Continuous positive airway pressure treatment of mild to moderate obstructive sleep apnea reduces cardiovascular risk

Feasibility and acceptability of switching from a previous-generation to a new-generation mask for positive airway pressure therapy of sleep apnea using remote care

Purpose

Mask selection could affect an individual's experience with positive airway pressure (PAP) treatment for obstructive sleep apnea, but there is very limited data on the impact of switching to a different mask once established on PAP therapy. This study investigated the patient's experience when switching from a previous-generation PAP mask to a new-generation mask via remote care.

Methods

A new-generation mask (AirFit F30i or AirFit N30i) was successfully fitted to 215 participants during video conferencing sessions. Participants completed online questionnaires on day 1, day 3, day 7, day 30 and day 90 after mask switch to collect subjective feedback and quality of life data; objective PAP device data were also downloaded.

Results

Residual apnea-hypopnea index showed statistically significant difference from baseline at day 30 (+0.2 ± 0.9/h [p = 0.026]) and day 90 (+0.2 ± 0.8/h [p = 0.006]), however unlikely to be clinically relevant. Average daily usage was significantly increased from baseline at day 30 (+0.2 ± 1.2 h/day [p = 0.010]) but not day 90 (+0.1 ± 1.0 h/day [p = 0.126]). Functional Outcomes of Sleep Questionnaire (FOSQ-10) score was significantly higher at day 90 (change from baseline to day 90: +0.48 ± 2.29 [p = 0.015]). Subjective ratings for comfort, seal, and usability of the new-generation mask were significantly better than the predefined acceptability level. Rates of PAP-related side effects were generally acceptable.

Conclusion

Remote management of mask change was associated with good outcomes in terms of objective device data and patient acceptability. This approach could be used to improve the overall therapy experience for individuals requiring a PAP therapy mask change for any reason.

Clinical trial registration

http://clinicaltrials.gov (NCT05262439).

Association Between Healthy Behaviors and Health Care Resource Use With Subsequent Positive Airway Pressure Therapy Adherence in OSA

BACKGROUND

The healthy adherer effect has gained increasing attention as a potential source of bias in observational studies examining the association of positive airway pressure (PAP) adherence with health outcomes in OSA.

RESEARCH QUESTION

Is adherence to PAP associated with healthy behaviors and health care resource use prior to device prescription?

STUDY DESIGN AND METHODS

Data from the Institut de Recherche en Santé Respiratoire (IRSR) des Pays de la Loire Sleep Cohort were linked to health administrative data to identify proxies of heathy behaviors, including adherence to cardiovascular (CV) drugs (medical possession ratio), cancer screening tests, influenza vaccination, alcohol and smoking consumption, and drowsiness-related road accidents during the 2 years preceding PAP onset in patients with OSA. Multivariable regression analyses were conducted to evaluate the association of heathy behaviors with subsequent PAP adherence. Health care resource use was evaluated according to subsequent PAP adherence.

RESULTS

We included 2,836 patients who had started PAP therapy between 2012 and 2018 (65% of whom were PAP adherent with mean daily use ≥ 4 h/night). Being adherent to CV active drugs (medical possession ratio ≥ 80%) and being a person who does not smoke were associated with a higher likelihood of PAP adherence (OR, 1.43; 95% CI, 1.15-1.77 and OR, 1.37; 95% CI, 1.10-1.71, respectively). Patients with no history of drowsiness-related road accidents were more likely to continue PAP (OR, 1.39; 95% CI, 1.04-1.87). Patients who were PAP adherent used less health care resources 2 years before PAP initiation than patients who were nonadherent (mean number of outpatient consultations: 19.0 vs 17.2, P = .003; hospitalization days: 5.7 vs 5.0; P = .04; ED visits: 30.7% vs 24.0%, P = .0002, respectively).

INTERPRETATION

This study indicated that patients who adhere to PAP therapy for OSA were more health-seeking and used less health care resources prior to device initiation than patients who were nonadherent. Until the healthy adherer effect associated with PAP adherence is better understood, caution is warranted when interpreting the association of PAP adherence with CV health outcomes and health care resource use in nonrandomized cohorts.

Assessment and management of continuous positive airway pressure therapy in patient with obstructive sleep apnea

Obstructive sleep apnea (OSA) causes excessive daytime sleepiness, impaired daytime functioning, and an increased risk of cardiovascular diseases. Continuous positive airway pressure (CPAP) is a highly effective therapy for moderate to severe OSA. Although CPAP adherence is commonly assessed using a 4-hthreshold, determining the optimal usage time based on clinical outcomes is crucial. While subjective sleepiness often improves with ≥4 h of CPAP usage, an extended duration (≥6 h) may be necessary to impact objective sleepiness. CPAP demonstrated a modest yet clinically meaningful dose-dependent effect on lowering blood pressure. For patients seeking antihypertensive benefits from CPAP therapy, the goal should extend beyond 4 h of use to maximize the therapeutic impact. Recognizing individual variations in sleep duration and responses to CPAP therapy is essential. The adoption of 'individualized goals for CPAP use,' outlining target times for specific outcomes, should also consider an individual's total sleep duration, including periods without CPAP. The impact of CPAP on clinical outcomes may vary, even with the same duration of CPAP use, depending on the period without CPAP use, particularly during the first or second half of sleep. Patients who remove or initiate CPAP midway or have a low CPAP usage frequency may require different forms of guidance. Tailoring patient education to address CPAP usage patterns may be necessary to enhanced satisfaction, self-efficacy, and adherence to therapy. Management of CPAP treatment should be personalized to meet individual needs and adapted based on specific response patterns for achieving treatment efficacy.

Effect of Continuous Positive Airway Pressure on Blood Pressure in Patients with Resistant Hypertension and Obstructive Sleep Apnea: An Updated Meta-analysis

PURPOSE OF REVIEW

The effect of continuous positive airway pressure (CPAP) on resistant hypertension in patients at high risk with obstructive sleep apnea (OSA) needs further investigation. We aimed to determine the effect of CPAP on blood pressure in patients with resistant hypertension and OSA. Databases including PubMed, EMBASE, MEDLINE, the Cochrane Library, and CMB were searched. Data were pooled using a random-effects or fixed-effects model to derive weighted mean differences (WMDs) and 95% confidence intervals (CIs).

RECENT FINDINGS

A total of 12 trials and 718 participants were included. Compared with control, CPAP significantly reduced 24-h systolic blood pressure (SBP) (WMD: - 5.92 mmHg [ - 8.72, - 3.11]; P＜0.001), 24-h diastolic blood pressure (DBP) (WMD: - 4.44 mmHg [- 6.26 , - 2.62]; P  ＜0.001),   daytime SBP (WMD: - 5.76 mmHg [ - 9.16,  - 2.36]; P ＜0.001),  daytime DBP (WMD: - 3.92 mmHg [- 5.55,  - 2.30];  nighttime SBP (WMD: - 4.87 mmHg [ - 7.96 ,  - 1.78]; P = 0.002), and nighttime DBP (WMD: - 2.05 mmHg [- 2.99,  - 1.11]; P＜0.001) in patients with resistant hypertension and OSA. CPAP improved the blood pressure both in the short (＜3 months) and long term (≥ 3  months). No significant impact on mean heart rate was noted (WMD: -2.76 beats per min [- 7.50, 1.97]; P = 0.25). CPAP treatment was associated with BP reduction in patients with resistant hypertension and OSA.

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.

