP) was measured both in the evening and in the morning.

RESULTS

Twenty-four-hour urinary norepinephrine was significantly higher in patients with OSA with objective EDS compared with those without objective EDS (p = 0.034), whereas it was lower in patients with OSA with self-reported EDS compared with those without self-reported EDS (p = 0.038) after adjusting for confounders. Differences in the sympathetic drive were most striking in those with an objective but not self-reported EDS versus those with self-reported but not objective EDS (p = 0.002). Moreover, shorter MSLT latency was significantly associated with higher diastolic BP (β = -0.156, p = 0.049) but not systolic BP. No significant association between ESS scores and BP was observed.

CONCLUSIONS

Objective, but not self-reported EDS, is associated with increased SNA and diastolic BP among males with OSA, suggesting that objective EDS is a more severe phenotype of OSA that is accompanied by higher sympathetic drive, higher BP, and possibly greater cardiovascular morbidity and mortality.

Konsensus-Statement der Österreichischen Gesellschaft für Schlafmedizin (ÖGSM/ASRA) zum Management der residualen exzessiven Tagesschläfrigkeit (rETS) bei obstruktiver Schlafapnoe

Hintergrund

Sechs bis zehn Prozent aller Patienten mit einer obstruktiven Schlafapnoe leiden trotz adäquater nächtlicher Überdrucktherapie oder einer effektiven Alternativtherapie an einer residualen exzessiven Tagesschläfrigkeit (rETS). Die Differentialdiagnose der rETS stellt im klinischen Alltag eine interdisziplinäre Herausforderung dar.

Fragestellung

Entwicklung eines übersichtlichen Leitfadens für die Erkennung, die differentialdiagnostischen Abwägungen und die Möglichkeiten der weiterführenden Behandlung der rETS in der klinischen Praxis.

Material und Methode

MeSH-Analyse basierte Recherche und interdisziplinäre Abstimmung von Fachvertreter:innen der Inneren Medizin und Pneumologie, Neurologie sowie Psychiatrie und Psychotherapie.

Ergebnisse

SPAIN-Checkliste zur systematischen differentialdiagnostischen Exploration der rETS mit den Parametern: S chlafverhalten, P sychische Ursachen, A namnese der Medikation, I nternistische Ursachen und N eurologische Ursachen.

Schlussfolgerungen

Die rETS sollte als behandlungswürdiges Symptom erkannt werden. Sie verlangt nach einer interdisziplinären Abklärung und der individuellen Abstimmung der Behandlung auf die Bedürfnisse der Betroffenen.

Investigation and management of residual sleepiness in CPAP-treated patients with obstructive sleep apnoea: the European view

Excessive daytime sleepiness (EDS) is a major symptom of obstructive sleep apnoea (OSA), defined as the inability to stay awake during the day. Its clinical descriptors remain elusive, and the pathogenesis is complex, with disorders such as insufficient sleep and depression commonly associated. Subjective EDS can be evaluated using the Epworth Sleepiness Scale, in which the patient reports the probability of dozing in certain situations; however, its reliability has been challenged. Objective tests such as the multiple sleep latency test or the maintenance of wakefulness test are not commonly used in patients with OSA, since they require nocturnal polysomnography, daytime testing and are expensive. Drugs for EDS are available in the United States but were discontinued in Europe some time ago. For European respiratory physicians, treatment of EDS with medication is new and they may lack experience in pharmacological treatment of EDS, while novel wake-promoting drugs have been recently developed and approved for clinical use in OSA patients in the USA and Europe. This review will discuss 1) the potential prognostic significance of EDS in OSA patients at diagnosis, 2) the prevalence and predictors of residual EDS in treated OSA patients, and 3) the evolution of therapy for EDS specifically for Europe.

Current and Novel Treatment Options for OSA

Obstructive sleep apnoea is a challenging medical problem due to its prevalence, its impact on quality of life and performance in school and professionally, the implications for risk of accidents, and comorbidities and mortality. Current research has carved out a broad spectrum of clinical phenotypes and defined major pathophysiological components. These findings point to the concept of personalised therapy, oriented on both the distinct clinical presentation and the most relevant pathophysiology in the individual patient. This leads to questions of whether sufficient therapeutic options other than positive airway pressure (PAP) alone are available, for which patients they may be useful, if there are specific indications for single or combined treatment, and whether there is solid scientific evidence for recommendations. This review describes our knowledge on PAP and non-PAP therapies to address upper airway collapsibility, muscle responsiveness, arousability and respiratory drive. The spectrum is broad and heterogeneous, including technical and pharmaceutical options already in clinical use or at an advanced experimental stage. Although there is an obvious need for more research on single or combined therapies, the available data demonstrate the variety of effective options, which should replace the unidirectional focus on PAP therapy.

The analysis of individual pathophysiological composition opens new directions towards personalised treatment of OSA, focusing not only on pharyngeal dilation, but also on technical or pharmaceutical interventions on muscle function or breathing regulationhttps://bit.ly/3sayhkd

Excessive daytime sleepiness: an emerging marker of cardiovascular risk

Excessive daytime sleepiness (EDS) is classically viewed as a consequence of insufficient sleep or a symptom of sleep disorders. Epidemiological and clinical evidence have shown that patients reporting EDS in tandem with sleep disorders (e.g., obstructive sleep apnoea) are at greater cardiovascular risk than non-sleepy patients. While this may simply be attributable to EDS being present in patients with a more severe condition, treatment of sleep disorders does not consistently alleviate EDS, indicating potential aetiological differences. Moreover, not all patients with sleep disorders report EDS, and daytime sleepiness may be present even in the absence of any identifiable sleep disorder; thus, EDS could represent an independent pathophysiology. The purpose of this review is twofold: first, to highlight evidence that EDS increases cardiovascular risk in the presence of sleep disorders such as obstructive sleep apnoea, narcolepsy and idiopathic hypersomnia and second, to propose the notion that EDS may also increase cardiovascular risk in the absence of known sleep disorders, as supported by some epidemiological and observational data. We further highlight preliminary evidence suggesting systemic inflammation, which could be attributable to dysfunction of the gut microbiome and adipose tissue, as well as deleterious epigenetic changes, may promote EDS while also increasing cardiovascular risk; however, these pathways may be reciprocal and/or circumstantial. Additionally, gaps within the literature are noted followed by directions for future research.

Independent Association Between Oxygen Desaturation Index and Cardiovascular Disease in Non-Sleepy Sleep-Disordered Breathing Subtype: A Chinese Community-Based Study

PURPOSE

Non-sleepy sleep-disordered breathing (SDB) is increasingly recognized as an important clinical subtype. The association between non-sleepy SDB and cardiovascular disease (CVD) is not well understood. Our objectives were to investigate the relationship between non-sleepy SDB and CVD and determine which nocturnal hypoxia parameter most strongly reflects this association in a large community population.

PATIENTS AND METHODS

Cross-sectional data from 3626 randomly-selected Chinese community-dwelling participants who underwent overnight type IV sleep monitoring were analyzed. Parameters of nocturnal hypoxemia were extracted from sleep monitoring devices, including mean nocturnal oxygen saturation, lowest oxygen saturation, oxygen desaturation index (ODI), and time with oxygen saturation <90%. An ODI ≥7.0 events/h was considered to signify SDB. An Epworth Sleepiness Scale score of 10 or less indicated no sleepiness.

RESULTS

The SDB rate was 30.7% (1114/3626), of which 96.5% (1075/1114) were considered the non-sleepy SDB subtype. ODI, typical nocturnal intermittent hypoxia indicator for SDB, was independently related to CVD, regardless of whether excessive daytime sleepiness was present. After adjusting for confounders, ODI most strongly reflected the association between non-sleepy SDB and CVD (OR:1.023; 95% CI:1.003-1.043). We observed a nonlinear association between ODI and the prevalence of CVD, where the likelihood of CVD increased with ODI≥10 events/h and a markedly increasing trend was observed with ODI ≥20 events/h (reference ODI = 7.0 events/h). Metabolic parameters, Pittsburgh Sleep Quality Index, and inflammatory marker did not mediate the association between ODI and CVD in the non-sleepy SDB subtype.

CONCLUSION

In the Chinese community-dwelling population, non-sleepy SDB was highly prevalent. ODI, an easily extracted indicator from a type IV sleep monitor, most strongly reflected the association between non-sleepy SDB and CVD.

Reliability and Efficacy of the Epworth Sleepiness Scale: Is There Still a Place for It?

The Epworth sleepiness scale (ESS) is a commonly used questionnaire to evaluate patients for excessive daytime sleepiness (EDS). The ESS has been validated as a measure of EDS, but a number of studies have shown more test-retest variability in clinical settings compared to the original validation study. This observation of higher-than-expected test-retest variability has called into question the utility of the ESS as a clinical tool to assess EDS. The purpose of this review article is to summarize how studies of test-retest variability in clinical populations compare to the original validation study of Johns and to highlight where they differ. Furthermore, use of the ESS as a continuous variable (with no specified cutoff value) versus a categorical variable (normal versus high) is described. These observations are put into a clinical context by comparing the test-retest variability observed on the ESS with that of the multiple sleep latency test (MSLT). Finally, how contributors to ESS scores differ within certain subpopulations is described. The ESS remains an important tool to measure EDS in patient populations, but an awareness of its limitations needs to be considered.

Sleep Apnea-Specific Hypoxic Burden, Symptom Subtypes, and Risk of Cardiovascular Events and All-Cause Mortality