[Primary open angle glaucoma and sleep apnea syndrome: A review of the literature]

The relationship between glaucoma and Obstructive Sleep Apnea Syndrome (OSAS) has long been discussed, with conflicting study findings. OSAS appears in the most recent studies to be more of an aggravating factor than an independent risk factor for glaucoma. Patients with OSAS may develop a more rapid progression of primary open-angle glaucoma (POAG). OSAS may damage the optic nerve not only by increasing the intraocular pressure (IOP) but also by altering the blood supply to the optic nerve as shown by more recent work with OCT-Angiography. Although the systemic benefits of Continuous Positive Airway Pressure (CPAP) have been demonstrated, few studies have evaluated its effect on the optic nerve. CPAP might act on glaucomatous neuropathy by improving the blood supply to the optic nerve. The study of this mechanism of action might provide new insights into the relationship between OSAS and glaucoma.

Adaptive servo-ventilation for sleep-disordered breathing in patients with heart failure with reduced ejection fraction (ADVENT-HF): a multicentre, multinational, parallel-group, open-label, phase 3 randomised controlled trial

BACKGROUND

In patients with heart failure and reduced ejection fraction, sleep-disordered breathing, comprising obstructive sleep apnoea (OSA) and central sleep apnoea (CSA), is associated with increased morbidity, mortality, and sleep disruption. We hypothesised that treating sleep-disordered breathing with a peak-flow triggered adaptive servo-ventilation (ASV) device would improve cardiovascular outcomes in patients with heart failure and reduced ejection fraction.

METHODS

We conducted a multicentre, multinational, parallel-group, open-label, phase 3 randomised controlled trial of peak-flow triggered ASV in patients aged 18 years or older with heart failure and reduced ejection fraction (left ventricular ejection fraction ≤45%) who were stabilised on optimal medical therapy with co-existing sleep-disordered breathing (apnoea-hypopnoea index [AHI] ≥15 events/h of sleep), with concealed allocation and blinded outcome assessments. The trial was carried out at 49 hospitals in nine countries. Sleep-disordered breathing was stratified into predominantly OSA with an Epworth Sleepiness Scale score of 10 or lower or predominantly CSA. Participants were randomly assigned to standard optimal treatment alone or standard optimal treatment with the addition of ASV (1:1), stratified by study site and sleep apnoea type (ie, CSA or OSA), with permuted blocks of sizes 4 and 6 in random order. Clinical evaluations were performed and Minnesota Living with Heart Failure Questionnaire, Epworth Sleepiness Scale, and New York Heart Association class were assessed at months 1, 3, and 6 following randomisation and every 6 months thereafter to a maximum of 5 years. The primary endpoint was the cumulative incidence of the composite of all-cause mortality, first admission to hospital for a cardiovascular reason, new onset atrial fibrillation or flutter, and delivery of an appropriate cardioverter-defibrillator shock. All-cause mortality was a secondary endpoint. Analysis for the primary outcome was done in the intention-to-treat population. This trial is registered with ClinicalTrials.gov (NCT01128816) and the International Standard Randomised Controlled Trial Number Register (ISRCTN67500535), and the trial is complete.

FINDINGS

The first and last enrolments were Sept 22, 2010, and March 20, 2021. Enrolments terminated prematurely due to COVID-19-related restrictions. 1127 patients were screened, of whom 731 (65%) patients were randomly assigned to receive standard care (n=375; mean AHI 42·8 events per h of sleep [SD 20·9]) or standard care plus ASV (n=356; 43·3 events per h of sleep [20·5]). Follow-up of all patients ended at the latest on June 15, 2021, when the trial was terminated prematurely due to a recall of the ASV device due to potential disintegration of the motor sound-abatement material. Over the course of the trial, 41 (6%) of participants withdrew consent and 34 (5%) were lost to follow-up. In the ASV group, the mean AHI decreased to 2·8-3·7 events per h over the course of the trial, with associated improvements in sleep quality assessed 1 month following randomisation. Over a mean follow-up period of 3·6 years (SD 1·6), ASV had no effect on the primary composite outcome (180 events in the control group vs 166 in the ASV group; hazard ratio [HR] 0·95, 95% CI 0·77-1·18; p=0·67) or the secondary endpoint of all-cause mortality (88 deaths in the control group vs. 76 in the ASV group; 0·89, 0·66-1·21; p=0·47). For patients with OSA, the HR for all-cause mortality was 1·00 (0·68-1·46; p=0·98) and for CSA was 0·74 (0·44-1·23; p=0·25). No safety issue related to ASV use was identified.

INTERPRETATION

In patients with heart failure and reduced ejection fraction and sleep-disordered breathing, ASV had no effect on the primary composite outcome or mortality but eliminated sleep-disordered breathing safely.

FUNDING

Canadian Institutes of Health Research and Philips RS North America.

Effects of obstructive sleep apnea during rapid eye movement sleep on cardiac autonomic dysfunction: Results from the Shanghai sleep health study cohort

In our large-scale study, the correlation between obstructive sleep apnea (OSA) related to rapid eye movement (REM) sleep and cardiac autonomic dysfunction was assessed by standard polysomnography (PSG). Cardiac autonomic dysfunction was evaluated by the measurement of heart rate variability (HRV). The cardiovascular disease (CVD) risk was determined using the cross-sectional prevalence of CVD and its overall 10 year risk according to the Framingham risk score (FRS). 4152 individuals were included in the study. A higher apnea-hypopnea index during REM sleep (AHIREM ) was correlated with increased CVD risk. The adjusted odds ratios (95% CIs) for CVD prevalence and its high 10 year risk in participants having severe OSA during REM sleep (AHIREM  ≥30 events/h) were 1.452 (1.012-2.084) and 1.904 (1.470-2.466) in the demographic adjusted model and 1.175 (0.810-1.704) and 1.716 (1.213-2.427) in the multivariate adjusted model, respectively, compared with the group with a AHIREM of <5 events/h. Fully adjusted multivariate linear regression models showed the independent association between AHIREM and a more elevated ratio of low-frequency and high-frequency (LF/HF) and LF in normalised units [LF (n.u.)] (P = 0.042, P = 0.027 in all participants and P = 0.033, P = 0.029 in participants with AHI during non-REM sleep <5 events/h, respectively). Mediation analysis demonstrated that OSA during REM sleep and CVD risk was significantly mediated by LF/HF and LF (n.u.). OSA during REM sleep may be a marker behind CVD risk because it promotes cardiac autonomic dysfunction.

Outcomes in Patients with Acute Myocardial Infarction and Known Sleep Apnea: A Nationwide Analysis

Background. Sleep apnea (SA) is a common breathing disorder characterized by repetitive upper airway narrowing and closure. Although SA has been demonstrated to be an independent risk factor for all-cause mortality, the direct contribution of SA to worse cardiovascular prognosis may be difficult to evaluate, and its independent association with the different types of cardiovascular outcomes may be debated, particularly in the context of patients with acute myocardial infarction (AMI). The aim of this study was to assess the impact of known SA on the outcomes of hospitalized patients who have had an AMI by analyzing 10-year data collected from a national registry. Methods. This longitudinal cohort study was based on the national hospitalization database that covers hospital care for the entire French population, including all patients admitted with AMI from January 2010 to June 2019. The clinical outcomes for the analysis were as follows: all-cause death, cardiovascular death, ischemic stroke, new-onset atrial fibrillation (FA), and re-hospitalization for heart failure (HF). Results. Among the 797,212 patients who presented with an AMI (528,351 men and 268,861 women), 37,075 (4.7%) had documented SA. During follow-up (mean [SD] 1.8 [2.4] years, median [interquartile range] 0.7 [0.1-3.1] years), 163,845 deaths (of which 85,649 were cardiovascular deaths), 20,168 ischemic strokes, 58,498 new-onset AF, and 92,381 rehospitalizations due to HF were recorded. Patients with known SA had a worse prognosis in the short and medium term, but after adjusting for all covariables, SA was only independently associated with a higher risk of rehospitalization for HF and new-onset AF in men and women. Conclusion. Data from our large nationwide analysis confirm that known SA is associated with poor cardiovascular outcomes in patients who have had an AMI. However, this impact is tem-pered when the model is adjusted for age, cardiovascular risk, or other covariables. Further studies need to be conducted to assess the independent impact of SA on the prognosis of patients with AMI.