Rationale: Data from population-based cohorts suggest that symptom subtypes and obstructive sleep apnea (OSA)-specific hypoxic burden (HB) could help to better identify patients with OSA at high cardiovascular (CV) risk. Objectives: We aimed to evaluate whether those new markers are associated with the risk of major adverse CV events (MACE) in clinical setting. Methods: Data from the Pays de la Loire cohort were linked to health administrative data to identify the occurrence of MACE (a composite outcome including all-cause mortality, acute myocardial infarction, stroke, and unplanned coronary revascularization) in patients with newly diagnosed OSA and no overt CV disease. Latent class analysis was used to identify subtypes based on eight clinically relevant variables. HB was defined as the total area under the respiratory event-related desaturation curve. Cox proportional hazards models were used to evaluate the association of symptom subtypes and HB with MACE. Measurements and Main Results: Four symptom subtypes were identified (minimally symptomatic [22.0%], disturbed sleep [17.5%], excessively sleepy [49.8%], and moderately sleepy [10.6%]). After a median follow-up of 78 months (interquartile range, 52-109), 592 (11.05%) of 5,358 patients experienced MACE. In a fully adjusted model, HB and overall nocturnal hypoxemia assessed by sleep time with oxygen saturation <90% were the only predictors of MACE (hazard ratio, 1.21; 95% confidence interval, 1.07-1.38; and hazard ratio, 1.34; 95% confidence interval, 1.16-1.55, respectively). The association appeared stronger toward younger patients and women. Conclusion: In clinical setting, patients with OSA who demonstrate elevated OSA-specific HB are at higher risk of a CV event and all-cause mortality. Symptom subtypes were not associated with MACE after adjustment for confounders.

OSA and cardiorespiratory fitness: a review

The effects of untreated obstructive sleep apnea (OSA) on cardiopulmonary function remain unclear. Cardiorespiratory fitness (CRF), commonly reflected by VO₂ max measured during cardiopulmonary exercise testing, has gained popularity in evaluating numerous cardiopulmonary conditions and may provide a novel means of identifying OSA patients with the most clinically significant disease. This emerging testing modality provides simultaneous assessment of respiratory and cardiovascular function with results helping uncover evidence of evolving pathology in either organ system. In this review, we highlight the current state of the literature in regard to OSA and CRF with a specific focus on changes in cardiovascular function that have been previously noted. While OSA does not appear to limit respiratory function during exercise, studies seem to suggest an abnormal cardiovascular exercise response in this population including decreased cardiac output, a blunted heart rate response (ie, chronotropic incompetence), and exaggerated blood pressure response. Surprisingly, despite these observed changes in the cardiovascular response to exercise, results involving VO₂ max in OSA remain inconclusive. This is reflected by VO₂ max studies involving middle-aged OSA patients showing both normal and reduced CRF. As prior studies have not extensively characterized oxygen desaturation burden, we propose that reductions in VO₂ max may exist in OSA patients with only the most significant disease (as reflected by nocturnal hypoxia). Further characterizing this relationship remains important as some research suggests that positive airway pressure therapy or aerobic exercise may improve CRF in patients with OSA. In conclusion, while it likely that severe OSA, via an abnormal cardiovascular response to exercise, is associated with decreased CRF, further study is clearly warranted to include determining if OSA with decreased CRF is associated with increased morbidity or mortality.

CITATION

Powell TA, Mysliwiec V, Brock MS, Morris MJ. OSA and cardiorespiratory fitness: a review. J Clin Sleep Med. 2022;18(1):279-288.

Sleep Apnea and Cardiovascular Disease

PURPOSE OF REVIEW

Obstructive sleep apnea (OSA) is associated with incident coronary and cerebral vascular disease. The mechanisms underlying this association are thought to include increased sympathetic nervous system activity, oxidative stress, and systemic inflammation, with these effects mediated in part by elevated blood pressure and impaired glucose metabolism. In observational studies, OSA treatment with positive airway pressure (PAP) is associated with a reduction in cardiovascular disease risk. The aim of this review is to evaluate evidence from recent clinical trials that tested the impact of OSA treatment on major cardiovascular disease outcomes.

RECENT FINDINGS

Multicenter randomized trials have demonstrated a significant, albeit modest, reduction in blood pressure with OSA treatment. Treatment of OSA has generally not demonstrated improvement in type 2 diabetes mellitus, although limited evidence suggests that treatment may be effective in the prediabetic period. However, recent randomized trials of PAP treatment for OSA failed to demonstrate a reduction in incident or recurrent cardiovascular disease events. This may reflect the enrollment of a mostly non-sleepy study sample, as recent evidence suggests that sleepiness is a predictor of adverse cardiovascular outcomes from OSA. PAP treatment of OSA lowers blood pressure and may improve glucose metabolism; however, randomized clinical trials do not indicate a reduction in cardiovascular risk with treatment of minimally symptomatic OSA patients.

Continuous positive airway pressure and adverse cardiovascular events in obstructive sleep apnea: are participants of randomized trials representative of sleep clinic patients?

STUDY OBJECTIVES

Randomized controlled trials (RCTs) have shown no reduction in adverse cardiovascular (CV) events in patients randomized to continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea (OSA). This study examined whether randomized study populations were representative of OSA patients attending a sleep clinic.

METHODS

Sleep clinic patients were 3,965 consecutive adults diagnosed with OSA by in-laboratory polysomnography from 2006 to 2010 at a tertiary hospital sleep clinic. Characteristics of these patients were compared with participants of five recent RCTs examining the effect of CPAP on adverse CV events in OSA. The percentage of patients with severe (apnea-hypopnea index, [AHI] ≥ 30 events/h) or any OSA (AHI ≥ 5 events/h) who met the eligibility criteria of each RCT was determined, and those criteria that excluded the most patients identified.

RESULTS

Compared to RCT participants, sleep clinic OSA patients were younger, sleepier, more likely to be female and less likely to have established CV disease. The percentage of patients with severe or any OSA who met the RCT eligibility criteria ranged from 1.2% to 20.9% and 0.8% to 21.9%, respectively. The eligibility criteria that excluded most patients were preexisting CV disease, symptoms of excessive sleepiness, nocturnal hypoxemia and co-morbidities.

CONCLUSIONS

A minority of sleep clinic patients diagnosed with OSA meet the eligibility criteria of RCTs of CPAP on adverse CV events in OSA. OSA populations in these RCTs differ considerably from typical sleep clinic OSA patients. This suggests that the findings of such OSA treatment-related RCTs are not generalizable to sleep clinic OSA patients.Randomized Intervention with Continuous Positive Airway Pressure in CAD and OSA (RICCADSA) trial, https://clinicaltrials.gov/ct2/show/NCT00519597, ClinicalTrials.gov number, NCT00519597.Usefulness of Nasal Continuous Positive Airway Pressure (CPAP) Treatment in Patients with a First Ever Stroke and Sleep Apnea Syndrome, https://clinicaltrials.gov/ct2/show/NCT00202501, ClinicalTrials.gov number, NCT00202501.Effect of Continuous Positive Airway Pressure (CPAP) on Hypertension and Cardiovascular Morbidity-Mortality in Patients with Sleep Apnea and no Daytime Sleepiness, https://clinicaltrials.gov/ct2/show/NCT00127348, ClinicalTrials.gov number, NCT00127348.Continuous Positive Airway Pressure (CPAP) in Patients with Acute Coronary Syndrome and Obstructive Sleep Apnea (OSA) (ISAACC), https://clinicaltrials.gov/ct2/show/NCT01335087, ClinicalTrials.gov number, NCT01335087.

Excessive daytime sleepiness, morning tiredness and major adverse cardiovascular events in patients with chronic coronary syndrome

BACKGROUND

Sleep-related breathing disorders (SRBDs), particularly obstructive sleep apnoea, are associated with increased cardiovascular (CV) risk. However, it is not known whether individual questions used for SRBD screening are associated with major adverse CV events (MACE) and death specifically in patients with chronic coronary syndrome (CCS).

METHODS

Symptoms associated with SRBD were assessed by a baseline questionnaire in 15,640 patients with CCS on optimal secondary preventive therapy in the STABILITY trial. The patients reported the frequency (never/rarely, sometimes, often and always) of: 1) loud snoring; 2) more than one awakening/night; 3) morning tiredness (MT); 4) excessive daytime sleepiness (EDS); or 5) gasping, choking or apnoea when asleep. In adjusted Cox regression models, associations between the frequency of SRBD symptoms and CV outcomes were assessed with never/rarely as reference.

RESULTS

During a median follow-up time of 3.7 years, 1,588 MACE events (541 CV deaths, 749 nonfatal myocardial infarctions [MI] and 298 nonfatal strokes) occurred. EDS was associated (hazard ratio [HR], 95% confidence interval [CI]) with increased risk of MACE (sometimes 1.14 [1.01-1.29], often 1.19 [1.01-1.40] and always 1.43 [1.15-1.78]), MI (always 1.61 [1.17-2.20]) and all-cause death (often 1.26 [1.05-1.52] and always 1.71 [1.35-2.15]). MT was associated with higher risk of MACE (often 1.23 [1.04-1.45] and always 1.46 [1.18-1.81]), MI (always 1.61 [1.22-2.14]) and all-cause death (always 1.54 [1.20-1.98]). The other SRBD-related questions were not consistently associated with worse outcomes.

CONCLUSIONS

In patients with CCS, gradually higher levels of EDS and MT were independently associated with increased risk of MACE, including mortality.

Randomized clinical trials of cardiovascular disease in obstructive sleep apnea: understanding and overcoming bias

Three recent randomized control trials (RCTs) found that treatment of obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) did not reduce rates of future cardiovascular events. This article discusses the biases in these RCTs that may explain their negative results, and how to overcome these biases in future studies. First, sample selection bias affected each RCT. The subjects recruited were not patients typically presenting for treatment of OSA. In particular, subjects with excessive sleepiness were excluded due to ethical concerns. As recent data indicate that the excessively sleepy OSA subtype has increased cardiovascular risk, subjects most likely to benefit from treatment were excluded. Second, RCTs had low adherence to therapy. Reported adherence is lower than found clinically, suggesting it is in part related to selection bias. Each RCT showed a CPAP benefit consistent with epidemiological studies when restricting to adherent patients, but was underpowered. Future studies need to include sleepy individuals and maximize adherence. Since it is unethical and impractical to randomize very sleepy subjects to no therapy, alternative designs are required. Observational designs using propensity scores, which are accepted by FDA for studies of medical devices, provide an opportunity. The design needs to ensure covariate balance, including measures assessing healthy user and healthy adherer biases, between regular users of CPAP and non-users. Sensitivity analyses can evaluate the robustness of results to unmeasured confounding, thereby improving confidence in conclusions. Thus, these designs can robustly assess the cardiovascular benefit of CPAP in real-world patients, overcoming biases in RCTs.