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.

Obstructive Sleep Apnea - Influence on the Cardiovascular System and Cognition

Kardiovaskuläre und kognitive Erkrankungen sind ebenso wie die obstruktive Schlafapnoe sehr häufige Krankheiten mit einer erheblichen Beeinträchtigung der Lebensqualität und einer deutlichen sozioökonomischen Bedeutung. Die Auswirkungen einer unbehandelten obstruktiven Schlafapnoe (OSA) auf das kardiovaskuläre und kognitive Erkrankungsrisiko und die Therapieeffekte einer OSA sind für die meisten kardiovaskulären und kognitiven Folgeerkrankungen wissenschaftlich nachgewiesen. Für die klinische Praxis besteht ein deutlicher Bedarf nach mehr Interdisziplinarität. Aus schlafmedizinischer Sicht müssen bei der Therapieindikation das individuelle kardiovaskuläre und kognitive Risiko berücksichtigt und kognitive Erkrankungen bei der Beurteilung der Therapieintoleranz und residuellen Symptomatik beachtet werden. Aus internistischer Sicht sollte bei Patienten mit schlecht einstellbarem Hypertonus, Vorhofflimmern, koronarer Herzkrankheit und Schlaganfall die Abklärung einer OSA in die Diagnostik integriert werden. Bei Patienten mit milder kognitiver Beeinträchtigung, Alzheimer-Krankheit und Depression können sich die typischen Symptome wie Fatigue, Tagesmüdigkeit und Reduktion der kognitiven Leistungen mit OSA-Symptomen überschneiden. Die Diagnostik einer OSA sollte in die Abklärung dieser Krankheitsbilder integriert werden, da eine Therapie der OSA die kognitiven Beeinträchtigungen reduzieren und die Lebensqualität verbessern kann.

Acceptability, adaptability and adherence to CPAP therapy among Aboriginal Australians with OSA - "The A5 study"

BACKGROUND

Studies examining how Australian Aboriginal people will accept, adapt and adhere to interventions such as continuous positive airway pressure (CPAP) therapy in the management of obstructive sleep apnoea (OSA) are sparsely reported.

METHODS

In this study, clinical, demographic, polysomnographic (PSG) and CPAP data were utilised to assess and predict acceptance and adherence to CPAP therapy among adult Aboriginal Australians diagnosed to have OSA.

RESULTS

Of the 649 Aboriginal patients with OSA, 49% accepted to trial CPAP therapy. Patients who accepted to trial CPAP showed more severe OSA (65vs.35% with severe OSA), reported higher daytime sleepiness (median 10vs.9), and had a higher BMI (83vs.73% obese). Of those who accepted to trial CPAP, 62% adapted to therapy (used the device for more than 30 days). Patients who adapted had more severe OSA (71vs.54% with severe OSA), and were more likely to live in urban areas (63vs.40%). Of those who adapted, 32% were adherent to therapy. Adherent patients were more likely to live in urban areas (84vs.53%), though there was no difference in OSA severity between adherent and non-adherent patients. In multivariate models remote location and more severe OSA predicted CPAP acceptance, while urban location and more severe OSA predicted adaptation, and urban location and higher oxygen saturation nadir predicted adherence.

CONCLUSIONS

Acceptance to trial CPAP therapy was observed in the presence of symptomatic and severe OSA. However, long term adherence to CPAP therapy was significantly influenced by patients' residential location, with patients residing in remote/rural settings demonstrating significantly lower adherence rates.

Adverse infant outcomes among women with sleep apnea or insomnia during pregnancy: A retrospective cohort study

OBJECTIVE

To evaluate whether sleep apnea or insomnia among pregnant people is associated with increased risk for adverse infant outcomes.

DESIGN

Retrospective cohort study SETTING: California PARTICIPANTS: The sample included singleton live births. Sleep apnea and insomnia were defined based on ICD-9 and -10 codes. A referent group was selected using exact propensity score matching on maternal characteristics, obstetric factors, and infant factors among individuals without a sleep disorder.

MEASUREMENTS

Adverse infant outcomes were obtained from birth certificate, hospital discharge, and death records (eg, Apgar scores, neonatal intensive care unit (NICU) stay, infant death, long birth stay, etc.). Logistic regression was used to calculate odds of an adverse infant outcome by sleep disorder type.

RESULTS

Propensity-score matched controls were identified for 69.9% of the 3371 sleep apnea cases and 68.8% of the 3213 insomnia cases. Compared to the propensity-matched referent group, individuals with a diagnosis of sleep apnea (n = 2357) had infants who were more likely to have any adverse outcome, low 1-min Apgar scores, NICU stay, and an emergency room visit in the first year of life. Infants born to mothers with a diagnosis of insomnia (n = 2212) were at increased risk of few negative outcomes relative to the propensity matched referent group, with the exception of an emergency room visit.

CONCLUSIONS

In unadjusted analyses, infants born to individuals with a diagnosis of sleep apnea or insomnia were at increased risk of several adverse outcomes. These were attenuated when using propensity score matching, suggesting these associations were driven by other comorbidities.

Symptoms Underestimate the Presence of Obstructive Sleep Apnea in Patients with Spontaneous Cerebrospinal Fluid Leaks of the Temporal Bone

OBJECTIVE

To determine the severity of symptoms and degree of obstructive sleep apnea (OSA) in patients with spontaneous cerebrospinal fluid (sCSF) leaks of the temporal bone given the known association between sCSF leaks and OSA.

STUDY DESIGN

Retrospective case review.

SETTING

Ambulatory clinics in tertiary referral centers.

PATIENTS

Polysomnogram testing in 34 consecutive patients who had been diagnosed with sCSF leaks of the temporal bone was examined. Diagnosis of sCSF leak was defined as biochemically confirmed CSF from middle ear fluid with no other obvious source.

INTERVENTION

Diagnostic.

MAIN OUTCOMES MEASURES

Patient characteristics (age, sex, body mass index, Epworth Sleepiness Scale score, presence of hypoxia, overnight change in blood pressure, and apnea hypopnea index [AHI]) were recorded. Diagnosis of OSA was defined as mild when AHI ≥5 and <15/h, moderate when AHI ≥15 and <30/h, and severe when AHI ≥30/h.

RESULTS

Of the 34 patients, 28 (82%) had a confirmed diagnosis of OSA. There was a male predisposition in those with OSA, and 17 of 28 (61%) were male. A majority were overweight, and the mean body mass index was 30.1 (SD, 4.8; range, 23.2-40) kg/m2. The mean severity of OSA was moderate, and the mean AHI was 28.7 (SD, 21.9; range, 5.4-92.8). Of the 28 patients, 13 with OSA (46%) had Epworth Sleepiness Scale scores higher than 8, suggesting that many were asymptomatic for excessive daytime sleepiness at the time of presentation.