Diagnostik und Therapie der residualen Tagesschläfrigkeit bei Patienten mit therapierter obstruktiver Schlafapnoe

Die residuale Tagesschläfrigkeit tritt bei 12–65 % der Schlafapnoe-Patienten unter eingeleiteter Positivdrucktherapie („positive airway pressure“) auf. Eine häufige Ursache ist die geringe PAP-Nutzungszeit. Mögliche weitere Gründe sind ein hoher Rest-Apnoe-Hypopnoe-Index und eine vorhandene Komorbidität. Prädiktoren sind ein initial hoher Epworth-Schläfrigkeitsscore, jüngeres Alter und die erst kurze PAP-Nutzung. Gesichert wird die Restschläfrigkeit mittels objektiver Testverfahren (z. B. multipler Wachbleibetest oder Oxford Sleep Resistance Test [Osler-Test]). Eine der wesentlichen Ursachen für die residuale Schläfrigkeit nach Ausschluss konkurrierender Auslöser ist die stattgehabte intermittierende nächtliche Hypoxämie, die zu nervalen Zellschädigungen, zu hormonellen und genetischen Veränderungen und zu Änderungen des Mikrobioms führen kann.

Die klinischen Beschwerden werden bestimmt durch eine ausgeprägte Tagesschläfrigkeit, depressive Verstimmung und eine Minderung der Lebensqualität.

Nach Ausschluss möglicher therapiebedingter Ursachen kann die residuale Tagesschläfrigkeit medikamentös mit u. a. Modafinil, Armodafinil, Pitolisant oder Solriamfetol behandelt werden. Die genannten Arzneimittel haben unterschiedliche Wirkmechanismen. Die Studien und die Effekte der Substanzen auf die Tagesschläfrigkeit, die Lebensqualität und die Leistungsfähigkeit der Betroffenen werden vorgestellt. Das Nebenwirkungsprofil der Wirkstoffe ist ähnlich. Für die Indikation residuale Schläfrigkeit einer therapierten obstruktiven Schlafapnoe ist in Europa derzeit nur Solriamfetol zugelassen.

Ein vom Autorenteam entworfener Behandlungspfad für Patienten mit therapierter obstruktiver Schlafapnoe mit residualer Tagesschläfrigkeit, von der Erstvorstellung nach Therapiebeginn über die Therapieoptimierung bis hin zu einer medikamentösen Behandlung, wird vorgestellt.

A novel parameter is better than the AHI to assess nocturnal hypoxaemia and excessive daytime sleepiness in obstructive sleep apnoea

To evaluate whether the percentage of total sleep time spent with apnoea and hypopnoea duration time (AHT%) is better than the apnoea-hypopnoea index (AHI) for the assessment of nocturnal hypoxaemia and excessive daytime sleepiness (EDS) in patients with obstructive sleep apnoea (OSA). Patients with suspected OSA were enrolled. Polysomnography, Epworth Sleepiness Scale, self-administered surveys and anthropometric measures were performed. The efficiency of AHT% and the AHI was evaluated for nocturnal hypoxaemia and EDS. A total of 160 eligible participants were analysed. The median AHT% in normal, mild, moderate and severe OSA patients was significantly different in the four-group patients with OSA. Spearman rank correlations analysis found that the associations were stronger between AHT% with percentage of total sleep time and O₂ saturation of < 90% and minimum nocturnal oxygen saturation than these parameters with the AHI. AHT% had a greater area under the curve than the AHI for predicting EDS in patients with OSA. AHT% was significantly higher in the EDS group. We present a novel parameter, AHT%, to evaluate nocturnal hypoxaemia and EDS in OSA patients. AHT% partially compensates for the shortcomings of the AHI. AHT% is better than the AHI for assessing nocturnal hypoxaemia and EDS. AHT% reflects different clinical characteristics associated with OSA from a new perspective.

Obstructive Sleep Apnea as a Cardiovascular Risk Factor-Beyond CPAP

Patients with obstructive sleep apnea (OSA) experience repetitive partial or complete airway collapse during sleep resulting in nocturnal hypoxia-normoxia cycling, and are at increased cardiovascular risk. The number of apneas and hypopneas indexed per hour of sleep (apnea-hypopnea index) along with the associated intermittent hypoxia predict the increased cardiovascular risk; thus, their attenuation or prevention are objectives of OSA therapy. Continuous positive airway pressure (CPAP) is the gold standard treatment for OSA and, when effective, mitigates the apnea-hypopnea index and hypoxemia. As such, it is reasonable to expect CPAP would decrease cardiovascular risk. However, 3 recent randomized clinical trials of CPAP vs usual care did not show any significant effects of CPAP in attenuating incident cardiovascular events in patients with OSA. In this review, we discuss these studies in addition to potential complementary therapeutic options to CPAP (eg, neurostimulation) and conclude with suggested therapeutic targets for future interventional studies (eg, the autonomic nervous system). Although these areas of research are exciting, they have yet to be tested to any similar degree of rigour as CPAP.

Obstructive sleep apnea increases heart rhythm disorders and worsens subsequent outcomes in elderly patients with subacute myocardial infarction

OBJECTIVE

Obstructive sleep apnea (OSA) is a potential cardiovascular risk. We aimed to investigate the association of OSA with heart rhythm disorders and prognosis in elderly patients with new-onset acute myocardial infarction (AMI).

METHODS

We prospectively enrolled 252 AMI elderly patients (mean age, 68.5 ± 6.9 years) who were undergoing revascularization and completed a sleep study during their hospitalization. All subjects were categorized into non-OSA (apnea–hypopnea index (AHI) < 15, n = 130) and OSA (AHI ≥ 15, n = 122) groups based on the AHI. The changes in the autonomic nervous system, incidence of arrhythmia during nocturnal sleep, and major adverse cardiovascular and cerebrovascular events (MACCEs) were compared between the groups.

RESULTS

The mean AHI value in all AMI patients was 22.8 ± 10.9. OSA patients showed higher levels of body mass index and peak high-sensitivity C-reactive protein and lower levels of minimum nocturnal oxygen saturation (MinSaO₂), as well as greater proportion of multivessel coronary artery disease (all P < 0.05). The OSA group also showed significant increases in heart rate variability and heart rate turbulence onset (both P < 0.05) and higher incidence of arrhythmia (including sinus, atrial, and ventricular in origin). At a median follow-up of 6 months (mean 0.8–1.6 years), OSA (AHI ≥ 15) combined with hypoxia (MinSaO ₂ ≤ 80%) was independently associated with the incidence of MACCEs (hazard ratio [HR]: 4.536; 95% confidence interval [CI]: 1.461−14.084,P = 0.009) after adjusting for traditional risk factors.

CONCLUSIONS

OSA and OSA-induced hypoxia may correlate with the severity of myocardial infarction, increase the occurrence of heart rhythm disorders in elderly subacute MI patients, and worsen their short-term poor outcomes.

Atherogenic Index of Plasma in Obstructive Sleep Apnoea

Background: Dyslipidaemia is well recognised in obstructive sleep apnoea (OSA) and could contribute to the development of cardiovascular disease (CVD). Atherogenic index of plasma (AIP) predicts cardiovascular morbidity and mortality better than the individual lipid levels. The aim of this study was to investigate the AIP in patients with OSA in relation with disease severity. Methods: Four hundred sixty-one patients with OSA and 99 controls participated in this study. AIP was assessed in the morning following a diagnostic sleep study. The association between lipid values and OSA were adjusted for age, gender, and body mass index. Results: Patients with OSA had higher AIP and triglyceride, and lower high-density lipoprotein cholesterol (HDL-C) levels (all p < 0.05). AIP significantly correlated with the Epworth Sleepiness Scale score (ρ = 0.19), the apnoea-hypopnoea index (ρ = 0.40) and oxygen desaturation index (ρ = 0.43, all p < 0.05). However, there was no relationship between the AIP and markers of sleep quality such as total sleep time, sleep period time, sleep efficiency, arousal index or percentage of REM sleep (all p > 0.05). AIP was not a better predictor for self-reported cardiovascular disease or diabetes than HDL-C. Conclusions: AIP is elevated in OSA and is related to disease severity. However, it does not seem to have an additional clinical value compared to HDL-C.

Prevalence of Major Cardiovascular Disease Events Among People Diagnosed With Schizophrenia Who Have Sleep Disturbance, Sedentary Behavior, or Muscular Weakness

Objective

To estimate prevalence of major cardiovascular events among people with schizophrenia who had experience of sleep disturbance, sedentary behavior or muscular weakness, and assess evidence for raised prevalence in these individuals compared to people with schizophrenia without these characteristics.

Methods

UK Biobank data on individuals diagnosed with schizophrenia (n = 1544) were used to examine the prevalence of major cardiovascular events, specifically myocardial infarction, stroke, heart failure and cardiovascular death, among participants with candidate risk factors. Generalized linear models were fitted to estimate prevalence ratios (PRs) for major cardiovascular events among participants with self-reported sleep disturbance, self-reported sedentary behavior, and muscular weakness measured using a handgrip dynamometer. These ratios were adjusted for QRISK3 score—a validated cardiovascular risk prediction algorithm for the UK population.

Results

Prevalence of major cardiovascular events was significantly higher among participants with daytime sleepiness, independent of QRISK3 score, and snoring, a proxy for sleep-disordered breathing (adjusted PR 1.26; 95% CI 1.03, 1.55, P = .03). Prevalence was also independently higher among participants with low muscular strength (adjusted PR1.36; 95% CI 1.05, 1.75, P = .02). The adjusted prevalence ratios among participants with short or prolonged sleep duration, insomnia, or sedentary behavior did not indicate independently raised prevalence among these groups.

Conclusion

Prevalence of major cardiovascular events among people with schizophrenia was higher in participants with muscular weakness and sleep disturbance evidenced by daytime sleepiness. Further research is required to determine how these factors can be routinely identified and addressed in the clinical management of cardiovascular risk among patients with schizophrenia.

Excessive Daytime Sleepiness and Cardiovascular Mortality in US Adults: A NHANES 2005-2008 Follow-Up Study

PURPOSE

Excessive daytime sleepiness is highly prevalent and has been associated with increased risk of cardiovascular diseases, but evidence for its association with cardiovascular mortality is limited and inconsistent. We aimed to determine whether excessive daytime sleepiness is independently associated with cardiovascular mortality in general adult population.