CONCLUSION

OSA is highly prevalent among patients with sCSF leaks of the temporal bone. Patients with sCSF leaks irrespective of symptoms of OSA should undergo formal polysomnogram testing.

Positive Airway Pressure Adherence, Mortality, and Cardiovascular Events in Patients with Sleep Apnea

Rationale: Randomized controlled trials showed no effect of positive airway pressure (PAP) therapy for obstructive sleep apnea (OSA) on cardiovascular (CV) risk. However, patient selection and low PAP adherence preclude the generalization of their data to clinical samples. Objectives: To evaluate the association between hours of PAP use, mortality, and CV morbidity in real-life conditions. Methods: Data from the Pays de la Loire Cohort were linked to health administrative data to identify incident major adverse cardiovascular events (MACEs; a composite outcome of mortality, stroke, and cardiac diseases) in patients with OSA who were prescribed PAP. Cox proportional hazards analyses were conducted to evaluate the association between MACEs and quartiles of average daily PAP use over the study period. Measurements and Main Results: After a median follow-up of 6.6 years, 961 of 5,138 patients experienced MACEs. Considering nonadherent patients (0-4 h/night) as the reference group, adjusted hazard ratios (95% confidence intervals) for MACEs were 0.87 (0.73-1.04) for the 4-6 h/night group, 0.75 (0.62-0.92) for the 6-7 h/night group, and 0.78 (0.65-0.93) for the ⩾7 h/night group (P = 0.0130). Sensitivity analyses using causal inference approaches confirmed the association of PAP use with MACEs. The association was stronger in male patients (P value for interaction = 0.0004), patients without overt CV disease at diagnosis (P < 0.0001), and those belonging to the excessively sleepy symptom subtype (P = 0.060). Conclusions: These real-life clinical data demonstrate a dose-response relationship between PAP adherence and incident MACEs in OSA. Patient support programs may help improve PAP adherence and CV outcomes in patients with OSA.

L-Citrulline Supplementation Reduces Blood Pressure and Myocardial Infarct Size under Chronic Intermittent Hypoxia, a Major Feature of Sleep Apnea Syndrome

Intermittent hypoxia (IH) is a landmark of obstructive sleep apnea (OSA) at the core of the cardiovascular consequences of OSA. IH triggers oxidative stress, a major underlying mechanism for elevated blood pressure (BP) and increased infarct size. L-citrulline is an amino acid that has been demonstrated to be protective of the cardiovascular system and exert pleiotropic effects. Therefore, we tested the impact of citrulline supplementation on IH-induced increase in BP and infarct size. Four groups of rats exposed to normoxia (N) or IH [14 days (d), 8 h/day, 30 s-O₂ 21%/30 s-O₂ 5%] and were supplemented or not with citrulline (1 g·kg^-1·d^-1). After 14 d, BP was measured, and hearts were submitted to global ischemia-reperfusion to measure infarct size. Histological and biochemical analyses were conducted on hearts and aorta to assess oxidative stress. Citrulline significantly reduced BP (-9.92%) and infarct size (-18.22%) under IH only. In the aorta, citrulline supplementation significantly decreased superoxide anion and nitrotyrosine levels under IH and abolished the IH-induced decrease in nitrite. Citrulline supplementation significantly decreased myocardial superoxide anion levels and xanthine oxidase enzyme activity under IH. Citrulline shows a cardioprotective capacity by limiting IH-induced pro-oxidant activity. Our results suggest that citrulline might represent a new pharmacological strategy in OSA patients with high cardiovascular risk.

Detection of obstructive sleep apnea in young patients suffering from coronary artery disease by performing portable polysomnography studies

Background

Obstructive sleep apnea (OSA) is known to be an important contributory factor of coronary artery disease (CAD), but the extent of contribution of OSA in young patients suffering from CAD is not known. Thus, with an aim to detect OSA in young patients suffering from CAD by performing portable polysomnography (PSG), the present study was carried out at a tertiary care chest center.

Methods

A prospective study was carried out from June 2015 to June 2018, wherein 100 consecutive young (age less than 40 years), non-smoking patients with angiographically confirmed CAD, with no identifiable risk factors for cardiovascular diseases except obesity, were subjected to level 3 portable PSG studies.

Results

Of 100 patients with CAD, 80% had OSA (24% with mild OSA, 28% with moderate OSA, and 28% with severe OSA). Body weight and severity of OSA showed a significant correlation with a P-value of 0.033. SPSS software was used for statistical analysis. The categorical variables were compared using Fischer's exact test.

Conclusion

The study detected a significant number of young patients with angiographically confirmed CAD having OSA. A significant correlation was also observed between weight and severity of OSA, suggesting that overweight patients and patients with obesity have higher grades of OSA.

Time Domains of Hypoxia Responses and -Omics Insights

The ability to respond rapidly to changes in oxygen tension is critical for many forms of life. Challenges to oxygen homeostasis, specifically in the contexts of evolutionary biology and biomedicine, provide important insights into mechanisms of hypoxia adaptation and tolerance. Here we synthesize findings across varying time domains of hypoxia in terms of oxygen delivery, ranging from early animal to modern human evolution and examine the potential impacts of environmental and clinical challenges through emerging multi-omics approaches. We discuss how diverse animal species have adapted to hypoxic environments, how humans vary in their responses to hypoxia (i.e., in the context of high-altitude exposure, cardiopulmonary disease, and sleep apnea), and how findings from each of these fields inform the other and lead to promising new directions in basic and clinical hypoxia research.

Daytime polysomnography to perform titration for upper airway stimulation in patients with obstructive sleep apnea

PURPOSE

Upper airway stimulation (UAS) is an innovative treatment for patients with obstructive sleep apnea (OSA). UAS titrations are performed 3 months after activation of the device to optimize its effectiveness. In general, these titrations are performed during an in-laboratory overnight polysomnography (PSG). However, overnight titrations are expensive and can be logistically challenging because they are labor-intensive which causes shortage of sleep technicians available for night shifts. In addition, recently, overnight PSGs were postponed and canceled due to the COVID-19 pandemic. We aimed to assess the feasibility of a daytime PSG to perform titration of UAS therapy as an alternative for a conventional overnight PSG.

METHODS

We performed a prospective single-center observational cohort study. Patients were included when planned for UAS titration; this was approximately 6 months after UAS activation. Data on sleep architecture, patient experience, and respiratory outcomes were collected to evaluate the feasibility. An overnight follow-up PSG 12 months after implantation was used to compare sleep architecture and therapy response.

RESULTS

Of 23 patients, four were excluded from analysis because of technical issues during PSG. Even though patients slept significantly shorter during the daytime PSG, this was enough time to complete the titration successfully with 30-min sleep in final therapeutic settings in 84% of the patients. Patients (94%) had a positive experience with the daytime titration. Respiratory outcomes were significantly reduced during titration and were maintained at the 12-month follow-up.

CONCLUSION

Daytime titrations are a valuable alternative for conventional overnight titrations. Our findings suggest the implementation of daytime titrations as standard of care. This will contribute to easier logistics and better work circumstances for sleep technicians without jeopardizing titration quality.

Patient-Defined Goals for Obstructive Sleep Apnea Treatment

Objectives

To characterize the treatment goals and values of adult patients with obstructive sleep apnea (OSA).