PATIENTS AND METHODS

A prospective study of 10,330 adult participants (aged ≥20 years) from National Health and Nutrition Examination Survey (NHANES) 2005-2006 and 2007-2008 was followed up until December 31st, 2015. Excessive daytime sleepiness was defined as the self-reported feeling of being overly sleepy often or always during the day. Cox proportional hazard ratios (HRs) with 95% confidence interval (CI) were estimated to assess risk for cardiovascular mortality.

RESULTS

A total of 10,330 participants with mean age of 47.3 years (95% CI, 46.0 to 48.1) were included in this analysis. Approximately, 18.5% of US adults reported excessive daytime sleepiness. Over a mean follow-up of 8.3 years, 262 cardiovascular deaths occurred. Participants with excessive daytime sleepiness had 2.85-times greater risk (95% CI, 1.33-6.09) of cardiovascular death than those without daytime sleepiness in multivariable analysis corrected for sociodemographic factors, comorbidities and cardiovascular risk factors including depression. Further adjustment for self-reported sleep disorders and sleep duration only slightly attenuated this association (HR, 2.55; 95% CI, 1.23-5.27). No interactions between excessive daytime sleepiness and age, sex or cardiovascular disease at study entry were observed (all Ps>0.05).

CONCLUSION

Excessive daytime sleepiness is highly prevalent among US adults and is independently associated with an approximately two-and-a-half-fold increased risk of cardiovascular mortality in a large national sample. Screening for excessive daytime sleepiness may be a simple and cost-effective tool for identifying individuals at high risk of cardiovascular death.

Evaluation of a multicomponent grading system for obstructive sleep apnoea: the Baveno classification

New findings on pathophysiology, epidemiology, and outcome have raised concerns on the relevance of the apnoea-hypopnoea index (AHI) in the classification of obstructive sleep apnoea (OSA) severity. Recently, a multicomponent grading system decision integrating symptomatology and comorbidities (Baveno classification), was proposed to characterise OSA and to guide therapeutic decisions. We evaluated whether this system reflects the OSA population, whether it translates into differences in outcomes, and whether the addition of AHI improves the scheme. A total of 14 499 OSA patients from the European Sleep Apnoea Database cohort were analysed. The groups were homogeneously distributed and were found to clearly stratify the population with respect to baseline parameters. Differences in sleepiness and blood pressure between the groups were analysed in a subgroup of patients after 24-36 months of treatment. Group A (minor symptoms and comorbidities) did not demonstrate any effect of treatment on outcome. However, groups B (severe symptoms, minor comorbidities), C (minor symptoms, severe comorbidities) and D (severe symptoms and comorbidities) were associated with improvement in either or both parameters with treatment. The AHI is an essential prerequisite of the diagnosis; however, adding the AHI did not improve the classification. Rather, it was inferior with respect to guiding the treatment decision. Thus, the Baveno classification allows a better stratification of the OSA population and may provide a better guidance for therapeutic decisions in OSA.

Diagnosis and Management of Obstructive Sleep Apnea: A Review

IMPORTANCE

Obstructive sleep apnea (OSA) affects 17% of women and 34% of men in the US and has a similar prevalence in other countries. This review provides an update on the diagnosis and treatment of OSA.

OBSERVATIONS

The most common presenting symptom of OSA is excessive sleepiness, although this symptom is reported by as few as 15% to 50% of people with OSA in the general population. OSA is associated with a 2- to 3-fold increased risk of cardiovascular and metabolic disease. In many patients, OSA can be diagnosed with home sleep apnea testing, which has a sensitivity of approximately 80%. Effective treatments include weight loss and exercise, positive airway pressure, oral appliances that hold the jaw forward during sleep, and surgical modification of the pharyngeal soft tissues or facial skeleton to enlarge the upper airway. Hypoglossal nerve stimulation is effective in select patients with a body mass index less than 32. There are currently no effective pharmacological therapies. Treatment with positive airway pressure lowers blood pressure, especially in patients with resistant hypertension; however, randomized clinical trials of OSA treatment have not demonstrated significant benefit on rates of cardiovascular or cerebrovascular events.

CONCLUSIONS AND RELEVANCE

OSA is common and the prevalence is increasing with the increased prevalence of obesity. Daytime sleepiness is among the most common symptoms, but many patients with OSA are asymptomatic. Patients with OSA who are asymptomatic, or whose symptoms are minimally bothersome and pose no apparent risk to driving safety, can be treated with behavioral measures, such as weight loss and exercise. Interventions such as positive airway pressure are recommended for those with excessive sleepiness and resistant hypertension. Managing asymptomatic OSA to reduce cardiovascular and cerebrovascular events is not currently supported by high-quality evidence.

Sleep Disordered Breathing in Hypertrophic Cardiomyopathy-Current State and Future Directions

Hypertrophic cardiomyopathy (HCM) is the most common inherited cardiomyopathy and sleep disordered breathing (SDB) is a treatable risk factor that has been seen to occur concurrently, and is known to propagate mortality and morbidity in a number of cardiovascular disease states including heart failure, and indeed hypertrophic cardiomyopathy. In this review, we summarize past studies that explored the simultaneous occurrence of HCM and SDB, and the pathophysiology of SDB in relation to heart failure, arrhythmias, cardiac ischemia and pulmonary hypertension in HCM. The current therapeutic modalities, with the effect of obstructive sleep apnea (OSA) treatment on HCM, are then discussed along with potential future directions.

Analysis of patients with obstructive sleep apnea with and without pharyngeal myopathy using brain neuroimaging

STUDY OBJECTIVES

Elements impairing upper airway anatomy or muscle function (e.g. pharyngeal neuromyopathy) contribute to obstructive sleep apnea syndrome (OSAS). Structural brain imaging may differ in patients with OSAS according to dilator muscle dysfunction. Magnetic resonance imaging (MRI) with voxel-based morphometry (VBM) and surface-based morphometry (SBM) was used to investigate this hypothesis.

METHODS

Eighteen patients with OSAS and 32 controls underwent 3T brain MRI. T1 volumetric images were used for structural analysis. Pharyngeal electroneuromyography was performed; patients with OSAS were classified as with or without neuromyopathy. VBM and SBM analyses were conducted using SPM12 and CAT12 software. Image processing was standard. Cortical surface parameters and gray and white matter volumes from participants with OSAS with and without neuromyopathy were compared with those from controls.

RESULTS

Eleven patients had OSAS with neuromyopathy and seven patients had OSAS without neuromyopathy (normal pharyngeal electroneuromyography). Comparing these groups to the controls, VBM revealed: four clusters (total volume 15,368 mm3) for patients with neuromyopathy, the largest cluster in the left cerebellum (9,263 mm3, p = 0.0001), and three clusters (total 8,971 mm3) for patients without neuromyopathy, the largest cluster in the left cerebellum (5,017 mm3, p = 0.002). Patients with OSAS with neuromyopathy showed increased proportion of atrophy (p < 0.0001). SBM showed abnormalities in patients without neuromyopathy (decreased cortical thickness, left precentral gyrus [672 vertices, p = 0.04]; increased cortical complexity, right middle temporal gyrus [578 vertices, p = 0.032]).

CONCLUSION

Damaged areas were larger in patients with OSAS with than in those without neuromyopathy, suggesting differences in brain involvement. Patients with OSAS and neuromyopathy may be more susceptible to cerebral damage.

Obstructive Sleep Apnoea Syndrome: Continuous Positive Airway Pressure Therapy for Prevention of Cardiovascular Risk

Obstructive sleep apnoea (OSA) syndrome is characterised by the presence of apnoea or obstructive hypopnoea during sleep, accompanied by hypoxia. It is estimated that the syndrome affects approximately 10% of men and 15% of women. Diagnosis and treatment rates have increased in recent years, but the condition remains undiagnosed in a high percentage of patients. Recent evidence suggests that OSA may increase the risk of cardiovascular disease. The relationship between OSA and cardiovascular disease can be explained, at least in part, by the coexistence of cardiovascular risk factors in the two pathologies, such as age, overweight, smoking and sedentary lifestyle. However, OSA has been independently associated with the risk of developing hypertension, cerebrovascular disease, ischaemic heart disease, heart failure and arrhythmias. Clinical trials that have evaluated the efficacy of continuous positive airway pressure (CPAP) treatment in primary and secondary cardiovascular prevention have not demonstrated a significant reduction in the incidence or recurrence of cardiovascular events. This article analyses the relationship between OSA and cardiovascular risk and discusses recent clinical trials on the efficacy of CPAP in primary and secondary cardiovascular prevention.

Sleep Apnea and Cardiovascular Disease: An Enigmatic Risk Factor

Synchronization of molecular, metabolic, and cardiovascular circadian oscillations is fundamental to human health. Sleep-disordered breathing, which disrupts such temporal congruence, elicits hemodynamic, autonomic, chemical, and inflammatory disturbances with acute and long-term consequences for heart, brain, and circulatory and metabolic function. Sleep apnea afflicts a substantial proportion of adult men and women but is more prevalent in those with established cardiovascular diseases and especially fluid-retaining states. Despite the experimental, epidemiological, observational, and interventional evidence assembled in support of these concepts, this substantial body of work has had relatively modest pragmatic impact, thus far, on the discipline of cardiology. Contemporary estimates of cardiovascular risk still are derived typically from data acquired during wakefulness. The impact of sleep-related breathing disorders rarely is entered into such calculations or integrated into diagnostic disease-specific algorithms or therapeutic recommendations. Reasons for this include absence of apnea-related symptoms in most with cardiovascular disease, impediments to efficient diagnosis at the population level, debate as to target, suboptimal therapies, difficulties mounting large randomized trials of sleep-specific interventions, and the challenging results of those few prospective cardiovascular outcome trials that have been completed and reported. The objectives of this review are to delineate the bidirectional interrelationship between sleep-disordered breathing and cardiovascular disease, consider the findings and implications of observational and randomized trials of treatment, frame the current state of clinical equipoise, identify principal current controversies and potential paths to their resolution, and anticipate future directions.