Study Design

Mixed methods design based on semistructured interviews followed by cross-sectional surveys.

Setting

Academic medical center and integrated managed care consortium.

Methods

Phase 1 involved qualitative analysis of focus groups and interviews to define treatment goal categories. Phase 2 included analysis of cross-sectional surveys on most important treatment goals from patients with OSA presenting to sleep surgery clinic. Positive airway pressure (PAP) use, Epworth Sleepiness Scale score, and apnea-hypopnea index were obtained to determine influences on goal choices.

Results

During focus groups and interviews, treatment goal themes identified included improving sleep quality, reducing daytime sleepiness, snoring sound reduction, and health risk reduction. In phase 2, 536 patients were surveyed, and they reported the primary treatment goals of health risk reduction (35%), sleep quality improvement (28%), daytime sleepiness improvement (21%), and snoring sound reduction (16%). The primary treatment goal was associated with age (P < .0001), excessive daytime sleepiness (Epworth Sleepiness Scale score >10, P < .0001), PAP use status (P < .0001), and OSA severity (apnea-hypopnea index, P < .0001). Severity of OSA was associated with increasing proportion of patients choosing health risk reduction as the main treatment goal (P < .05).

Conclusions

Adult OSA treatment goal choices vary with age, symptoms, PAP history, and OSA severity. Understanding patient-specific goals is the essential first step in the shared decision-making process when choosing surgical or nonsurgical treatments. Ultimately, goal-focused discussions ensure alignment of priorities and definitions of success between the patient and the provider.

Cluster-derived obstructive sleep apnea phenotypes and outcomes at 5-year follow-up

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is a heterogeneous, complex disease. We aimed to identify OSA phenotypes through cluster analysis and to perform a long-term follow-up to validate the phenotypes.

METHODS

We applied a partitioning around medioids technique in a cohort of 1,217 participants recently diagnosed with OSA. We performed a 5-year follow-up analyzing the incidence of comorbidities, chronic medication, hospital admissions, mortality, and the influence of continuous positive airway pressure treatment on mortality risk.

RESULTS

We identified three phenotypes: two predominantly male clusters, one composed of middle-aged participants with overweight, moderate OSA, and cardiovascular risk factors and the other consisting of older, obese participants with severe OSA, cardiovascular risk factors, ischemic heart disease (18.4%), and atrial fibrillation (9.7%). The third cluster was composed of 77% female participants with moderate OSA; cardiovascular risk factors; the highest prevalence of depression (15.7%); and high prescription of antidepressants (55.1%), anxiolytics (40.0%), hypnotics, sedatives (11.1%), nonsteroidal anti-inflammatory drugs (67.9%), and weak opioids (15.1%). The baseline characteristics of each cluster maintained the same trend over time regarding the incidence of new comorbidities, medication intake, hospitalization rates, and reasons for admission. The absence of continuous positive airway pressure treatment was associated with a significantly higher risk of all-cause mortality (hazard ratio 5.84, confidence interval 2.9-11.8), especially in the older men (hazard ratio 7.7, confidence interval 4.06-14.63) and predominantly female clusters (hazard ratio 2.79, confidence interval 1.34-5.79).

CONCLUSIONS

We identified three phenotypes with relevant clinical and prognostic implications in order to improve personalized strategies in OSA management.

CITATION

Silveira MG, Sampol G, Mota-Foix M, Ferrer J, Lloberes P. Cluster-derived obstructive sleep apnea phenotypes and outcomes at 5-year follow-up. J Clin Sleep Med. 2022;18(2):597-607.

CPAP adherence is associated with reduced inpatient utilization among older adult Medicare beneficiaries with pre-existing cardiovascular disease

STUDY OBJECTIVES

To examine the impact of adherence to continuous positive airway pressure (CPAP) therapy on health care utilization among a nationally representative and sample of older adults with multiple morbidities and pre-existing cardiovascular disease and subsequently diagnosed with obstructive sleep apnea in the United States.

METHODS

Our data source was a random 5% sample of Medicare administrative claims data. All participants (n = 1,921) were of age ≥ 65 years, diagnosed with cardiovascular disease and obstructive sleep apnea, and subsequently began treatment with CPAP between 2009-2013. Based on the number of CPAP machine charges, individuals were categorized as low, partial, or high adherers (ie, < 4, 4-12, and > 12 CPAP charges, respectively). The impact of CPAP adherence status on health care utilization was assessed across multiple points of service, including outpatient encounters, inpatient stays, emergency department visits, and prescription fills over 24 months following CPAP initiation.

RESULTS

Significant differences in demographic and comorbid disease characteristics were observed between low adherers (n = 377), partial adherers (n = 236), and high adherers (n = 1,308). After adjusting for covariates and relative to low adherers, high adherers demonstrated reduced inpatient visits (hazard ratio 0.75; 95% confidence interval 0.57, 0.97).

CONCLUSIONS

In this nationally representative sample of older Medicare beneficiaries with multiple morbidities and relative to low adherers, high adherers demonstrated reduced inpatient utilization.

CITATION

Wickwire EM, Bailey MD, Somers VK, et al. CPAP adherence is associated with reduced inpatient utilization among older adult Medicare beneficiaries with pre-existing cardiovascular disease. J Clin Sleep Med. 2022;18(1):39-45.

The effect of obstructive sleep apnea on the increased risk of cardiovascular disease: a systematic review and meta-analysis

BACKGROUND

Obstructive sleep apnea (OSA) is a disorder characterized by intermittent airway obstruction during sleep. The association between OSA and the incidence of cardiovascular disease (CVD) has been investigated in many studies; however, the results are not entirely consistent between studies. The aim of this study was to investigate the relationship between OSA and the risk of CVD through a meta-analysis of cohort studies.

METHODS

A systematic review and meta-analysis of literature was conducted using the PubMed, WoS, Embase, ScienceDirect, Scopus, and Web of Science databases up to the year 2020. In order to analyze the eligible studies, the stochastic effects model was used and the heterogeneity of the studies with the I² index was investigated. Data analysis was performed with Comprehensive Meta-Analysis software (Version 2).

RESULTS

A total of 24 studies were included in the meta-analysis according to the inclusion criteria. Twelve studies reported CVD results, 11 studies reported stroke results, 9 studies reported mortality results, and 8 studies reported CVD results. The odds ratio of CVD in patients with OSA 1.71 (1.17-2.27: 95% confidence interval) stroke in patients with OSA, 1.86 (1.28-2.69: 95% confidence interval), mortality in patients with OSA, 1.77 (1.37-2.29: 95% confidence interval) and CHD in patients with OSA, and 1.48 (1.06-2.28: 95% confidence interval) was obtained.

CONCLUSION

OSA is considered a cardiovascular risk factor. There is a relationship between the severity of OSA and the risk of cardiovascular disease. OSA increases the risk of heart attack, CHD, and death from cardiovascular disease.

Obstructive sleep apnea and stroke: The mechanisms, the randomized trials, and the road ahead

When considered separately from cardiovascular disease, stroke is the third leading cause of death in the U.S. and is the leading cause of long-term disability in adults. New approaches that can be offered to the majority of ischemic stroke patients, can be continued throughout post-stroke care, can limit stroke severity, and can complement or even enhance rehabilitation, would transform ischemic stroke recovery. The treatment of obstructive sleep apnea (OSA) in patients with acute ischemic stroke may represent one such approach. This manuscript reviews the epidemiologic studies of the bidirectional association between OSA and stroke, and the mechanisms and molecular signatures of OSA leading to transient ischemic attack and stroke as well as the randomized controlled trials and observational cohort studies examining continuous positive airway treatment efficacy on the impact of stroke outcomes. Finally, the insights these studies provide on future research are also discussed.

Implementing a sleep technician supervised and personalized APAP interface fitting session prior to initiation of home APAP therapy improves adherence in patients with obstructive sleep apnea

STUDY OBJECTIVES

Home Automatic Positive Airway Pressure (APAP) therapy is becoming a mainstay treatment of obstructive sleep apnea (OSA). It is typically prescribed without any prior supervised titration. Initial experience of APAP treatment dictates subsequent use. Discomfort related to the APAP interface contributes to poor APAP adherence.

METHODS

After obtaining IRB approval, 156 adult patients newly diagnosed with OSA were prospectively randomized into two groups (groups A and B). Group A received a 30-minute personalized interface/mask fitting session supervised by a certified sleep technician during which APAP therapy was simulated and patients were educated on proper use. Patients sampled different interfaces to address any issues with comfort. Group B received usual care where patients obtained an interface through Durable Medical Equipment suppliers. Primary endpoints included percent APAP usage (number of days APAP was used for ≥4 hours divided by 30 days) and APAP usage (number of days APAP was used for any duration) during the initial 30 days of home APAP therapy. Interface associated air leak served as the secondary endpoint.

RESULTS

Mean percent APAP usage was higher in group A compared to group B (78.4% vs 67.8%; p=0.04). On average, group A utilized the APAP machine on more days compared to group B (27 vs 24 days; p=0.01). APAP interface associated air leak was lower in group A compared to group B (14.9 vs 21.1 l/min; p=0.03).

CONCLUSIONS

Our findings demonstrate that implementing a personalized interface fitting session supervised by a sleep technician improves APAP adherence.

The impact of continuous positive airway pressure treatment on retinal vascular changes in obstructive sleep apnea

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) was recently shown to be associated with quantifiable retinal vascular changes, which correlate with disease severity. This follow-up study examines the response of retinal vascular changes in patients with OSA receiving continuous positive airway pressure (CPAP) treatment.

METHODS

This prospective cohort study recruited adult patients undergoing diagnostic polysomnography at a tertiary sleep clinic in Sydney, Australia, stratified into 4 groups by the apnea-hypopnea index; control patients and patients with mild, moderate, and severe OSA. At baseline and follow-up approximately 24 months later, static retinal vascular calibers were derived from fundus photographs, and dynamic vascular pulsation amplitudes were measured on video fundoscopy. A proportion of patients started CPAP therapy after baseline assessment.

RESULTS

Seventy-nine patients participated in this follow-up study: 9 control patients and 18 patients with mild OSA, 21 patients with moderate OSA, and 31 patients with severe OSA. Twenty-five patients started CPAP after baseline. In the severe group, patients not on treatment showed progressive narrowing of retinal arteries from baseline, whereas those on CPAP showed a slight improvement (mean, 171.3-165.1 and 171.2-174.0 μm, respectively; P = .012). Arterio-venous ratio was also significantly reduced in the nontreatment group compared to the treatment group in those with severe OSA (0.836-0.821 and 0.837-0.855, respectively; P = .031). CPAP did not seem to have a significant impact on venous caliber or vascular pulsatility.

CONCLUSIONS

This study shows that patients with severe untreated OSA demonstrate progressive retinal arterial narrowing, whereas CPAP treatment may be protective.

Evaluation and Management of Adults with Obstructive Sleep Apnea Syndrome

Obstructive sleep apnea syndrome (OSAS) is a common and underdiagnosed medical condition characterized by recurrent sleep-dependent pauses and reductions in airflow. While a narrow, collapsible oropharynx plays a central role in the pathophysiology of OSAS, there are other equally important nonanatomic factors including sleep-stage dependent muscle tone, arousal threshold, and loop gain that drive obstructive apneas and hypopneas. Through mechanisms of intermittent hypoxemia, arousal-related sleep fragmentation, and intrathoracic pressure changes, OSAS impacts multiple organ systems. Risk factors for OSAS include obesity, male sex, age, specific craniofacial features, and ethnicity. The prevalence of OSAS is rising due to increasing obesity rates and improved sensitivity in the tools used for diagnosis. Validated questionnaires have an important but limited role in the identification of patients that would benefit from formal testing for OSA. While an in-laboratory polysomnography remains the gold standard for diagnosis, the widespread availability and accuracy of home sleep apnea testing modalities increase access and ease of OSAS diagnosis for many patients. In adults, the most common treatment involves the application of positive airway pressure (PAP), but compliance continues to be a challenge. Alternative treatments including mandibular advancement device, hypoglossal nerve stimulator, positional therapies, and surgical options coupled with weight loss and exercise offer possibilities of an individualized personal approach to OSAS. Treatment of symptomatic patients with OSAS has been found to be beneficial with regard to sleep-related quality of life, sleepiness, and motor vehicle accidents. The benefit of treating asymptomatic OSA patients, particularly with regard to cardiovascular outcomes, is controversial and more data are needed.

Continuous Positive Airway Pressure Improves Renal Function in Obese Patients With Obstructive Sleep Apnea Syndrome

Background: Obstructive sleep apnea syndrome (OSAS) is an independent risk factor for cardiovascular morbidity and mortality, and it has a detrimental effect on renal function. Obesity is the major risk factor for OSAS, and represents a risk factor for chronic kidney disease. Continuous positive airway pressure (CPAP) is the suggested therapy for moderate-to-severe OSAS. We designed this study to evaluate the effect of CPAP on estimated glomerular filtration rate (e-GFR) in a cohort of obese patients with moderate-to-severe OSAS and normal renal function. Methods: We enrolled 198 obese subjects, divided into two groups (OSAS+ and OSAS-), on the basis of cardiorespiratory monitoring; mild OSAS patients (n = 33) were excluded from the study, thus the analyses were conducted on 165 patients. Comparisons between groups were made by Student t-test or χ² test as appropriate. Linear regression analyses were used to assess the relationship between baseline e-GFR and different covariates and, in the OSAS+ group, between Δe-GFR and different covariates. A multivariate regression analysis was performed to determinate the independent predictor of the Δe-GFR. Results: OSAS+ subjects showed significantly increased values of systolic blood pressure, HOMA, pulse wave velocity, high-sensitivity C reactive protein and uric acid compared with OSAS- group. OSAS+ group showed significantly lower values of e-GFR and increased values of microalbuminuria. At linear regression analysis e-GFR resulted significantly and inversely related to AHI in the whole study population and in the two groups. After 6 months of CPAP therapy, OSAS+ subjects showed an improvement in respiratory parameters, as well as a significant increase in e-GFR values (104.2 + 19.0 vs. 84.0 + 13.1 ml/min/1.73 m², P < 0.0001). At multiple regression analysis, Δ apnea/hypopnea index (AHIa) resulted the main independent predictor of Δe-GFR explaining 22% of its variation. Conclusions: Obese OSAS patients show significantly lower values of e-GFR, even if in the normal range, compared with obese non-OSAS subjects. After 6 months of CPAP, e-GFR significantly improved (+20 ml/min/1.73 m²) and ΔAHIa resulted the most important independent predictor of Δe-GFR.

Association Between Obstructive Sleep Apnea-Hypopnea Syndrome and Outcomes in Patients With Myocardial Infarction in the Absence of Obstructive Coronary Artery Disease

Background and Aims: Myocardial infarction in the absence of obstructive coronary artery disease (MINOCA) occurs in 5-10% of all patients with acute myocardial infarction. Obstructive sleep apnea-hypopnea syndrome (OSAHS) is linked to increased cardiovascular morbidity and mortality, but the relationship of OSAHS and outcomes in patients with MINOCA remains unknown. We aimed to evaluate the association between OSAHS and clinical outcomes in patients with MINOCA. Methods: Between January 2015 and December 2016, we carried out a consecutive cohort study of 583 patients with MINOCA and followed them up for 3 years. An apnea-hypopnea index of ≥ 15 events per hour recorded by polysomnography was defined as the diagnostic criterion for OSAHS. The primary end point was all-cause mortality, and the second end point was major adverse cardiovascular or cerebrovascular events (MACCE), a composite of cardiac death, non-fatal myocardial infarction, heart failure, cardiovascular-related rehospitalization, and stroke. Results: All-cause mortality happened in 69 patients and MACCE occurred in 113 patients during the 3-year follow-up. Kaplan-Meier survival curves indicated the significant relationship of OSAHS with all-cause mortality (log-rank P = 0.012) and MACCE (log-rank P = 0.002). Multivariate Cox regression analysis indicated OSAHS as an independent predictor of all-cause mortality and MACCE [adjusted hazard ratio: 1.706; 95% confidence interval (CI): 1.286-2.423; P = 0.008; and adjusted hazard ratio: 1.733; 95% CI: 1.201-2.389; P < 0.001; respectively], independent of age, sex, cardiovascular risk factors and discharge medications. Conclusions: OSAHS is independently associated with increased risk of all-cause mortality and MACCE in patients with MINOCA. Intervention and treatment should be considered to alleviate OSAHS-associated risk.

ECG-Derived Heart Rate Variability Interpolation and 1-D Convolutional Neural Networks for Detecting Sleep Apnea

Feature extraction from ECG-derived heart rate variability signal has shown to be useful in classifying sleep apnea. In earlier works, time-domain features, frequency-domain features, and a combination of the two have been used with classifiers such as logistic regression and support vector machines. However, more recently, deep learning techniques have outperformed these conventional feature engineering and classification techniques in various applications. This work explores the use of convolutional neural networks (CNN) for detecting sleep apnea segments. CNN is an image classification technique that has shown robust performance in various signal classification applications. In this work, we use it to classify one-dimensional heart rate variability signal, thereby utilizing a one-dimensional CNN (1-D CNN). The proposed technique resizes the raw heart rate variability data to a common dimension using cubic interpolation and uses it as a direct input to the 1-D CNN, without the need for feature extraction and selection. The performance of the method is evaluated on a dataset of 70 overnight ECG recordings, with 35 recordings used for training the model and 35 for testing. The proposed method achieves an accuracy of 88.23% (AUC=0.9453) in detecting sleep apnea epochs, outperforming several baseline techniques.

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.

Maxillomandibular Advancement for the Treatment of Obstructive Sleep Apnea in Patients With Normal or Class I Malocclusion

BACKGROUND

Maxillomandibular advancement is an effective surgical option for obstructive sleep apnea (OSA) that achieves enlargement of the upper airway by physically expanding the facial skeleton. The authors sought to determine whether an advancement of 10 mm predicts surgical success and if any correlation existed between the magnitude of mandibular/maxillary advancement and improvement in polysomnography metrics using aggregated individual patient data from multiple studies.

METHODS

A search of the PubMed database was performed to identify relevant articles that included preoperative and postoperative polysomnography data and measurements of the advancement of both the maxillary and mandibular portions of the face in patients with normal or class I malocclusion. Each patient was stratified into "Success" or "Failure" groups based on criteria defining a "Success" as a 50% preoperative to post-operative decrease in AHI or RDI and a post-operative AHI or RDI <20.

RESULTS

A review of the PubMed database yielded 162 articles. Review of these resulted in 9 manuscripts and a total of 109 patients who met the inclusion criteria. There was no statistically significant difference in the amount of anterior advancement of either the mandible (P = 0.96) or the maxilla (P = 0.23) between the "Success" or "Failure" groups.

CONCLUSIONS

While there is a paucity of individual data available, the current data does not support an ideal amount of maxillary or mandibular advancement that is required to obtain a surgical success in the treatment of OSA. Until a multicenter, prospective, randomized trial is performed, surgical planning should be tailored to patient-specific anatomy to achieve the desired result.

Preoperative Predictors of Response to Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea

Objective

Hypoglossal nerve stimulation (HGNS) is an effective treatment for patients with obstructive sleep apnea (OSA) who fail continuous positive airway pressure (CPAP). We assessed the relationship between patient characteristics and response to HGNS.

Study Design

Retrospective cohort study.

Setting

Single tertiary care institution.

Subjects and Methods

This study included CPAP-intolerant patients with moderate to severe OSA after HGNS system implantation from November 2015 to December 2017. Patient measures, drug-induced sleep endoscopy (DISE) findings, and apnea-hypopnea indices (AHIs) were recorded.

Results

Forty-eight patients underwent implantation with the following median measures: age, 66 years; body mass index, 28.6; and neck circumference, 41.0 cm. Patients were classified by Friedman tongue position (II, 27%; III, 56%; IV, 17%) and Mallampati grade (I, 25%; II, 50%; III, 23%; IV, 2%). By DISE, 71% had anterior-posterior palatal collapse. Additionally, 38% had lateral oropharynx collapse; 50%, tongue base collapse; and 27%, epiglottis collapse. Following implantation, median AHI improved from 38.5 to 2.7 ( P < .001), and 92% of patients had no worse than mild OSA (8% moderate). Patients with Friedman tongue position grade II/III experienced greater change in AHI as compared with grade IV (94.2% vs 73.8%, P < .001). Patients with Mallampati score I/II experienced greater improvement versus score III/IV (94.7% vs 66.5%, P < .001). No DISE findings, including any obstruction or collapse, were associated with change in AHI.

Conclusion

This study further confirms HGNS as an effective treatment of CPAP-intolerant OSA. Office measures such as Friedman tongue position IV and Mallampati III/IV were associated with mildly decreased response. DISE findings were not associated with patient response.

Obstructive sleep apnoea in acute coronary syndrome

Obstructive sleep apnoea (OSA) syndrome affects about 13% of the male and 7-9% of the female population. Hypoxia, oxidative stress and systemic inflammation link OSA and cardiovascular and metabolic consequences, including coronary artery disease. Current research has identified several clinical phenotypes, and the combination of breathing disturbances during sleep, systemic effects and end-organ damage might help to develop personalised therapeutic approaches. It is unclear whether OSA is a risk factor for acute coronary syndrome (ACS) and might affect its outcome. On the one hand, OSA in patients with ACS may worsen prognosis; on the other hand, OSA-related hypoxaemia could favour the development of coronary collaterals, thereby exerting a protective effect. It is unknown whether positive airway pressure treatment may influence adverse events and consequences of ACS. In non-sleepy patients with OSA and stable coronary artery disease, randomised controlled trials failed to show that continuous positive airway pressure (CPAP) treatment protected against cardiovascular events. Conversely, uncontrolled studies suggested positive effects of CPAP treatment in such patients. Fewer data are available in subjects with ACS and OSA, and results of randomised controlled studies on the effects of CPAP are expected shortly. Meanwhile, the search for reliable markers of risk continues. Recent studies suggest that daytime sleepiness may indicate a more severe OSA phenotype with regard to cardiovascular risk. Finally, some studies suggest sex-related differences. The picture is still incomplete, and the potential role of OSA in patients with ACS awaits confirmation, as well as clear definition of subgroups with different degrees of risk.

May Dyspnea Sensation Influence the Sexual Function in Men With Obstructive Sleep Apnea Syndrome? A Prospective Control Study

INTRODUCTION

Dyspnea sensation is frequently present in obstructive sleep apnea syndrome (OSA) patients; however, its possible influence on sexual function and body image has not been well analyzed.

AIMS

To evaluate sexual function, the prevalence of sexual dysfunction (SD), and body image during sexual activity and its relationship with dyspnea in men with OSA.

METHODS

129 men were included in the prospective study, with 61 diagnosed with OSA (cases) and 68 age- and BMI-matched healthy control subjects. Patients were assessed for the severity of heart failure by the New York Heart Association scale and dyspnea by the Visual Analogue Scale. OSA was confirmed by in-laboratory polysomnography.

MAIN OUTCOME MEASURES

International Index of Erectile Function (IIEF) was used as a measure of sexual function, body image during sexual activity was assessed by the Body Exposure During Sexual Activity Questionnaire, whereas SD was diagnosed using criteria from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition.

RESULTS

The mean age of the studied population was 57.9 ± 10.8 years. Presence of dyspnea interfered with sexual life in 20% of men diagnosed with OSA and with work performance in 33%. Men with OSA had worse scores in IIEF-15 compared with control subjects and higher frequency of sexual distress compared with men with OSA. There were no differences in the rate of SD according to criteria from the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. The presence of OSA worsened the perceived body image during sexual activity. The presence of dyspnea was the only negative factor affecting sexual function in general (IIEF-15 score) and 1 of the factors affecting erectile function and orgasmic function.

CONCLUSION

In men with OSA, body image is negatively influenced by the presence of OSA. Furthermore, the presence of dyspnea assessed by the New York Heart Association scale impairs sexual function in that group of men. Skoczyński S, Nowosielski K, Minarowski Ł, et al. May Dyspnea Sensation Influence the Sexual Function in Men With Obstructive Sleep Apnea Syndrome? A Prospective Control Study. Sex Med 2019;7:303-310.

Treatment of obstructive sleep apnoea as primary or secondary prevention of cardiovascular disease: where do we stand now?

PURPOSE OF REVIEW

The aim of this study was to provide an update of the primary and secondary prevention of obstructive sleep apnoea (OSA) treatment on cardiovascular disease.

RECENT FINDINGS

Consistent evidence suggest that OSA can contribute to cardiovascular diseases, including hypertension, atrial fibrillation, coronary artery disease and stroke. In patients with no previous history of cardiovascular events (primary prevention scenario), observational studies suggest that continuous positive airway pressure (CPAP), the main treatment for OSA, is able to prevent hypertension incidence and to decrease nonfatal cardiovascular events in men and fatal cardiovascular events in men, women and elderly. In patients with a previous history of cardiovascular events (secondary prevention scenario), recent randomized trials showed that CPAP was not able to prevent a new cardiovascular event. These findings may suggest that in patients with high cardiovascular risk and multiple comorbidities, OSA may not have an incremental role on cardiovascular disease. However, a subanalysis from the same trials showed that good CPAP compliance was able to prevent cerebrovascular events.

SUMMARY

OSA may predispose to cardiovascular disease, but additional efforts for improving CPAP use or development of new treatments may help to understand the magnitude of OSA on cardiovascular disease.

Treatment of Adult Obstructive Sleep Apnea With Positive Airway Pressure: An American Academy of Sleep Medicine Systematic Review, Meta-Analysis, and GRADE Assessment

INTRODUCTION

The purpose of this systematic review is to provide supporting evidence for the clinical practice guideline for the treatment of obstructive sleep apnea (OSA) in adults using positive airway pressure (PAP).

METHODS

The American Academy of Sleep Medicine commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies that compared the use of PAP with no treatment as well as studies that compared different PAP modalities. Meta-analyses were performed to determine the clinical significance of using PAP in several modalities (ie, continuous PAP, auto-adjusting PAP, and bilevel PAP), to treat OSA in adults. In addition, meta-analyses were performed to determine the clinical significance of using an in-laboratory versus ambulatory strategy for the initiation of PAP, educational and behavioral interventions, telemonitoring, humidification, different mask interfaces, and flexible or modified pressure profile PAP in conjunction with PAP to treat OSA in adults. Finally, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to assess the evidence for making recommendations.

RESULTS

The literature search resulted in 336 studies that met inclusion criteria; 184 studies provided data suitable for meta-analyses. The data demonstrated that PAP compared to no treatment results in a clinically significant reduction in disease severity, sleepiness, blood pressure, and motor vehicle accidents, and improvement in sleep-related quality of life in adults with OSA. In addition, the initiation of PAP in the home demonstrated equivalent effects on patient outcomes when compared to an in-laboratory titration approach. The data also demonstrated that the use of auto-adjusting or bilevel PAP did not result in clinically significant differences in patient outcomes compared with standard continuous PAP. Furthermore, data demonstrated a clinically significant improvement in PAP adherence with the use of educational, behavioral, troubleshooting, and telemonitoring interventions. Systematic reviews for specific PAP delivery method were also performed and suggested that nasal interfaces compared to oronasal interfaces have improved adherence and slightly greater reductions in OSA severity, heated humidification compared to no humidification reduces some continuous PAP-related side effects, and pressure profile PAP did not result in clinically significant differences in patient outcomes compared with standard continuous PAP.

Heart Rate Variability in the Diagnostics and CPAP Treatment of Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is the most common manifestation of sleep-related breathing disorders that are often accompanied by dysfunction of the autonomic nervous system. The main objective of the study was to assess the usefulness of heart rate variability (HRV) analysis in the diagnosis of patients with severe OSA and in the assessment of the effects of 3-month treatment with continuous positive airway pressure (CPAP). There were 54 patients enrolled in the study. The OSA group consisted of 39 patients suffering from severe OSA (apnea/hypopnea index >30/h), and the control group included 15 non-OSA patients with matched demographic characteristics and comorbidities. All patients underwent 24-h Holter electrocardiographic monitoring. HRV was analyzed using the time- and frequency-domains. We found that OSA patients had decreases in time-domains and increases in frequency-domains of HRV, compared to non-OSA controls, which strongly suggested a clinically disadvantageous shift in the balance of parasympathetic/sympathetic activity toward the latter. Further, CPAP treatment, partly, albeit significantly, reversed the OSA-induced changes in HRV. We conclude that HRV analysis may be of help in the diagnosis of OSA and in the monitoring of the effectiveness of treatment.

The epidemiology of obstructive sleep apnoea and cardiovascular disease

Obstructive sleep apnoea, the most common form of sleep-disordered breathing, is highly prevalent in patients with cardiovascular disease. The last 30 years has seen a plethora of large scale epidemiological studies investigating the relationship between sleep apnoea and cardiovascular outcomes. This review highlights the key epidemiological studies addressing the links between sleep apnoea and hypertension, cardiac arrhythmias, cerebrovascular disease, coronary artery disease, heart failure and pulmonary hypertension, with a particular focus on some of the most recent reports.